4. 7
HEALTH&BEHAVIOUR|EDITORIAL
Good health, and how to achieve and maintain it, is
the most significant issue facing both governments
and individuals in the developed world. The concern
for individuals is that we are living longer, but many
of those extra years may not be healthy or especially
happy ones. Meanwhile, the state must balance the
unlimited need for sophisticated (and expensive)
healthcare treatments with a global trend towards
restraining the size of the state.
It is now widely accepted that the way
to square this impossible circle is through public
health; but our understanding of how to persuade
populations to make healthy choices is still evolving.
Until relatively recently, it was assumed that there
were two choices. Dictatorial state intervention;
banning substances or activities. Or rational choice
decisions by individuals to do the right thing
based on better information.
We now understand however, that humans
are not just rational but emotional. Many of us
prioritise short-term gratification over long-term
benefit. We don’t act in our own best interests. We
ignore information given to us by the state, and often
flout legal sanctions intended to protect us. We
are, in short, all too human.
So building a healthier society requires a
sophisticated understanding of human behaviour, a
far cleverer set of public health tools, and a coalition
of public and private sector organisations joining
together to create a movement for change.
freuds has for many years worked at this nexus.
This has ranged from supporting with
Public Health England to create a series of
campaigns, like Change4Life and Stoptober,
which have measurably impacted Britain’s health
outcomes. It also encompasses our work with
London 2012, when as the lead agency involved in
the Olympic Games, and in particular responsible
for organising the torch relay, we worked to build
a health legacy from this key national event.
But it also extends to our work with
a series of private sector companies in the food,
drink and related sectors, where we have supported
their journey towards becoming partners in the
coalition working to ensure that consumers make
healthy choices. Nor does it exclude our work
with companies in other sectors who have used
their consumer engagement to make an impact on
healthcare outcomes, such as Sky and Nike.
This journal explores the current and
future development of health and behaviour. It
includes insightful and impactful public sector
contributions by Sir Liam Donaldson and Sheila
Mitchell, exploring the role of government in this
mix. It includes some really exciting thinking about
the role of the private sector, ranging from companies
in the health space like Nuffield, AbbVie and GSK,
to insurance firms with innovative models like
Vitality, to global food businesses like Wrigley.
It encompasses the latest thinking on
the role of technology from entrepreneurs like Ali
Parsa, founder of babylon and Suzanne Clough
from WellDoc, and includes a keynote contribution
from Alan Milburn, former UK Secretary of State
for Health and a think piece from a leading health
psychologist. It looks at new ideas in the mental health
space, with articles from Charlie Howard,
an innovative social entrepreneur, as
well as from Ruth Sutherland, the Chief
Executive of the Samaritans.
Finally, there is an essay on
our relationship with food and how
that might be changed from Heston
Blumenthal, one of the world’s most
innovative philosopher-chefs. We have
also included some freuds insight and
research in this area, exploring how and
why we as individuals are reluctant to
take responsibility for the health impact
of choices that we make.
We hope you enjoy the journal,
and that it takes forward the discussion
about how to help human beings achieve
longer, healthier, happier lives.
EDITORIAL
6. ‘Whether it is nano-technology
or cloud computing,
technology is going to change
what healthcare is able to do
and how it does it’
11
HEALTH&BEHAVIOUR|FACTORFIVE
Wherever I go in the world, two words are virtually
synonymous: health and crisis. The National
Health Service is not the only healthcare system
under more pressure than ever before. It is true
in country after country. For some, the answer lies
in more cash. For others, it is in optimising more
value and driving greater efficiency. In this series
of essays, a distinguished panel of contributors
argues that whilst these incremental changes may be
necessary, they will not be sufficient to make modern
healthcare sustainable. Instead, the key that can
unlock sustainability is what individual citizens do
to improve their own health. That makes behaviour
change the next frontier in healthcare.
Over centuries, healthcare worldwide has
had to adapt to new circumstances, new challenges
and new opportunities. In the last part of the
nineteenth century, progress in sanitation opened
a new frontier in public health. A century ago, the
discovery of new vaccines opened up a new frontier
in preventative health. In more recent times,
new treatments have opened up a new frontier
in interventional and in mental health. But each
of these new frontiers has been predicated on a
consistent philosophy about the relationship between
service and citizen - with an active role for the
former and a passive one for the latter.
Until recently, there has been too little
focus on the contribution that individuals can make
to better health and care. As our contributors explain,
that is now changing. An inflection point has been
reached with profound implications both for how
we think about healthcare and what it does. The
citizen-patient is emerging as the most powerful way
to improve health and care.
Five big factors are producing a platform
for change. Each is too often seen as a challenge
when it should be viewed as an opportunity.
First, demography. We live in an ageing society.
By 2030, one fifth of the population of Britain will
be elderly. But this will not be old age as we have
known it. There will be more very old people living
with more health problems - co-morbidities - than
ever before. And as the post-war baby boomer
generation grows old we are likely to want to live
out the end of our lives cared for in our own homes
by people we choose, with budgets we control. The
challenge is that the new generation of the old will
not tolerate a system of care that tells us what to do.
We will want to tell it what to do. The opportunity
An Introduction to Health and
Behavioural Change
In the following article, the former UK Secretary of State for Health,
Alan Milburn, introduces the concept of behaviour change in the
health arena. He argues that the sustainability of healthcare systems,
both in the UK and on a global level, rests on the ability of individuals
to change their own behaviour and improve their health. As such, he
asserts that behaviour change is ‘the next frontier in healthcare’.
is to refashion care so that it is aligned with the
mindset of this century rather than the last.
Second, malady. If the healthcare challenge
of the last century was to beat infectious disease,
the battle for this century is about tackling chronic
disease. It is responsible for 70% of NHS costs. This
change in the pattern of disease calls for less focus on
the state of the nation’s healthcare and more on the
state of each nation’s health. The focus needs to move
from treatment to prevention. What differentiates
diabetes or arthritis from other forms of illness is
that they become a permanent fixture of people’s
lives. So what patients do to manage their own
condition – their lifestyle, and diet and exercise – is
as important as what clinicians do. The challenge
is to find ways of treating patients less as passive
recipients of care in a system that denies them both
power and responsibility and instead empowers them
to take greater charge and more responsibility for
their own health. The opportunity is to bring patients
inside the decision-making tent – so they share the
day-to-day dilemmas clinicians and managers face –
rather than keeping them outside.
Third, changes brought by technology
also make likely the advent of more citizen-
controlled services. In the long-term, if the benefits
of pharmocogenetics can be realised, the next few
decades could see our whole model of healthcare
moving from one that has been about detecting and
then treating illness, to one that instead
predicts and prevents ill-health. In the
short-term the rising ride of chronic
disease means the focus has to shift from
episodic treatment – largely in hospitals
– towards earlier preventative action
and continuity in treatment – in the
community and peoples’ homes.
The world is on the verge of a huge leap
forward in how healthcare is delivered.
Whether it is nano-technology or cloud
computing, technology is going to change
what healthcare is able to do and how it
does it. The potential here is enormous,
but the challenge is to address the
mismatch between the services that are
provided – with an over-concentration on
hospital-based care – and those that are
needed – for more care in the community
and at home. The opportunity is to
harness technology – from big data to
patient-owned health records to mobile
health applications and wearable devices –
to help make that transition.
Fourth, expectancy. We live in
a world where people are more informed
and inquiring. They are demanding a
greater say. Ordinary people are getting
a taste for greater power and control
7. have mainly relied on structural and organisational
change to drive improvement in the NHS. Levers like
competition, transparency and incentives have been
deployed with some success but ‘patient power’ has
remained a marginal, rather than mainstream idea.
That now has to change both for health reasons
and financial ones.
It is time for citizens to own greater
responsibility for improving their own health.
That will not happen without a better understanding
about what drives certain behaviours and what
incentivises others. Nor will it happen without the
participation of both health professionals and new
providers. Above all else, it will mean thinking of the
public less as outsiders and more as insiders – as
part of the decision-making process rather than
by-standers to it.
Change will have to happen not just
because the cash is running out but because time is
running out for a system that was designed to deal
with yesterday’s challenges, not tomorrow’s. Meeting
these challenges will be daunting but it opens up
an enormous opportunity - to reshape how care is
delivered so that we optimise resources, empower
patients and improve outcomes.
in their lives. People today want choice and expect
quality. It is not that the public wants surgeries or
hospitals to behave like supermarkets or salesrooms.
