A report by think-tank Demos has hit the headlines after it advised that people who lead healthy lifestyles should be rewarded with easier access to healthcare. The report, which was sponsored by a private health insurance company, explores the impact of having a more 'responsible' population, and is largely focused on public health.
The Demos report makes a series of recommendations based on engagement with experts, policy makers and politicians. In terms of public health, it argues that the health service should use a model of care similar to the insurance industry.
For example, drivers with a good safety record are often 'rewarded' with lower insurance premiums. The report suggests that people who commit to reducing their risk of developing chronic health disorders – by taking regular exercise or quitting smoking, for example – should also be rewarded.
One reward proposed by the report, which has dominated many of the headlines, is that people who live healthily should be moved to the front of the queue for non-emergency NHS procedures. However, as these proposals have been put forward by a think-tank, they are unlikely to become NHS policy any time soon, if at all.
What is Demos?
Demos is an independent educational charity – what the media would describe as a 'think-tank'. This means that it performs research and tries to influence public policy. Some think-tanks are closely allied to political parties. For example, the Adam Smith Institute is associated with the Conservative Party and the Fabian Society is associated with the Labour Party.
Demos is unusual in that it describes itself as cross-party, although political commentators have referred to it as left-of-centre. Its stated goal is helping to create a "society populated by free, capable, secure and powerful citizens".
The lead author of this report, Max Wind-Cowie, is described on the Demos website as head of the Progressive Conservatism Project, which it says "identifies Conservative values and policies that have progressive ends". He has previously written on the subject of personal responsibility and the NHS in The Guardian.
This report was supported by Zurich, an insurance company. This could be seen as a conflict of interests, as the report suggests that private medical insurance products could play a greater role in the NHS. Indeed, the model of rewarding people categorised as 'lower risk' is already used by much of the insurance industry.
What has Demos recommended?
The Demos report argues that, in terms of funding public health, the NHS is based on the principle of 'nationalising risk'. This means taxpayers enter into a 'social contract' in which they agree to meet the costs of the nation's health.
But the report argues that this 'nationalisation model' is unfair. Some of us take responsibility to reduce our health risks, while others do very little. Some of us engage in behaviour known to significantly increase the risk of long-term illness and disability, the report rightly says.
Interestingly, the author does make the point that perceivably middle-class pursuits – such as skiing – also arguably represent high-risk behaviour that can result in severe injury and incur significant costs for health providers.
The report is keen to stress that it recommends a reward-based system (a 'carrot' rather than a 'stick'). People should be rewarded for good behaviour rather than being punished for risky behaviour, it says.
Possible rewards suggested in the report include:
- people receiving the new Universal Credit could be rewarded with cash top-ups if they regularly attend the gym
- non-emergency appointments could be 'fast-streamed' for people who register to share information on their healthy behaviours (from their supermarket or gym, for example)
- supermarkets should be encouraged to give feedback on shopping baskets, and to remind shoppers of the benefits of fruit and vegetables and the dangers of alcohol and saturated fats
- private medical insurance products could be developed to reduce the burden on the NHS and also encourage greater links between the costs of healthcare and lifestyle choices
The report also recommends that the government establishes a 'risk commission' to help collect, collate and communicate knowledge about risk. However, this point was overlooked in the media coverage.
The Demos report acknowledges that people are bombarded with contradictory and often scary information about risks and behaviour and their impact on health (Behind the Headlines aims to address some of these apparent conflicts). Mixed messages surrounding risk can lead to people feeling unable to affect their own health.
It says that a 'risk commission' could help overcome these public misunderstandings of risk and promote responsible reporting on risk in the media, as well as by public bodies such as NHS Choices.
How have the Demos recommendations been received?
In an editorial, The Independent argues that while the idea of rewarding healthy behaviour is "not unreasonable", there is the risk that the recommendations in the report reinforce "the Victorian distinction between the deserving and the undeserving poor". It points out that there are strong associations between poverty and ill health, and that the proposals "would inevitably punish those already at the bottom of the social ladder".
Katherine Murphy, the chief executive of the Patients Association, has been quoted as saying: "Proactive investment in prevention, public campaigns and health literacy can deliver change more constructively than punitive sanctions."
However, it is impossible to predict how such proposals would be received by the public. Many of us may like the idea of being rewarded for 'healthy' behaviour, but would we really be happy about sharing our shopping habits with central government?
The debate on the relationship between personal responsibility and public health will continue for many years to come. But it's worth remembering that you personally can do a great deal to try to avoid some diseases and lead a healthy life, simply by ensuring you get enough exercise and eat a balanced diet, and stopping smoking if you are a smoker.