Paying for the NHS

Around half the population claim to be aware of a trio of key health guidelines but the numbers claiming to actually follow them is poor.

.1.     Key Findings

The Failure of Persuasion.  Around half the population claim to be aware of a trio of key health guidelines but the numbers claiming to actually follow them is poor.  For many these guidelines are unrealistic and unachievable.

Prevention as cure.  A third of us need to be incentivised to live a healthy lifestyle, whilst 58% of young people feel that healthy behaviours should be rewarded. In advancing preventative medicine we need to move from advocating generalised guidelines to a more financially rewarding and individualised approach.

Healthy hedonism.  Understanding how people think about diet and exercise is the first step to making a positive change.  People seek a balance; indulgence is paid for at the gym.  In encouraging change, we need to be offered a carrot while feeling the impact of the stick. Future efforts to encourage healthy behaviours will be more effective if they acknowledge and work with this mentality.

Eating ourselves fit.  It’s human nature to seek a short cut or take the easy option.  Functional foods offer that benefit and they will be a much bigger part of grocery sales by 2020.  Functional foods have a useful contribution to make but the danger is that they distract us from following a balanced diet.

Health tourism.  There is a latent demand for health tourism.  Its growth will be determined by two things – the length of waiting lists (particularly among the elderly) and the costs of treatment.  Very few people believe that the quality of care offered abroad is superior to that at home.

Looking Good, Feeling Good.  Celebrity culture is a very costly guilty indulgence.  A focus on superficial looks is creating perverse behaviours and attitudes among the young in particular; one in five people aged between 16 and 24 would rather look good than feel good.  Our obsession with a narrowly-defined view of human beauty will corrupt a generation and threatens to have a major impact on the health of the nation.

1.2.     The Failure of Persuasion

For this report we have surveyed the public awareness of government guidelines across a range of factors.  The numbers claiming to be aware of the guidelines look like this:

• Calorie intake: 51%
• Exercise: 60%
• Alcohol units: 49%

The proportion of people claiming to adhere to the guidelines look like this:

• Calorie intake: 17.5%
• Exercise: 19%
• Alcohol units: 34%

It is likely that there is a degree of over-claim in the numbers claiming to adhere to government guidelines which only makes the gap between awareness and action greater.

Studying the consumer response to government attempts at persuasion is instructive.  On calorie intake 18% of our sample think the guidelines are ‘aspirational’.  Another 10% think that ‘people aren’t actually expected to follow them’ and the same proportion think they are ‘unrealistic’. Nearly one in four (23%) think the information is ‘confusing’.  Only 4% think the guidelines are ‘too lenient’.

One of the reasons why persuasion has not been effective is that it does not take account of the individual.  Generalised targets are of limited value when the robustness of individuals varies so much.

“[current guidelines] are seen as unrealistic and certainly the work we’ve done in the field shows that, for some communities, five portions of fruit and vegetables a day is seen as unachievable.  A lot of men would see drinking 21 units of alcohol a week as unachievable and so on – this is what I am saying about public health being disempowering.  People need to be involved in the setting of their own targets; these blanket targets are very unhelpful for a lot of people.”  Andrew McCulloch, Chief Executive of the Mental Health Foundation.

While individualised targets promise a significant improvement in preventative healthcare, it is likely that government will legislate on health as the cost of caring for an ageing population soars.  They will also expect citizens to take more responsibility for their health.