The relationship people desire is not merely a
transactional one. They want a personal one. The
challenge is to find new ways of treating each patient
as an individual rather than as just another number.
The opportunity is to harness the modern citizen’s
appetite for knowledge and control in order to
make self-care a reality.
Fifth, and most potently of all, money.
In the last three decades, health budgets have been
growing faster than the economy has grown. In 1960
developed nations spent on average 4% of GDP on
healthcare. Today it is closer to 10%. We have been
spending more than we have been earning. The
global financial crisis and a squeeze on government
spending have brought those good times to an
end. The problem is that resources might slow but
pressures won’t. So the accent will be on finding new
ways of getting more out of healthcare for what is put
in. That is a challenge. But it is also an opportunity.
None of these challenges are unique to our
country. They affect every healthcare system in every
country. Their combined effect is to break the old
assumption that improvements in performance could
only be created by large increases in investment.
That is no longer sustainable. A new holy grail in
global health policy has emerged – how to get better
outcomes for lower costs. That relies on moving
people from being passive by-standers as patients to
active participants as citizens in healthcare.
The explosion in chronic conditions we are
now witnessing across the world calls into question
the whole paradigm of how we have traditionally
delivered healthcare. Clinicians have prescribed and
patients have received. But if you have diabetes, what
the patient does – the food they eat, the exercise they
take, the lifestyle they choose – has a huge bearing
on their health. Better still would be the adoption of
behaviours that prevent conditions like obesity in the
first place. The contributors to this journal suggest a
multitude of ways that can happen.
For decades there has been much talk
about giving patients more power. But policy-makers
‘Change will have
to happen, not
just because cash
is running out, but
because time is
running out for a
system that was
designed to deal
with yesterday’s
challenges, not
tomorrow’s’ 13
HEALTH&BEHAVIOUR|FACTORFIVE
8. The Cost
of Living
Employee Wellbeing: the New
Corporate Responsibility
By David Mobbs | Chief Executive, Nuffield Health Group
David Mobbs is the former Chief Executive of the Nuffield Health Group – a non-
profit group which operates a range of health and wellbeing facilities including
Nuffield Health Hospitals and Nuffield Health Fitness & Wellbeing Centres. The
charity was established in 1957 and has established 31 hospitals and 77 gyms
across the UK, delivering a comprehensive network of healthcare and wellbeing
services. In this article, David Mobbs explores the need for Corporate Britain to
increase its responsibility for employee wellbeing. 15
HEALTH&BEHAVIOUR|THECOSTOFLIVING
It’s time to come to terms with the fact that while
on the surface the UK offers free health care, we in
fact run a co-funded system. Your health is free at
the cost of recovery, but there is a cost to stay well.
It is a cost nobody is taking responsibility for, which
lumbers the NHS with higher bills as more people
become ill due to poor lifestyle decisions.
The question is, who should pay to look
after the population’s wellbeing? In a world where
corporate responsibility implies supporting local
communities and looking after the health of the
planet, why would it not also extend to keeping your
workforce happy and healthy?
After the individual, UK businesses are
next in line to reap the benefits of a well workforce.
In 2012, Nuffield Health launched a joint research
project with Ashridge Business School to discover
sustainable wellbeing initiatives that would result
in real benefits. Judith Parsons, Business Director
for Ashridge Business School, said at the time: “The
costs of not attending to employee wellbeing are
enormous – both at an individual level and to the
company bottom line. Ill health and absence costs the
UK economy £100 billion per year. Poor nutrition
is estimated to cost 97 million working days in the
UK per year and a staggering 50% + of workers are
dehydrated. However, only half of UK employers
have an employee wellbeing strategy.”
Further, the World Economic
Forum’s Global Competitiveness Report
2010-2011 identified the health of the
workforce as one of the four pillars
of global competitiveness. They link a
country’s competitiveness and productivity
to having a healthy workforce. Illness
impacts not only attendance but also
productivity and so they make it clear that
investment in efficient health services is
critical to on-going economic success.
The link between everyday
wellbeing and avoiding health
breakdowns is so intrinsic, in 2008 we
made the decision to transform Nuffield
Health from a provider of recovery
services into an organisation which covers
the whole journey, from prevention to
cure and recovery.
It needs to be up to the
individual, ultimately, to make the decision
to improve their wellbeing – but this can
be a symbiotic relationship with work. An
employer can influence their employee’s
environment to promote a better lifestyle,
and at the same time an individual will be
tempted to work for a company who take
their wellbeing seriously.
‘Ill health and
absence costs the
UK economy £100
billion per year’
9. supermarkets employing a compulsory 5p fee for
plastic bags.
While the state can attack the bigger, more
obvious issues impacting our health (e.g. smoking
indoors, minimum alcohol costs) it is impractical and
unwanted for the government to interfere in our day-
to-day lives. There’s no platform for the government
to enforce a more granular approach – more balanced
diets, increased exercise or even just better posture.
A business, however, has the perfect
platform to address these within its own workforce.
This is where the idea of a Wellbeing Levy comes to
play. Just like a tax aimed at promoting the cutting
of carbon emissions, a wellbeing levy would tax
organisations not providing the right environments
and initiatives to make sure their employees are
looking after themselves.
In effect, such a wellbeing levy would be
an incentive to businesses to offer proactive solutions
to the future health problems of their staff (and, as
a result, the UK). The levy would be offset when a
business offered routes for their staff to achieve a
better wellbeing.
This would create a wedge-shaped fund,
offering a large amount of money now while the
NHS needs to reform, with that amount of money
decreasing over time as UK businesses offer more
wellbeing solutions to their staff (and thus decrease
their workforce’s demand on the NHS).
In 2013 Nuffield Health published a
study in collaboration with the London School of
Economics titled ‘12 minutes more’, highlighting
the impact increased physical activity among Britons
could have on their health, their finances and their
impact on the NHS.
For instance, we found that if each obese
person were to engage in moderate activity for five
days a week, there would be a 7% decrease in the
likelihood of that person continuing to be classified
as obese, which would imply a cost saving to the
NHS of £360 million per annum. Highlighting the
link between wellbeing and impact on the NHS,
there would also be a 6% decrease in those suffering
from psychological distress, yielding £6.3 billion in
potential savings overall (taking in to account loss of
The modern work week, despite the
digitalisation and the rise of remote working, still takes
up the lion’s share of our time. According to the ONS,
from May to July in 2015 people working full-time
worked, on average, 37.3 hours per week in their main
job. That gives an employer a significant opportunity to
make a difference.
It can be argued then, that the solution
to the major challenges that NHS faces lay outside
of NHS and indeed beyond real state control. That
means Corporate Britain has got a responsibility to
help UK plc with its health issues.
Ill health prevention and wellbeing is
territory Nuffield Health knows well. We know
what it takes to bring wellbeing benefits to
corporations - we service 60% of the FTSE 100
and 40% of the FTSE 250.
We’ve been working with corporations
to improve the health and happiness of their
workforce. A happier and healthier workforce
is reward in itself, but those corporations don’t
work with us out of their own benevolence – they
recognise what wellbeing brings to their bottom
line. Productivity goes up, those who were flagging
stop flagging and those who were already high
performers sustain their output longer. Then
there’s the obvious benefit of a well workforce –
the reduction of ill-health provision needed. In
short, less sick pay and better continuity in the
workplace.
Employee wellbeing will be at the centre
of a war for talent, which will become increasingly
apparent as millennials enter the workforce in
higher numbers. This new breed of employee arrive
with the desire to choose an employer based not on
salary, but on the impact on their own happiness
and health, as well as the organisation’s other
corporate responsibility credentials. Consumers
will also feel loyalty to organisations that clearly
look after the wellbeing of its people and the UK.
Sometimes the state is forced to do
something bold, something that will influence a
company’s corporate responsibility. So we have
organisations focusing on their use of renewables
and green energy, or for a more recent example 17
HEALTH&BEHAVIOUR|THECOSTOFLIVING
‘Corporations
don’t work with
us out of their
own benevolence
– they recognise
what wellbeing
brings to their
bottom line’
earnings, associated treatment and welfare costs.). If
businesses were able to help implement these changes
to their workforce, the benefits are obvious.
