The ancient Greeks had a term for self-destructive behaviour. It was called akrasia – the tendency to indulge in behaviour which goes against our better judgement or received wisdom – and there is plenty of this in health. It’s a fact: we eat too much and too much of the wrong things; we drink alcohol excessively; dabble in recreational drugs on a less than occasional basis; and lead sedentary lives (punctuated by brief visits to the pub or the local fast food take out or local drug dealer).
The 2012 Health Survey for England (but likely to reflect trends in other parts of the UK) estimates that only 7% of respondents actually live what are regarded as healthy lifestyles as measured on a seven-point risk factor scale, while 93% of us having at least one risk factor. Because of unwise lifestyle choices, we are prone to diabetes, heart disease and high blood pressure, which can ultimately lead to premature death – a case of “eat, drink and be ill, for tomorrow you will probably die prematurely.”
The problem is that the health services can barely cope; and this was so even before the government broke the public piggy bank to bail out the banking industry from financial Armageddon in 2008.
Last year, NHS London published a report that outlined a doomsday financial shortfall of £4 billion by 2020 because of growing demands on hospital and primary care services. Expanding acute care services (building more hospitals) is simply not an option, London already has a vast concentration of teaching hospitals.
The long-held feeling, according to people such as Alan Maryon-Davis, former president of the Faculty of Public Health, is that the public play fast and loose with their health and with potentially lethal health risks because the NHS is seen as a health safety net. And in the meantime, four in every five deaths in London result from living unhealthily. For health apparatchiks, addressing lifestyle rather than disease would make a more sustainable health care system. Behaviour change is one way to do this.
A shove in the right direction
Governments can shove individuals towards better and healthier lifestyles. There are small shoves, which can include regular financial disincentives, such as taxation on cigarettes or bans of tobacco advertising. And there are big shoves that involve definite and forceful pushing of individuals to take up what are regarded as less harmful habits. Shoving is accomplished by actively restricting choices through bans, such as smoking in public places, or restrictions of certain goods or services regarded as harmful, such as the outlawing of multi-purchase, buy one get one free alcohol promotions in Scotland.
Shoves to restrict alcohol and smoking are now largely seen as legitimate targets. But what about pushing individuals towards healthy eating, taking up regular exercise or giving up their car? These could be regarded more as bullying, potentially flying in the face of individual liberty and expensive in terms of regulation and intervention.
Recent governments have chosen a less contentious intervention: persuading through social marketing techniques. Citizens are persuaded to make better (healthier) lifestyle choices through campaigns highlighting the benefits (or costs) of one set of choices over another. Prior to the austerity budgeting in Whitehall, figures from 11 UK government departments from 2008-09 revealed that spending on advertising and marketing had increased by 40% to £253m, with Department of Health doubling its spending to £66m. The Cabinet Office justified these increases on the grounds that it improved life expectancy, from a fall in smoking and road deaths for example, and saved the exchequer money through savings like the £547m from nudging people to complete tax returns.
Despite these positive noises, social marketing campaigns can lead to “reactance behaviour” – encouraging the very type of unhealthy lifestyle you’re trying to discourage. In the US, a 2005 paper showed this was happening with anti-smoking campaigns aimed at teenagers. In the UK, there was research that demonstrated reactance behaviour among those targeted by advertising campaigns to reduce obesity and drink driving.
A nudge too far
There is another intervention that avoids the potential heavy handedness of shoving: nudging. Promoted by Chicago economist Richard Thaler, it uses a popularised form of behaviour economics to steer a course between paternalism and libertarianism. Nudging respects individual liberties while also assuming that governments have a duty of care to citizens – especially if they engage in self-destructive behaviour.
Nudge essentially works by getting individuals to behave in way which is socially desirable without them realising they were influenced in the first place. By using visual prompts, peers norms and beliefs, they can subtly nudge people in the right direction in the same way that supermarket layouts nudge customers to consume and shop in a certain manner. You could call it manipulation but also that when it comes to health, the end justifies the means.
The UK’s Behaviour Insights Team, set up in 2010, seems fairly unconcerned about the ethical implications of nudging; it seems on the right side of psychological manipulation and is a lot less intrusive than shoving. In fact, the “nudge unit”, as it is known in Whitehall, is not a passing fad but something of success story. There’s also evidence that local authorities, responsible for public health since 2013, have embraced nudging with various initiatives from reducing salt intake to encouraging organ donation.
Not all are wowed
Despite this, some UK government departments have been wary of the unit and nudging as a strategy. Oliver Letwin, minister for government policy, revealed in 2011 that the insights team weren’t welcomed with open arms and departments largely ignored them. The House of Lords science and technology committee said that nudging was only part of the solution and not a panacea for bringing about socially desirable and healthy behaviour.
There is still a part to play for the occasional “shove” or the laden hand of regulation, but perhaps it is the combination of these and nudge that will work most effectively in changing socially undesirable behaviour.