“I think so [that the government will legislate more].  Given the drive to save money at the moment, I think Government has to, at some point, hand over responsibility to patients to start looking after their own health.”  Dr Jonty Heaversedge, GP and Broadcaster

1.3.     Prevention as Cure

“I think preventative healthcare has to be the way forward and I think it’s going to be something that we increasingly focus on.  The problem with preventative healthcare is showing that it’s effective in producing outcomes.  The focus for the health service, I suspect, over the coming years is going to be much more on outcome, on showing that we have benefited patients.  Preventative healthcare often doesn’t provide short-term outcomes; the benefits are going to be in the longer term...”  Dr Jonty Heaversedge, GP and broadcaster

“[Preventative health will] ...be radically changed [by 2020] because I think we will have a much better understanding of prevention for certain major conditions including cancer, heart disease and dementia and we may have more targeted ways in which people can understand how to prevent [them].”  Andrew McCulloch, Chief Executive, Mental Health Foundation

Among our Delphi Panel the consensus is that preventative medicine will become more important by 2020.  While many of the experts we spoke to believe that a preventative approach will be boosted by advances in science, there is also a recognition that individuals will have to take more responsibility for their own health.  As pressure on public health budgets increases through a burgeoning demand for acute care among an ageing population, it is perhaps inevitable that the individual will take on a greater role.  While prevention is already a priority for GPs there may not be sufficient resources (both in terms of time and money) available to focus on prevention work among patients.

“I think there will be more responsibility on the individual to maintain their own health but there won’t be a lot of money coming from the state to help people do that: I think it will increasingly be up to them.  There will be a stronger emphasis from school-age onwards that this is what can happen to your health, now go away and manage it yourself.”  Dr Patricia Macnair, medical practitioner, journalist and broadcaster.

Some would argue that the population is already aware of the basic forms of disease prevention, such as exercise and diet. 

The explanation for this comes from a number of factors – as we have seen a third of people just do not want to think about their long term health.  A similar proportion state that they need some sort of incentive to engage in a healthier lifestyle.  This attitude varies with age.  As our respondents get older they require fewer incentives.

In some cases this is already happening.  Cash payments of up to £425 were offered by an NHS primary care trust in Kent to volunteers who signed up for a ‘Pounds for pounds’ scheme in 2009.  Some organisations now provide an incentive to live healthily.  Companies like Weight Wins provide a cash payout for those who lose a certain amount of weight over a set period of time.  Employers have also offered schemes to incentivise healthy behaviour.  The multi-national insurance broker Willis offers staff an incentive package that rewards healthy behaviour with discounts on products and services from around 2,000 retailers and manufacturers.

A financial incentive is likely to be more effective than scaring people and it may provide the incentive that our respondents are looking for.  However our Delphi Panel is split on the likelihood of this being part of preventative medicine in 2020.  Monitoring patients would pose problems and it would also be difficult to determine the eligibility of individuals.  For these reasons it may be easier to increase ‘sin taxes’ on alcohol and tobacco – to financially penalise rather than to reward. 

1.4.     Healthy Hedonism

We are often told that we cannot kid ourselves when it comes to health.  However we do and we are quite good at it.

A quarter of our respondents imagine that doing exercise allows them a guilt-free run through any menu.  Exercise provides permission to eat what we like.  Younger people are more likely to believe this, perhaps because exercise is often an easier and less onerous undertaking for the young.  Similarly 77% of us will sometimes treat ourselves to compensate for a healthy diet – we seek to balance the healthy against the unhealthy.

This desire for equilibrium between health and hedonism takes other forms.  We are interested in foods that provide positive healthy benefits (as discussed in section 5.5).  The guilt that we feel in not taking enough exercise and eating the wrong things gives rise to an interest in supplements and quick food fixes.

We believe that this trend will be more marked in 2020 than it is now continuing exhortations from government on health, the sensitivity of food retailers and manufacturers and concerns over the health of children.  All of these factors combine to ensure that our hedonistic ways are increasingly counter-balanced by that which is good for us. This has implications for the next generation.

“You find more people providing their children with fresh vegetables.  So, in ten years time, when those children grow up, their habits will change and they will be much more informed consumers and they will look at the salt amount and the rest of it.”  Dr Amit Bhargava, GP, NHS Alliance

1.5.     Five Portions a Day Keeps the Doctor Away - Eating Ourselves Fit

Confronting your own failings and imperfections is uncomfortable work particularly in a society that places ever greater emphasis on looking good (section 5.7).