A Kings Fund report last year identified
that we are currently spending 8.5% of GDP on
health. If this continues without change, in 20
years time providing a similar level of service
would require more than 30% of GDP. Even
without the current pressure on public
finances, this would be unaffordable.
It’s a massive problem for
the NHS that the NHS is powerless to
solve. It’s time for Corporate Britain
to enter the battle, redefine corporate
responsibility and help improve
Britain’s wellbeing.
10. The future of our NHS depends on the decisions
we make today. We need to ask ourselves – as
individuals, patients, healthcare professionals,
industry and Government – what can I do to ensure a
sustainable future for the NHS?
Turning the vision of a sustainable NHS as
set out in the ‘Five Year Forward View’ into a reality
demands a new approach, with behaviour change on
all sides. We need fresh thinking about what each of
us – as individuals and in our professional roles – can
bring to the table.
The need for change is obvious and urgent.
The NHS deals with a million patients every 36
hours. Over a quarter of our population – some 15
Beyond Medicine: Why Patient Self
Management is the New Frontier
of Healthcare
By Matt Regan | UK General Manager, AbbVie
A Fitter Pill
Matt Regan is the UK General
Manager of AbbVie, the global
biopharmaceutical company. In the
following article, Regan explores
how shared decision-making and
improved patient self-care are
essential for the long-term survival
of the NHS.
million people – have a long-term health condition,
like arthritis, diabetes or asthma. As the ‘Five Year
Forward View’ puts it, the NHS must “evolve to meet
new challenges: we live longer, with complex health
issues, sometimes of our own making.”
Certainly there is more that each of us
can do for ourselves. If we make small changes every
day – moving more, eating well, not smoking – we
can avoid some of the preventable conditions that
thousands of people already live with. As an employer,
AbbVie want our people to be healthy and to have
a good work-life balance. Through our Vitality
programme, we’re encouraging our team to get their
health checked and supporting them to make positive
lifestyle changes where they feel the need.
But our person-centred approach isn’t only
about our workforce. It’s also about the people we
serve – individuals living with long-term conditions
– understanding their needs and working to improve
their care and quality of life.
As a pharmaceutical company, our mission
is to bring breakthrough medicines and innovative
medical approaches to patients across the globe. The
traditional view of what companies like ours can
contribute has been focused on the medicine: efficacy,
risk/benefit profile and cost. But we have decided
we can do more than discover and manufacture. We
are committed to a partnership approach that goes
beyond medicine.
Our approach is three-fold. First, work in
partnership with patients, healthcare professionals,
academics, Government and beyond to understand
the challenges and find solutions. Second, focus on
the interventions that have been shown to be most
effective. Third, get them to patients early, when they
have greatest chance of working.
‘Our partnerships are taking us
into non-traditional territory
for a pharmaceutical company’
Collaboration is critical. We are
partnering with a wide range of different
organisations and individuals. We each
have different expertise. What unites us is
the belief that our NHS is precious and,
by harnessing our collective insights and
ingenuity, we can find practical solutions
to the urgent challenges it faces.
Our partnerships are taking
us into non-traditional territory for a
pharmaceutical company. For example,
one of our key areas of focus is around
the interventions that can support people
with a long-term condition to get back
to work as early as they can. Sickness
absence costs our economy a massive
£100 billion every year. Musculoskeletal
conditions – such as lower back pain,
osteoarthritis, rheumatoid arthritis and
ankylosing spondylitis – are the biggest
cause, accounting for around 31 million
days of sick leave each year in the UK.
Here, we’ve put our
international experience to use. We’ve
taken a model of care that we’ve seen
working in Spain and put it into action
in the UK. The model shows that by
supporting people to get specialist help
quickly, they can often manage their
condition effectively, improving their
experience and helping them stay in
work. We’re now partnering with the
Leeds Community Healthcare NHS
Trust to create the UK’s first Early
Intervention Clinic for people with
musculoskeletal conditions.
HEALTH&BEHAVIOUR|AFITTERPILL
19
11. ‘By treating people
in their homes and
supporting them to
self-manage where
possible, we can
keep them out of
hospital and help
them stay where
they want to be’ 21
addressing their hepatitis C can be an important step
towards their overall recovery from addiction. As one
former drug user put it, “getting tested and treated
for Hepatitis C can be the first positive thing you’ve
done for yourself in a long time.”
But people who use drugs often find it
difficult to access traditional health services. The two
charities came to us to help them bring information
and testing into the drug service. The initiative we’ve
co-created includes workforce development for drug
service key workers, peer-to-peer education delivered
by former drug users and a buddying scheme to
support people through testing and treatment.
Just four peer educators in Cornwall have reached
236 service users, busting myths around risky
behaviours, testing and treatment. Specialist nurses
based in the drug services will be tracking how many
people decide to get tested and go on to complete
treatment successfully.
Ultimately, the goal is to eliminate hepatitis
C as a public health problem and reduce the burden
of liver diseases on patients and on our hospitals. It’s
ambitious, but achievable. If we can contribute to this
by improving the whole care pathway for people with
hepatitis, we’ll be very proud.
This example also illustrates what can be
achieved when you change the traditional hospital-
dominated model of care. By moving services – in
this case the specialist nurses – into the community
and closer to the patient, we can release capacity
and get better outcomes. By treating people in their
homes and supporting them to self-manage where
possible, we can keep them out of hospital and help
them stay where they want to be.
Here, Government needs to change its
behaviour too. It needs to recognise and invest in
the interventions today that have a future payoff.
Preventable disease, lower disability, avoidable
mortality and lower costs – all of these will ease the
burden on stretched health and care services at a
time of financial pressure. It’s easy to talk the talk,
but the Government needs to walk the walk.
At AbbVie, we believe we can make
medicines work better for patients, services work
better for the NHS, and investments in health and
The aim is to cut the many weeks people
signed off work can wait for a specialist appointment
to just five days. Six clinics over three sites will
serve a population of 750,000. Over the next year
we will track the clinics’ impact on improving
people’s health, experience of care and ability to
work. Estimates suggest that, if the scaled-up model
works for the UK, we could reduce temporary work
disability by 25% – the equivalent of having nearly
40,000 additional workers available for work each
day. We’ll also have a proof of concept that may be
transferable across different locations, populations
and disease areas.
We believe that a true partnership
between patients and professionals can transform
outcomes and experience. “Doctor knows best”
may have satisfied the patients of yesterday, but
it’s not going to cut it today. As a group of experts
brought together by AbbVie to examine healthcare
sustainability wrote: “individuals will be able to
make a transition from being a passive recipient of
advice and treatment to increasingly directing their
own care [in a sustainable system].”
Yet, when we reviewed the tools available to
support shared decision-making, we found that not a
single one mentioned work. We’re now working with
a team at the University of Cardiff to close that gap.
The team is developing a shared-decision making tool
that specifically supports better conversations around
work – whatever the individual’s long-term condition.
We’ve helped the Cardiff team find testing sites for
the tool to be piloted in hospital out-patient clinics
and in general practice.
With shared decision-making and a
supported self management approach, we can also
unlock the potential of individuals to change their
own lives.
One of the most inspiring examples I’ve
seen is through the initiative we’ve set up with The
Hepatitis C Trust and Addaction in the South West,
working with people who use intravenous drugs.
Around half of people who use intravenous drugs
are thought to have hepatitis C, putting them at
increased risk of liver cirrhosis and liver cancers.
With the right treatment hepatitis C is curable, and
HEALTH&BEHAVIOUR|AFITTERPILL
care work better for society. We’re committed to
playing our part to meeting the tough challenges
and choices that we face.
It will take all of us – patients,
the public, professionals, national and local
government, industry. We’ll all need to change our
behaviour, think creatively, work in partnership.
It will take time. But if we start today, we’ll have a
healthier tomorrow.
12. How Health Insurance Can Ensure
Healthier Living
By Derek Yach | Chief Health Officer, Vitality
Vital Signs
Derek Yach has focused his career on advancing global health. He is the Chief
Health Officer of Vitality, and leads the Vitality Institute. The organisation
offers health and life insurance and is one of the first of its kind that rewards its
customers for choosing healthier lifestyles. Here, Derek shares his perspective on
how companies are able to pursue profit but in a way that is beneficial to society
as a whole.
and making healthy choices the easy choice. They
were filling a gap in what was then a widespread
failure to apply the work of Nobel Prize winning
behavioural economists like Daniel Kahneman and
Robert Shiller to public health issues.
