Feature / A healthy option

Simon Leary and Mike Palmer argue that well designed public health incentive schemes could be a key weapon for delivering the prevention agenda under QIPP

Health minister Mike O’Brien has recently called on commissioners to ‘use a bit more nous’ when commissioning services in order to ride out the recession. Giving individuals financial incentives to live more healthily, so as to reduce the burden on finite and costly care options, might be one answer.

We are currently seeing the emergence of schemes both to promote healthy behaviours, either through direct payment or subsidy, and to disincentivise unhealthy ones through taxation or some other means.

These range from widely publicised national initiatives, such as the recent overhaul of Scotland’s licensing laws, where promotions such as ‘happy hours’ are now forbidden, to primary care trust-driven schemes aimed at tackling public health issues at a local level.

While initial results from such local schemes have been largely positive, the question at the forefront of the minds of PCT decision makers will be whether these schemes constitute the best use of funds in the current fiscal environment.

QIPP (quality, innovation, productivity and prevention) is firmly on the government agenda and is very much part of the landscape in which commissioners are being asked to operate. Incentive schemes can certainly be innovative and clearly set their sights on prevention.

What is less obvious is whether they are productive – whether there is a sufficient rate of health gain per taxpayer’s pound.

Measuring the long-term payback versus the short-term cost of such schemes is always a difficult exercise, which often forces us to rely on process measures or, at best, ‘proxy’ outcome measures.

Nonetheless, this measurement is vital for commissioners to demonstrate competency 11 – an understanding of the effectiveness and efficiency of spend in the new world class commissioning assurance round.

Health England’s March 2009 report, Incentives for prevention, suggests measuring actual and potential incentives against five criteria: effectiveness, cost, equity, feasibility (political and administrative) and the impact of the intervention on individual autonomy. These look like the usual suspects, but there is probably room for at least two more – safety (could ‘over-incentivising’ an individual to lose weight lead to rapid and unsafe weight-loss?) and efficiency (what if only a handful of individuals meet the necessary criteria to take part in a scheme?).

When it comes to evaluating existing schemes in the UK, many of which are in their infancy, commissioners are left trying to decide whether a scheme is worth replicating on the basis of a short press release and, often, optimistic projections. 

Local incentive schemes

First, let us consider some real examples of local financial incentive schemes. In terms of interventions targeted at specific groups, one PCT in the south-east is at the mid-point of a pilot offering people financial incentives (ranging from £70 to £425) to lose weight in association with a private weight loss company.

As well as schemes like this that incentivise people to engage in healthier behaviour, there are those that exist to encourage individuals to not engage in unhealthy behaviour. For example, a Scottish health board is paying smokers £12.50 a week to not smoke, conditional on a carbon monoxide test, as part of its stop smoking campaign.

Schemes are also emerging that target entire communities, such as a free scheme in Manchester, due to begin next year, that will reward people with points for making healthy choices – such as buying brown bread instead of white – or exercising, be it walking in the park or swimming, that can be redeemed against a wide variety of rewards such as discounted groceries or free sports lessons.

Building the case

The problem facing commissioners is building a solid evidence-based business case for these schemes. Of the examples already referred to, no results from the weight loss scheme are being released until after the completion of the pilot in February 2010 and the community-wide reward scheme has not yet begun.

Early results from the Scottish case, however, have been positive. Almost 40% of the 700 registrants to date are staying smoke-free after four weeks. And in the first 20 weeks of the project alone almost as many people had given up smoking as in the whole of 2007. A thorough evaluation by Health Scotland, both qualitative and economic, is under way.

This positive result has been mirrored in other financial incentives across the world. A Philippine bank offers an innovative savings programme, where a would-be non smoker deposits an amount of money that he or she would otherwise spend on cigarettes into the account. After six months, the individual takes a urine test to determine whether they have recently smoked. Passing means he or she gets her money back; a fail results in the automatic closure of the account and the money is donated to charity. While evaluation of the scheme is ongoing, initial results have been evaluated by MIT’s Poverty Action Lab and appear extremely positive: opening an account makes those who want to quit 53% more likely to achieve their goal. Not even the nicotine patch appears to have been as successful.

Furthermore, there is strong evidence for at least the short-term effectiveness of financial incentives in drug misuse programmes. Meta-analyses of interventions where vouchers are provided if patients successfully abstain from drug use, show significantly better outcomes than control treatments. The greater the monetary value of the voucher and the closer in time it is given to measuring the targeted behaviour, the larger the effect.

Yet the effect of incentives in achieving sustained behavioural change remains uncertain: a recent systematic review of financial incentives to reduce obesity found that at a 12 and 18 months follow-up, use of financial incentives was not statistically significant. Nonetheless, a review of patient-targeted incentives by the Health Foundation in 2008 suggests that financial incentives can work to bring about discrete changes in patient behaviour, albeit these changes may not be sustained.

The cost of local targeted schemes is low. The initial results from the Scottish example would suggest that, even if all 700 people registered for the scheme remain smoke-free for the maximum period of 12 weeks, the total outlay in terms of incentives would have been only a little over £100,000. In reality, with only 40% of registrants remaining smoke-free for at least a month, the actual cost in terms of incentive payments has been far lower.

Even with the associated expense of project management and weekly testing, the cost of the scheme is potentially low enough to warrant immediate replication, though we will not know the true cost-effectiveness of the scheme until the economic analysis being conducted by Health Scotland is complete.

Of the studies reviewed by the University of Pennsylvania’s Institute for Health Economics, none relied on expensive, resource intensive behavioural interventions and, given that  incentives were the only significant cost and are paid only if people are successful in changing their behaviour, the cost of schemes will always be proportionate to the health gain.

Larger community-wide reward schemes, which mirror private insurance policies from companies such as PruHealth and Humana and reward members with ‘points’ that can be redeemed against a range of ‘healthy’ goods or services, will typically be more expensive.

The reward scheme in Manchester has ear-marked roughly £5m up to end of the 2010/11 financial year and includes a contribution from a local PCT. While market research points towards the potential for positive results, unlike the other schemes referred to there is no guarantee of proportionate health gain.

Rewarding individuals with points is already a key feature of German social health insurance systems and a study in 2009 has shown these to be potentially both clinically and cost effective.

Even when incentives change behaviour, and do so in a cost-effective way, there are still issues as to whether they are ethically right. Some of the most vociferous criticism has focused on incentivising patients to remain on anti-psychotic drugs, with healthcare professionals viewing such schemes as undermining patients’ autonomy and personal responsibility, as well as damaging the trust inherent in the doctor-patient relationship.

Public objection towards the use of incentives in other healthcare contexts often centres on the perceived unfairness of schemes, given that it is those who stay healthy who have to subsidise those who don’t.

The weight loss scheme in the south-east, for example, has been criticised for being short-termist, inequitable and potentially unsafe, despite having gained the public backing of the National Obesity Forum, which has described it as a ’judicious use of the public purse’.

There is huge potential for incentivisation and as pilot studies in the UK are evaluated, we should get a clearer idea of the benefits and pitfalls. If schemes are well designed, where possible rewarding long-term success, they may become a key weapon in a commissioner’s armoury as the QIPP agenda takes hold.