Consider the very high level of agreement (70%) with the statement ‘the availability of cheap food has lead to people eating to excess’.  Certainly fast food has been stridently portrayed as damaging to young people in particular. Cheap food is a contributory factor in the widening waist belts of the nation but a lack of exercise is a significant factor too.

The latest ONS Social Trends report (July 2010) makes clear that despite the fact that we eat more fruit and vegetables than we used to, we simply eat too much food and don’t take enough exercise.  We also tend to overstate how much fruit and vegetables we eat – our research shows that 62% of the population currently believe they eat five portions of fruit and vegetables a day.  According to the Department of Health 29% of adult women and 25% of adult men eat five portions a day (Health Profile of England 2009).

It is easy to blame food – 44% of our respondents support the notion of a ‘fat tax’ being levied on foods with a high fat content.

The converse of this blame culture is a strong interest in ‘functional foods’ (i.e. those that offer health giving qualities over and above mere nutrition).

“I think human beings have always looked for a quick fix and the marketing [of ‘super-foods’] will become much more sophisticated... And human beings, being the suckers that we are, will always fall for it.  But we won’t live longer because of these foods.  We will live longer because we exercise more and eat healthily.” Dr Amit Bhargava, GP, NHS Alliance. 

For this report we asked consumers how interested they would be in a range of foods which offered various health and beauty benefits.  In terms of an interest in trying them, we see the following results:

• Functional foods that boost creativity – 35%
• Functional foods that boost confidence – 44%
• Functional foods that heighten libido – 33%
• Functional foods that clarify skin – 50%
• Functional foods with antioxidants – 56%
• Functional foods with anti-ageing properties – 54%

Other experts expressed frustration that legislation is stifling the progress of useful functional foods.

“Although increasingly popular, the EFSA [European Food Safety Authority] legislation from Europe means that functional food claims are VERY difficult for manufacturers to make. Probiotic claims have been thrown out without even looking at the evidence because of a difficulty in exactly identifying the organism involved (i.e. because full genome not supplied). It is a ludicrous situation.”  Dr Sarah Brewer

We have no doubt that functional foods will be a bigger part of our diet by 2020.  The human desire for easy solutions combined with innovation makes this inevitable.  Functional foods are the logical conclusion to our desire for healthy hedonism – a ready-balanced lifestyle solution.  The only inhibitions on the growth of these products are likely to be legislation and the ability to produce enough healthy ingredients such as Omega 3.

1.6.     Health Tourism

The concept of going abroad for medical treatment is widely understood.  Some 61% of our respondents are familiar with the term ‘health tourism’.

The motivation for going abroad is quite evenly split between a desire to save money (perhaps on cosmetic treatments) and a frustration with the length of an NHS waiting list.  Only one in ten people would consider going abroad because they have more faith in foreign health professionals.

The majority of experts on our Delphi Panel predict that health tourism will be more common by 2020.

“Health tourism will grow but will still be a minority activity. Plastic surgery is already accepted and is certain to rise to become more common among lower socio-economic patients.” Niall Dickson, Chief Executive and Registrar, General Medical Council.

Our data shows that willingness to consider treatment overseas is largely dependent on age and waiting lists.  The older people are, the more likely they are to look at treatment overseas.  This provides the key to understanding the growth potential of health tourism.  The speed with which the NHS can treat older patients determines the numbers travelling abroad.

The other - currently latent – motivation will be the introduction of charges for treatments.  If the NHS should start charging for more treatments we would expect health tourism to grow.

“Health tourism will increase if there is a charge for treatments in the UK. PMIs may negotiate cheaper fees abroad so patients willing to accept treatment abroad can opt to pay reduced insurance premiums. Aesthetic plastic surgery will always be a privately paid-for option not available on the NHS except where there is a medical need (e.g. to improve disfigurement).”  Dr Sarah Brewer.