Kahneman focused on the critical insight
that we are imperfect in how we make decisions, in
the sense that the short-term often dominates our
thinking and actions at the cost of our long-term
health and wealth. We act irrationally in terms of
daily behaviors. Other thinkers, like Robert Thaler
and Cas Sunstein, suggested that it might be possible
to “nudge” rather than force consumers towards
behaving in their own best long term interests.
Vitality is an insurance and finance
company, and they set out, well before I joined, to
answer a complex question: How do we persuade
people to do more exercise if they would rather lie
in bed, avoid sugary sweets when presented with
appetising treats, or go to the doctor even if they
don’t really feel like it?
My early career in public health in South Africa
was traditional. It focused on surveillance and the
use of government regulations and taxes, marketing
bans and advertising controls on harmful products
like tobacco. I took this view to the World Health
Organization (WHO), where for a decade I worked
on government-led approaches to addressing tobacco
use, unhealthy food consumptions, and a lack of
physical activity.
When I moved to the United States (US),
however, and went to work for PepsiCo, I observed
that in the private sector there was a far greater
intensity of interest in understanding what determined
consumption behaviour. What do consumers love
and dislike? What really mattered to them and drove
them in their daily life? It was clear to me that if
you understood this, you stood a far better chance of
guiding people towards healthier lives.
So it made sense to join Vitality (part of
Discovery Holdings) who were pioneering the notion
and excitement around incentivising better health
Vitality realised that it would be in their
interest as a company to have a positive impact on the
health of their clients, because as a health insurer
there would be lower healthcare payouts, and as a life
insurer they would get more premiums. Consumers
would also benefit, from longer and healthier lives.
At the start, they put in place a range of
rewards, including dramatic discounts at the gym,
intended to overcome the natural bias towards the
short-term. The results surprised even the programme
advocates, as hospitalisation rates fell and customers
became less likely to succumb to common diseases.
These results, which have been clinically proven,
have now been replicated in the US as well.
The longer clients stay with Vitality,
it turns out, the more substantial the decline in
their risks for heart disease and diabetes, and the
steeper the decline in healthcare costs due to such
conditions. Not that this is necessarily enough
to persuade people to stay with the programme
– which is why it has built-in safeguards against
backsliding. People don’t like losing rewards which
they have already unlocked, and will take actions
that improve their health to safeguard seemingly
unrelated rewards!
The programme has expanded
to allow for people who dislike going to
the gym, so we can track their activity
on a range of wearables devices like the
iPhone. People receive rewards based
on how much exercise they are doing,
regardless of whether they are walking
the dog or jogging to work.
The exponential expansion
of personal health technology opens up
whole new areas for health promotion.
For example, around 50% of people
over the age of 50 are on one or more
chronic disease medication, but in many
populations, only around 30% of those
people are taking it regularly. Using the
right technology in the right way can
boost that to 80%, a vast difference that 23
HEALTH&BEHAVIOUR|VITALSIGNS
13. freuds Case Study;
Sky Ride
In May 2010, Sky launched Sky Ride; a
series of 12 free, mass participation cycling
events in 10 cities across the UK. Participants
were offered the unique opportunity to cycle
around their city on traffic-free streets and
celebrity ambassadors, including Kelly Brook
and Sir Chris Hoy, took part to help promote
the events.
From Great Britain's success in the
Beijing Olympics in 2008, cycling had a new
fan base. Sky saw an opportunity to tap into
this cultural zeitgeist in order to highlight
the benefits of cycling to those that were not
engaged in the sport at an elite level. In order
to achieve this, freuds looked at different
consumer groups and created platforms that
would talk to them through a cycling lens
including fashion, music and lifestyle.
In year one, over 200,000 people
participated. freuds also managed consumer
communications around Sky Ride for the
successive 2011, 2012 and 2013 campaigns,
managing media relations and consumer
engagement at multiple locations across the UK,
with a total reach of 1.1bn people. Sky’s aim was
to get 1 million more people cycling by 2015 and
this was achieved by 2013.
‘This is not about
Big Brother
watching them,
but Big Sister
helping them’
will have real impact on death and hospitalisation
rates for diseases like strokes and diabetes.
New technologies bring new challenges.
Privacy is one. Individuals and society will need to
balance the benefits of data sharing with the need for
protecting people’s personal space. We have worked
proactively with technology companies, leading
privacy advocates, national regulators, and health
groups to develop guidelines to ensure the highest
privacy standards are built into our programs.
The future direction is clear – consumers need to
be aware of the bargain they are making at each
stage of the data transfer process, and have the
option to explicitly opt in or out of that transaction.
Ultimately, it is up to us all to convince people that
this is not about Big Brother watching them, but
Big Sister helping them.
Our company’s profitability depends upon
our clients living longer and healthier lives. We call
our model “shared value insurance”. We are not
alone in developing business models that work for
business and society.
One example is CVS, the pharmacy chain in the
US. Last year, they announced they were taking all
tobacco items out of their stores. The result was a
short-term profitability hit, and a massive long-
term profitability gain. They renamed themselves
as CVS Health, in line with their new direction.
Another example is Tesco, who I work with in the
UK. They took sweets and chocolate away from
the immediate area around checkouts. This has
had a positive business impact, mainly because of
the indirect effect of sending messages to mothers
that they no longer need to worry about “pester
power” if they shop at Tesco. So that has led to
them asking what else they can do to advance
health! Leading food companies are going through
a similar process.
After many years of struggle we now see
that the financially healthiest part of Unilever,
PepsiCo, and many other food companies’ portfolios
is increasingly the healthiest products, with less
sugar, less saturated fat, and less processing. I see
the simple principle of advancing health through
better aligned business models having a critical
impact on tackling the major threats to health we
face today.
This is not just about finding easy ways
for companies to change. Furthermore, there
should not be any no-go areas when it comes to
public health, so we should be talking to alcohol
companies who are starting to think about the long
health, they will see more and more
opportunities for profit which are also
good for society. To accelerate this, we
need to move away from a traditional
view of health as the province of the
pharmaceutical industry or the medical
profession, and to understand that the
future will see firms in technology
and other sectors helping individual
consumers get healthier and being
rewarded for doing so. They are effective
because they understand consumers and
realise that government regulation does
not change behaviour. That requires a
far more subtle process of nudges and
incentives which private companies are
often better placed to provide than the
state. The future of health is not solely
in the hands of civil servants, but with
individual consumers and those who
provide for all of their needs.
term profitability of low alcohol products including
zero alcohol beers.
Even the tobacco industry is no longer the
clear-cut case that it was when I campaigned against
cigarette firms in my youth. In many nations, public
health professionals have taken a very hard line
on e-cigarettes and I think that is wrong for two
reasons. First, because it seems clear to me that
any means of ingesting nicotine without the tar
content of a cigarette could have major public health
benefits. Second, because if the tobacco companies
were encouraged to invest more in this area, that
would accelerate the decline of traditional smoking.
Philip Morris has already stated quite explicitly
that in a decade, the majority of their products will
be reduced risk. There are difficult issues here, but
nearly anything which brings down the death rate is
worth trying.
Overall, I believe that when major
corporations and corporate interests start looking at
their product portfolio through the lens of public
25
HEALTH&BEHAVIOUR|VITALSIGNS
15. Chewing Gum: No Longer A Sticking
Point For Better Oral Healthcare
Martin Radvan is the President of Wrigley, a subsidiary of Mars, Incorporated.
As a recognised leader in confectionary, Wrigley has been involved in the
improvement of global dental care by promoting the benefits of chewing sugar-
free gum. Radvan believes Wrigley has a considerable role to play in educating
consumers, dental health professionals and policy makers on the health benefits
of chewing.
The consumer preference ‘why’ is simple to
understand – the flavor of sugar-free gum lasts much
longer. In short, it tastes better. That’s because in gum
it’s the sweetener that plays a big role in delivering
the flavor - when you think the flavor has gone it’s
actually the sweetener that has gone. So gum is one of
the few food categories where we can actually improve
product performance by taking sugar out.
Sugar-free gum is also very low calorie, but
the big bonus comes from what it does for your teeth.
Chewing gum stimulates the production of saliva –
and saliva is the body’s natural way of looking after
teeth and the mouth in general.
It’s simple science. When you eat food,
plaque acids form on your teeth and the acidity
in your mouth rises, damaging the teeth. Saliva
neutralizes these acids, reducing the damage done. It
also promotes the remineralisation of tooth enamel
and reduces ‘dry mouth’. In a nutshell - chewing
sugar-free gum after eating protects your teeth.
For Wrigley, our interest in getting more
people chewing more sugar-free gum isn’t just about
driving our sales. Poor dental care is a huge issue for
society: the World Health Organisation estimates that
nearly 100 per cent of adults and 60-90 per cent of
children have cavities globally. In the UK, the latest
NHS data shows that dental problems are now the
fourth most common reason that young people under
17 are admitted to hospital.
Wrigley has focused for some time on
promoting the individual benefits of chewing sugar-
Chewing gum has always been much more than
simply a fun confection. Women in classical Greece
chewed mastic gum to clean their teeth and sweeten
their breath. Early settlers in America were taught
by Native Americans to use gum from spruce trees to
quench their thirst.
During the 20th century, of course, gum
came to be seen as primarily about fun and fresh
breath. But in recent years, inherent and deeper
benefits of chewing gum have, once again, come to
the fore with widening recognition of the positive
difference it has on oral care. As a consequence,
at Wrigley we increasingly spend our time working
with dental professionals and public health experts
worldwide – because more people chewing more
gum will lead to better oral health and reduced
healthcare costs.
The beginnings of this breakthrough can
be traced to our continual search for better gum for
consumers. Older readers might recall the 1950s hit
for Lonnie Donnigan ‘Does your chewing gum lose
its flavor on the bedpost overnight?’ Well it wasn’t
just something he sang about. Indeed, for most of
our history, the search for longer lasting and better
flavored gum has been central to our R&D efforts
and that’s where sugar-free gum came in.
We launched EXTRA™ sugar-free gum
in the US in 1984, and now sugar-free gum is
available around the globe. It’s usually the gum that
consumers prefer and it accounts for over 80% of
global gum sales – indeed much more in the UK.
free gum, but recently we have also turned our
attention to the broader public health benefits. There
is now good research that is beginning to quantify the
impact that this can have on individual dental health
as well as health care costs across a whole population.
We recently commissioned a study that
looked at the impact of taking German consumption
of sugar-free gum to the levels of Finland. In
Finland, the government – and dentists – encourage
the very regular use of sugar-free gum to great effect,
with 202 pieces being chewed per person per year.
In Germany, by contrast, per capita consumption is
at 111. The research showed that if Germans chewed
like the Finns, not only would national health care
costs be 313 million euros lower per year, but over
a lifetime the average person would also have seven
more cavity-free teeth. Another study looking at the
UK has concluded that if every 12-year-old chewed
three times a day, there would be an estimated
annual saving of £8.1-8.4 million to the NHS.
As the world’s largest gum company there is
a clear convergence of our commercial interest with
that of public health. We want more people to chew
more gum – and that’s in the health interest of the
population as a whole.
Now we are not trying to say we are
an oral care company – and so don’t expect us to
launch Wrigley toothbrushes any time soon. But
we do believe we have a role to play in educating
consumers, dental health professionals and policy
makers on the health benefits of chewing.
The health benefits of chewing are
increasingly recognised in policy making circles. We
have strong support from national and international
dental federations. Several Governments explicitly
support the chewing of gum as part of their national
oral health care plan. At a European level, the body
that regulates health claims for food have supported
eight specific claims for sugar-free gum – and we are
one of the very few categories where health claims
are allowed.
Our understanding of what makes our
consumers tick makes us a valuable partner for
public health initiatives around the world. That’s
why we currently have partnerships with dozens of
dental associations around the world.
We work with these associations to help
them and their members educate patients
on an effective and enjoyable part of
good oral health. We also partner with
them through the Wrigley Company
Foundation to provide better access to
oral health in under-served communities.
One of our big challenges
as a business is chewing gum is an
impulse purchase – it rarely makes it
to the shopping list. That means our
business success is very dependent on
having our product on sale wherever
money (legally) changes hands. So as
checkouts change through technology
and some customers look to restrict
confections at checkout, it becomes even
more important to get across the health
message about gum.
It’s great to work in a business
that not only brings such great pleasure
to billions of consumers but also has
such a positive health contribution. It
is something that really motivates our
Associates. Plus it is a good example of
the principle of Mutuality that is at the
core to how Mars does business.
I believe that at Wrigley we
are demonstrating Mutuality in action –
illustrating how businesses can and must
be a positive, as a well as a profitable, part
of the societies in which they operate.
HEALTH&BEHAVIOUR|GUMCONTROL
29
‘More people
chewing more
gum will lead to
better oral health
and reduced
healthcare costs’
16. ‘Developing
vaccines is
pointless
if they sit
on a shelf,
out of the
reach of
those who
need them’
GSK: Changing its Business Model to
Change the World
By Luc Debruyne | President and General Manager, GSK Vaccines
Needle Work
Luc Debruyne is President and General Manager of Vaccines for GSK – a science-
led global healthcare company – and is based in Belgium. He is currently
a member of the Vaccines CEOs Roundtable convened by the International
Federation of Pharmaceutical Manufacturers Associations (IFPMA). In this article
he stresses the need for pharmaceutical and other health companies to alter their
business models to ensure the long-term sustainability of healthcare provision.
Rapid medical advances have transformed millions
of lives over recent decades. Antibiotics have made
complex surgery possible. Antiretroviral therapies
mean HIV is now a long-term condition with the life
expectancy of many people living with the virus now
approaching that seen in HIV negative people.
One of the most extraordinary changes has been the
way vaccines have transformed public health, turning
the tide against infectious diseases such as polio and
tetanus. With the exception of clean drinking water,
no intervention has rivalled vaccination in its ability
to save lives.
Despite all the achievements of recent
years, the World Health Organization estimates that
nearly 19 million infants worldwide are still not
being reached by routine immunisation. Even very
close to home here in Europe, the last 12 months
have seen outbreaks of infectious, vaccine-preventable
diseases like measles and diphtheria with devastating
consequences. While we have made great progress,
clearly we need to do more to make sure the tools we
have in hand today help prevent these diseases are
available to all those that need them.
At the same time as overcoming the
obstacles preventing wider uptake of vaccination,
equally pressing is the need to find new vaccines
for diseases such as RSV – a respiratory virus which
largely affects children and is not currently vaccine-
preventable – as well as emerging threats like MERS
and the still elusive HIV vaccine.
In such constantly evolving circumstances,
it’s clear we all need to step up and evaluate our ways
of working in order to continue to make advances in
public health. In this process, we’ve had to challenge
ourselves as a business. How can we change our
behaviour to ensure we continue to play our role
in developing and providing quality
medicines and vaccines that meet public
health needs and, at the same time,
perform financially?
For a healthcare business
like GSK, this demands invention both
inside and outside our laboratories. This
can be hard in the risk-averse corporate
world where you may have thousands of
employees to convince as well as the board.
But over a number of years at GSK, we
have been radically changing our business
model in three key ways – through
innovation, collaboration and access.
Getting a new medicine or
vaccine from bench to patient can take
many years, not to mention millions of
pounds of investment that may never
be realised – it is a fine line between
success and failure. Cracking these
challenges requires a different approach
to research and development. So now
our scientists work in smaller groups
dedicated to particular disease areas or
therapies. These units are more focused,
nimble and entrepreneurial.
HEALTH&BEHAVIOUR|NEEDLEWORK
31
17. 33
developing countries which include least developed,
low and middle income countries.
Underpinning innovation, access and
collaboration are other important behaviour changes.
Transparency with clinical trial data is one example.
We know this resource is incredibly valuable to the
scientific community to learn about what research
has and hasn’t worked. So we post summaries of all
our clinical trial results, whether positive or negative,
on our website for anyone to see and we have
committed to seek publication of all of our clinical
studies in peer-reviewed journals.
More recently, we have embarked on a
journey to reform and modernise how we sell and
market our products to health care professionals,
phasing out payments to doctors to speak on our
behalf about our products. Instead of individual sales
targets, our sales people are increasingly evaluated
and rewarded for their technical knowledge and
quality of service. These new approaches will improve
how we provide information to doctors and will make
us more transparent.