What our research indicates is that awareness of health tourism is high and that more than one in five of us would consider it.

1.7.     Looking Good, Feeling Good

“I think we have a very unhealthy obsession on how much reward we think we get from looking good.  We’ve become obsessed by it to the point that we’ve lost track of the other things that bring happiness and success and move us on.”  Dr Patricia Macnair, medical practitioner, journalist and broadcaster

 

Our research clearly shows that the vast majority of the population feel there is more pressure to look good now than in the past.  This feeling is particularly acute among women and younger people (16 to 24 year olds).

Our idea of beauty is narrowly defined and the value placed upon it has never been higher. 

In recent years the idea that youthful looks are the preserve of young people has diminished due in large part to a number of high-profile celebrities who retain a fresh-faced appeal at an age that would previously have been considered impossible.  Women like Jane Fonda, Goldie Hawn, Helen Mirren, Meryl Streep and Twiggy exemplify this phenomenon.  As growing old gracefully becomes less of an option the pressure on people to look good applies to all ages.

Over the next decade it is hard to imagine any rejection of celebrity culture.  Popular media is in thrall to celebrities and their ability to sell products and influence the rest of us is growing.

“I think it takes long years of grass roots level education in the community to change people’s values and at the moment our values are increasingly obsessed with superficiality and looks...” Dr Patricia Macnair, medical practitioner, journalist and broadcaster.

The risk in this is that people will continue to focus on looking good rather than feeling good.

 “Yes, I think this is increasingly a mental health issue or certainly a morale issue anyway...  For women it has increased (although it’s always been there) and young men are getting there now as well.  We’re certainly seeing more anorexia in young men.  I think this will only get worse if we don’t change our attitude towards this.  I think it’s particularly tough on middle-aged women actually. 

And role-models, the media; all this stuff’s important but it’s partly self-driven as well.  You know it’s no good just blaming models and the media if the whole of society has bought into it...”  Andrew McCulloch, Chief Executive of the Mental Health Foundation

For those who recognise that looking good can result from following a healthy lifestyle, our current pre-occupation with physical appearance may not be entirely negative.

“Yes, that [a focus on looks] is the direction of travel and it is not all bad. Many people now in their sixties look and feel like people used to in their 40s and 50s – it can add to as well as detract from self esteem.”  Niall Dickson, Chief Executive and Registrar, General Medical Council 

The continued and growing focus on looks and appearance is to the detriment of our overall health.

“What we’re busy doing is making ourselves look younger so we will still die at the same age but we might look better in our coffins.  But actually if you think about it, if you genuinely want to extend your life it’s got much more about what’s happening inside our bodies than it has on the outside of our bodies; but it’s very hard to get people to engage with taking care of their heart and their lungs and their bowels when actually what they’re confronted by every day is their face in the mirror.”  Dr Jonty Heaversedge, GP and broadcaster.

1.8.     Conclusions

“I cannot say that I like it when an image is retouched to death, or when the person doesn’t look like themselves any more.  When it comes to retouching wrinkles, we try to be as conservative as possible.  But it is part of our culture now; we have all become avatars.”  Inez van Lamsweerde, fashion and celebrity photographer, quoted in The Guardian, 8 July 2010

When it comes to influencing young people Cheryl Tweedy will always appeal to them more than the Department of Health.  In assessing the prospects for 2020 all the gains from better knowledge on healthy living (particularly among the young) are threatened by being in thrall to a shiny, superficial celebrity culture.

Various attempts at persuading the public to live healthier lives have been largely ineffectual, as the rising obesity rate demonstrates.  To be effective, preventative medicine needs to consider the individual rather than pushing generalised guidelines.  Furthermore, in preventing ill health we need to understand the trade-offs we make, the balance between indulgence and virtue.  Working with this dynamic rather than trying to overcome it would surely be a more effective approach.