None of this is easy. Big bold changes
take time and demand each and every individual
plays their part. Businesses are made up of the
people who work for them; one of the hardest yet
most important actions a company can take is to
embed change by instilling the right culture and
processes to help employees understand that “how”
you do things can be as important as “what” you do.
As individuals and as an organisation, we are still
working to achieve this.
It is a challenge worth taking on. In a
setting where it may seem like change is the only
constant, we need to keep open the dialogue on new
ways of working. Innovation, collaboration and access
are the bedrock on which we can respond in the right
way to a shifting environment – and ultimately do
better in a sustainable way for patients, shareholders
and society.
Nobody has a monopoly on science or
great ideas. So we are also innovating through
collaboration – thinking hard about how we can
best combine the considerable skills, expertise and
resources of GSK with the complementary qualities
of different organisations to help tackle some of the
biggest global health issues. By creating networks
across academia, industry, government and civil
society, we can bring together the best minds and
share expertise, which stimulates innovation.
Malaria is a case in point – it is a
particularly tough challenge because the parasite
is clever enough to evade human immune system
responses. This year, we achieved a significant
milestone for our malaria vaccine candidate, designed
for young children in Africa. It is the first in the
world to receive a positive scientific opinion from
European regulators. Getting to this point has taken
30 years and scientists from Washington to Malawi.
Only by working with partners from other countries
and sectors, could we together shoulder the scientific
and economic risk of developing such a vaccine.
The experience gained from malaria is
now lending itself to other vaccines, for example
opening the way for vaccines against other
infections that affect older people or those with
weakened immune responses.
Developing vaccines like this is pointless if
they sit on a shelf, out of reach for those who need
them. So we have tried to be more innovative in our
approach to access – flexing our business model and
working with others to help keep vaccines affordable.
In GSK’s vaccines division, we use tiered
pricing which asks countries, at each step of their
development journey, to pay a fair price which
reflects their particular circumstances and the return
on investment that they receive from vaccination.
This is designed to support those countries which
commit to vaccination for the long-term. We also
work with Gavi, the Vaccines Alliance, and Unicef,
who can purchase large volumes of vaccines at our
lowest prices for children in the poorest countries.
Our approach has been successful in
broadening access. Of the 800 million doses of
GSK vaccines distributed in 2014, over 80% went to
HEALTH&BEHAVIOUR|NEEDLEWORK
‘Our approach has
been successful
in broadening
access. Of the
800 million doses
of GSK vaccines
distributed
in 2014, over
80% went to
developing
countries’
18. HEALTH&BEHAVIOUR|INASTATE
35
Fear of Nanny Could Make the NHS
Unsustainable
By Sir Liam Donaldson | former Chief Medical Officer for England
In A State
Sir Liam Donaldson is recognised as a global leader in patient safety and public
health. He is currently Associate Fellow in the Centre on Global Health Security at
Chatham House and Chancellor of Newcastle University. From 1998 to 2010 he was
the Chief Medical Officer for England. In this role, Sir Liam was the chief advisor
to the UK Government on health matters and was one of the most senior figures
in the National Health Service. In the following article, Sir Liam discusses the
importance of political leadership in improving public health.
the North of Ireland. As my colleague was parking
the car, he heard the six-year old on the back seat
whisper to his brother: “If Daddy gives you a burger,
don’t eat it; they’ve got the Mad Cow up here.”
The BSE crisis quickly became a scandal
as the public lost confidence in the health advice
coming from government. Trust between the citizen
and their elected representatives lay in tatters.
Deference was not quite dead but there would
certainly be no going back to the uncritical public
acceptance of bland reassurances. BSE cast a long
shadow over modern public health and certainly
fuelled mistrust in Government when the next crisis
- loss of confidence in the Measles, Mumps and
Rubella (MMR) vaccine - came along. I found this to
my cost in managing the fall-out as the Government’s
Chief Medical Officer.
What did the public think was the role
of government? It was pretty obvious that people
expected it to protect them against risks to their
The biggest public health crisis of the last 30 years
involved Bovine Spongiform Encephalopathy (BSE),
a fatal disease of cattle whose soubriquet “Mad Cow
Disease” gave it a lurid escape from dry scientific
terminology into everyday parlance. With the
dramatic discovery in 1996, that it could transmit
to people as new variant Creutzfeldt-Jakob disease
(nvCJD), the term “Human form of Mad Cow
Disease” was born.
Public concern and awareness of the
disease spread more rapidly than the disease itself.
This was fuelled by the knowledge that it was
incurable, by the idea that seemingly any meat eater
could catch it, and by the distressing, grainy image
of an afflicted cow staggering to keep its foothold.
This image accompanied virtually every news report,
and there were many. I remember a colleague who
lived in Dublin at the time telling me about taking
his two young sons, aged six and four years, for a day
out. They drove to a beauty spot across the border in
health. They became particularly angry if there
was any hint of a cover-up and they didn’t like it if
the government seemed to be placing the interests
of industry ahead of the public’s health. This was
long before social media were developed. Surely,
there would have been complete meltdown in public
confidence if BSE had happened today.
Moving into the 21st century, after
the BSE experience, the (largely unwritten)
rules for handling a putative health risk seemed
straightforward. Be completely open about what is
known. Never, ever cover up. Be prepared to say
the words that were taboo in the 20th century: “We
don’t know.” Rather than waiting to see whether
people were harmed, adopt the “precautionary
principle”, and take action to mitigate a hypothetical
risk. Don’t get cosy with industry.
Governments now seem to accept their
responsibility to protect the public against threats like
pandemic flu and SARS. They certainly gave me full
support, as Chief Medical Officer, in the planning
and action necessary in mitigating their risks. They
wavered when I insisted that they should keep the
beef-on-the-bone ban in place for a bit longer. I
pointed out that the public enquiry had said that the
infective dose for people was an amount of tissue “the
size of a peppercorn.” It surprised me, after all that
had happened with BSE, how quickly pragmatism
flooded in to replace the precautionary approach to
this residual risk, but then politicians do not like
media ridicule, and that was what was beginning
to happen. Their idea was now to give people an
informed choice, as to whether to eat a T-bone steak.
Helping the public to avoid the risks of
modern living is contentious and is not usually
seen through the lens of “protection.” It is an area
governed by a different frame of reference and
polarises opinion between those who see solutions
through strong state and regulatory action and
those who believe only in providing information
and inviting people to make their own choices
and decisions. This does not always split down
right-left political lines. The problem with the
second approach is that whilst it is ideologically
comfortable it brings about change very slowly
and usually only benefits the health
conscious and risk-averse middle classes;
people in disadvantaged communities are
constrained by their circumstances from
making healthy choices.
During my time as Chief
Medical Officer I made a range of
recommendations to government but two
were dismissed out of hand. One was
eventually introduced. The other is still
in the long grass. When I proposed that
England should have smoke-free enclosed
public spaces and workplaces, the media
were briefed that it would never happen.
When I proposed, in my final annual
report, that there should be a minimum
price for a unit of alcohol, not only was
my report leaked (the first time ever that
this happened), the government got its
rejection in first. The same government
was wedded to “evidence-based
policy-making.” Both proposals were
underpinned by evidence.
So what was the problem about
taking a Chief Medical Officer’s carefully
considered advice? And what happened
to the government’s role in protecting
the public, especially children? The
answer turns on two primal political
forces: firstly, the politician’s mortal
dread of being labelled a member of
the Nanny State; secondly, a fear of
removing people’s perceived pleasures,
especially those of the poor, ironically,
in this case, the group that suffers most
harm from the risk factors at the centre
of the controversy.
Such polling of public attitudes
as has been undertaken suggests that
the population quite approves of strong
action to protect the public health.
Certainly, in building to the position
where Parliament passed smoke-free
legislation, large-scale engagement of the
public by my regional directors of public
19. HEALTH&BEHAVIOUR|INASTATE
37
health, together with strong advocacy by
Action on Smoking and Health (ASH)
and major professional bodies, meant
that public opinion eventually led the
politicians, not vice versa. Not so with
minimum pricing on alcohol, a sensible
policy that would hit heavy drinkers and
children who drink dirt-cheap cider and
lager just to get drunk, and not moderate
drinkers. Three governments have rejected
it. Good scientific modeling work by
researchers at the University of Sheffield
has consistently pointed to the benefits.
It will not on its own solve the medical,
social and economic damage caused by
excessive alcohol intake but it will make
an impact on what is an intractable and
worsening problem. Most public health
problems need a range of interventions
but action on price and access are usually
the most powerful. This is an evidence-
based policy that is seen as politically
toxic. Progress on one of the biggest
health and social problems of modern
times is denied. The need for more livers
for transplantation is only one costly
consequence of such a situation.
Historically, Britain has been a
pioneer in public health policy-making.
The great sanitary reformers of the
Victorian era waged war against filth and
disease and their victory left a legacy to
all of us: the 20th century’s low child
mortality and greater longevity. Almost a
century earlier, Edward Jenner, a country
physician practising in Gloucestershire,
made a discovery that effectively invented
vaccination. There can be few individuals
who have a stronger claim to have made
the greatest contribution to the health
of Humankind. His statue was removed
from Trafalgar Square because he did not
fit in with the military heroes. Richard
Doll and Austin Bradford Hill uncovered
the link between smoking and lung
20. ‘Our forefathers
encountered
controversy in making
public health policy
but they were bold
and showed courage.
Today’s health policy-
making too often with
the question: ‘Who
will we upset?’’
task. Yet, the fundamental challenge for every
government is how to create a sustainable health
care system: one that provides safe, high quality care
to everyone without running out of money. The
National Health Service in Britain is in the same
boat. There is no simple answer to preserving what
is still a national treasure, celebrated in the Olympic
opening ceremony. One inescapable need, though, is
to change the pattern of disease. Delaying the onset
of chronic disease, extending years of healthy life,
and promoting behaviours that preserve health rather
than initiating disease would be a giant step forward
to achieving a sustainable NHS.
The management guru Jim Collins spoke
of the galvanising effect of BHAGs - Big Hairy
Audacious Goals. In my role as Chairman of the
independent board that monitors the global polio
eradication programme, I have seen how pursuing a
clear, common cause unites people and inspires them.
The commitment is deeply impressive and people
have lost their lives going into the most dangerous
parts of the world to give the precious drops of
vaccine to prevent children becoming paralysed and
dying. Health matters to people in the poorest parts
of the world. In India, 300 million children are
vaccinated three times a year. Yet, in Britain, services
cannot organize themselves to eliminate measles.
Today, the public in Britain needs to see
inspirational leadership and the big health challenges
being addressed. It also needs a government willing
to act with boldness and imagination that unites
everyone to achieve an audacious goal. Why couldn’t
we become the healthiest country in the world?
Politicians’ fear of being branded as the Nanny State
currently makes this impossible. It makes Britain
a limping also-ran in the race to be the best. Given
the failure to reduce the rising tide of chronic
disease that is placing great pressure on our health
care system, fear of Nanny may mean that the NHS
becomes unsustainabl
cancer, and began the long march towards a tobacco-
free world. Today, Britain is no longer a public
health leader.
The government of the day faced with
epidemics of obesity, diabetes, heart disease and
cancer recently rejected a sensible measure to
promote health: the so-called sugar tax. Our
forefathers encountered controversy in making public
health policy but they were bold and showed courage.
Today’s health policy-making too often starts with the
question: “Who will we upset?” followed by adoption
of the first of the possible actions that appear in every
civil service briefing - “The do-nothing option.” Fear
of Nanny runs deep.
There are moments when strong state
action can be more acceptable. For example, when
someone’s choice affects someone else. The harm of
passive smoking was the powerful argument for the
smoke-free legislation. Similarly, when someone is
not able to make a choice for themself – particularly
children – all political viewpoints tend to be happier
with regulation.
To tackle obesity, where the third party
effects are harder to see and the individual is easy
to blame, the risk of the Nanny label is high. The
argument of strong measures to protect children may
be the easiest place to start. Here, public attitudes are
starting to change. Public awareness of the societal
burden of obesity related illness is growing. It is
becoming less publicly acceptable to offer a can of a
sugar sweetened fizzy drink to a child. Jamie Oliver’s
restaurant chain is starting to tax sugary drinks.
Public health leaders and politicians need to use
these changing societal views to their advantage. We
may not be able to immediately replicate the brave
action of countries like Mexico – with their national
soda tax – but we need to be getting closer.
The last couple of years have seen
the world’s political leaders, in the throes of an
unprecedented and very serious outbreak of Ebola
virus, majoring on so-called global health security.
A great deal of resource has been allocated to the
task of learning from Ebola and on understanding
how to strengthen health care systems against the
potential threats of the future. This is an essential
HEALTH&BEHAVIOUR|INASTATE
39
21. By Sheila Mitchell |
Director of Marketing, Public Health England
What PHE has Learnt to Help Kick
the Habit
Having joined Public Health England as Director of Marketing in 2013, Sheila
Mitchell has been heavily involved in a series of mass public health awareness
campaigns. She discusses PHE’s learnings from the past two years and how
communications can prove most effective in altering behaviour.We’ve
Cut
Down
41
HEALTH&BEHAVIOUR|WEGIVEUP
“We need to do more. We need more investment
so that we can do X as well as Y”. The general
assumption is always that progress comes
from doing more things. People diversify their
activities; scope always creeps. There was even a
company called “New Zealand Towel Services”
which, after a period of diversification, adopted
the advertising slogan “We offer so much more
than just towels.”
But in fact progress more often comes
when you stop doing things. When you get rid
of lazy assumptions; when you break bad habits;
when you focus on the things which nobody else
can do as well as you can.
If you want to become a better runner,
it is more important to lose bad habits than
it is to acquire new skills. Deciding what not
to do is often the most important decision you
make in life. AOL began by offering dial-up
Internet access, a portal and proprietary content
and a search function; Yahoo came along and
didn’t bother with offering Internet access - it
just offered content and search. Then Google
supplanted it - with just search.
In the same way, progress in public
health can proceed not just by attempting
to do more, but by deliberately doing less:
focussing on the interventions, leverage
points and behaviours where you can really
make a difference, and stopping the kind of
activities which can be ineffective or give rise
to unintended consequences. What follows is a
list of things which we have stopped doing and
assumptions we have stopped making: these
changes have been made in the light of rigorous
testing and evaluation and have been informed
by the significant advances in the understanding
of psychology and behaviour which have been
made in the last 20 years.
Less nanny, more waiter.
Telling people what to do is often
counterproductive. It may even reinforce some
people’s determination to continue with the
condemned behaviour. By contrast, oblique
approaches, or presenting people with a scalable
menu of manageable and sustainable choices
make it far harder for people to do nothing.
“Still or Sparkling?” often sells more water than
“You should drink more water.” If the choices
are Easy, Attractive, Social and Timely, even
better.
Less assumption,
more evidence.
Many people who work in public health (and
medicine, and academia) lead pretty healthy
lives and can be perplexed as to why others
don’t do the same. Well-educated people tend to
consider long term rewards and consequences
(after all, they spent seven years in medical
school); so to them, the idea that smoking or
drinking or poor diet could give you cancer, or
heart disease or diabetes thirty years from now
is a no-brainer: it’s not worth the risk. We are
often subject to very strident pleas to lecture
22. It acknowledges the path dependence in changing
human behaviour. And, as a result, it also forces us
to stop focussing on “perfect” to the exclusion of the
“pretty good”. If people shift from cola to diet cola,
that may not be perfect, but it is better. Similarly
if people switch from cigarettes to e-cigarettes, they
reduce the harm. One problem with approaches
which emphasised the “perfect” was that they seemed
completely unrealistic and unattainable (and hence
irrelevant) to the highest-risk groups. If you weigh 19
stone, images of jogging are not an encouragement -
they may be an active disincentive. Similarly asking
people with a litre-a-day carbonated drinks habit to
change from cola to water: well, nice idea, but it isn’t
going to happen. The biggest gains come not from
getting someone who jogs to take up circuit training,
but from getting someone who takes no exercise to
take some - even if just five 30 minute bursts per
week. Most of all, we have abandoned the assumption
that people are possessed with limitless willpower,
and are incapable of self-deception.
We’ve abandoned
vague prescriptions - such as
“eat more healthily”, “lose
weight” or “take more
exercise”.
We have instead replaced these vague perscriptions
with specific actions that really matter. More
importantly, we have tried to make these targets
“binary” rather than “quantitative”. If a rule is
specific it is more likely for us to follow it than if it
is a question of degree - people feel more conscious
of rule breaking when there is a specific prohibition
(running a red traffic light) than when there is a
numerical limit (breaking the speed limit). Hence we
are willing to entertain the idea that a short period of
total abstinence from alcohol, as in Dry January, may
be an easier regimen to follow than counting daily
units. Almost every society in the world has periods
of feasting and periods of abstinence: this insight
acknowledges that human psychology seems to be
better suited to variety than to regularity - and second-
order variety may even be better for human health.
the public about health harms – ‘just get them to
see the world like we do and they will change their
behaviour’ runs the assumption. The trouble is,
behaviour doesn’t work like that. Many of the people
we serve have very short horizons. If you’re worried
about how you’re going to pay your rent at the end of
the month, that’s where your focus is: not on thirty
years hence. We recently completed an evidence
review on the role of ‘health harms’ communication
in behaviour change and what emerges is a mixed
picture. Sometimes, as in smoking, fear of future
illness can act as a spur to change your lifestyle;
sometimes, as in obesity it doesn’t. So despite calls to
shame the obese into changing their behaviour, we
won’t be doing that.
We’ve stopped
assuming that behavioural
change must always be
preceded by attitudinal
change.
Recent advances in psychology suggest that the
process often, perhaps more commonly, operates
in reverse. People form opinions to be congruent
with their behaviours, rather than the other way
round. Hence an emphasis on “awareness” or
“consciousness raising” has given way to more focus
on choice architecture, interface design or multi-stage
behavioural change, where people are encouraged to
make small, incremental changes to their behaviour
rather than focussing exclusively on attempts to
change attitudes. In many cases, even a small change
in behaviour can be a decisive first step from which
further beneficial changes follow. Change4Life’s
ten-minute shake up is a perfect example of a specific
behavioural aim. This campaign from Change4Life
and Disney breaks down the recommended 60
minutes of moderate-vigorous physical activity needed
by children into manageable 10-minute bursts.
A step-by-step approach
(chunking) is important.
43
HEALTH&BEHAVIOUR|WEGIVEUP
of what we’ve achieved in the past year.
But, as we go into 2016, I’m hopeful
that, by doing less, we will be able to
achieve even more.
We’ve also abandoned the idea
that social factors don’t
matter.
If many of your friends smoke, it is simply much
harder to quit if you try to go it alone. Therefore far
more focus is on creating collective, synchronous
actions (such as ‘Stoptober’, where smokers are
encouraged to quit for the duration of October) than
relying on individual willpower. Group actions are
more likely to stick. New year’s resolutions work
better if people declare them to one another as a
mark of commitment.
We’ve stopped trying to do
everything alone.
If a partnership under a different brand such
as Change4Life is a better vehicle for changing
behaviour, then why not work in concert with other
organisations, like Disney, rather than acting alone.
Finally, we’ve stopped
pretending that social
marketing will work for every
problem or every person.
Health inequality is a gradient, and you do more
to reduce it by improving the lives of the 46%
of the population classified as C2DE than by
focusing relentlessly on the most disadvantaged
decile. We have evidence that our programmes
disproportionately engage people with lower
incomes, less education and unhealthier lifestyles,
but we also know that for some people in extreme
circumstances, a marketing-led intervention isn’t
going to do it. We’re currently putting the final
touches to a digital support product, designed for
and tested with C2DE adults, to help them change
behaviours like smoking, drinking, diet and activity.
But we also don’t forget that one in ten of the UK
population has still never accessed the Internet, four
in ten has not downloaded an app. So there is still
a role for local, face-to-face, services and intensive
interventions to support these people. I’m proud
freuds Case Study;
Public Health
England
Public Health England (PHE) was formed
in April 2013 to protect and improve
the nation’s health and wellbeing and
reduce health inequalities. freuds has
been working with PHE, and previously
the Department of Health since 2008,
delivering high profile behaviour change
programmes that make it easier for
mums, dads, daughters and sons to make
positive changes to their health. From
the creation of national movements such
as Change4Life, Stoptober and Dementia
Friends, to the ongoing public education
for a variety of cancers and diseases under
the Be Clear on Cancer umbrella, all
campaigns are evidence-based. They use
behavioural science, commercial best
practice, digital tools and popular culture to
engage hundreds of thousands of people on
a journey to better health.
24. Obesity is an
acknowledged
problem
62%
of England’s
adults are
overweight
or obese¹
1. Health survey for England: 2013
2. freuds focus: freuds conducted
a nationally representative poll
of 2,000 people. The survey was
hosted by Bilendi in August 2014
79%
acknowledge
that there is an
obesity crisis²
47
HEALTH&BEHAVIOUR|VITALSTATISTICS
25. 49
HEALTH&BEHAVIOUR|VITALSTATISTICS
But who should tackle
the obesity crisis?
54% blame
advertisers for
influencing the
unhealthy food
choices we make
42% blame
the influence
of food
companies
33%
blame
ineffective
education
in schools
Blame for UK obesity levels is placed
at many doors:
freuds focus
23% think
government
comms
and health
policy are
to blame
23% say it’s
a matter for
parents or
individuals
20% blame
GPs for
not being
proactive
enough
26. 51
HEALTH&BEHAVIOUR|VITALSTATISTICS
It’s an emotional, not rational issue and
changing habits isn’t always easy:
74% say bad habits
are hard to break
7% say there are no
barriers to reducing
obesity levels in the UK
So what is
preventing
individuals
taking action?
freuds focus
27. 53
HEALTH&BEHAVIOUR|VITALSTATISTICS
Many parents don’t want to
acknowledge, or recognise
the problem:
While medical assessments
placed the number of
overweight children in
the group at 369, only 4
parents thought their child
was very overweight¹
1. Black, Park, Gregson et al. Child obesity cut-offs as derived from parental perceptions:
cross-sectional questionnaire, British Journal of General Practice
2. freuds focus
34% of mums agree that
they don’t look too closely
at the food they buy and eat
because it’s often better not
to think about it²
In a recent study of 2,976
families in the UK, nearly
a third, 31%, of parents
underestimated the weight
of their child¹
28. 55
HEALTH&BEHAVIOUR|VITALSTATISTICS
Half (46%) are
dissatisfied with
food manufacturers’
efforts to help
consumers with the
UK’s obesity issues¹
73% claim that common
sense based on
ingredients and level of
processing is helpful when
it comes to choosing
which foods to eat¹
89% of us say that eating
healthily is common sense¹1. freuds focus
2. Opinium conducted a nationally representative poll of 2006 UK adults, 30 October to 3
November 2015
81% say their main
concern about sugar is
the levels of sugar hidden
in prepared foods¹
87% think there is
often too much sugar
in foods that seem like
they are healthy¹
There is a lack of confidence in
the industry:
There’s a desire for education to
enable informed personal choice:
78% said that education
would work better and
allow people to make their
own choices²
29. By Ali Parsa | CEO, babylon
Tech
Tonic
A Revolution: How Tech is Transforming
the Future of Healthcare
Just about everything we do to look after ourselves will be revolutionised in
the next ten years, British health entrepreneur Ali Parsa says. He believes the
answers for the UK’s embattled health care system lie just around the corner.
After creating a major healthcare firm, the Tehran-born physicist now believes
the world’s future health literally lies in our own hands. His mobile app, babylon,
promises it can help patients answer medical queries, check symptoms, consult
a doctor, monitor their health and seek referrals from anywhere in the world.
Ali’s pioneering app won the Innovation Prize at the World Extreme Medical
Conference, organised by freuds earlier this year.
HEALTH&BEHAVIOUR|TECHTONIC
57
30. ‘Just about everything we do to look after ourselves
will be revolutionised in the next ten years’
I am a health entrepreneur. Entrepreneurs do things
because they have a vision for fixing a problem.
It’s the stuff of dreams, passion, stubbornness and
essentially being a maverick – that’s what makes
them mortgage their houses. For me, it’s the belief
that we can absolutely solve the problem of access to
healthcare. In fact, healthcare will be unrecognisable
in 10 years, the same way 10 years ago no one
imagined we’d be able to socialise, find information,
restaurants and even date with our smartphones.
Today, when we are sick we must ring up to
book an appointment, wait days in some cases until a
slot is available, take half a day off work and then
queue up in a waiting room which is probably one
of the most infectious places on the planet. More
importantly, what we call healthcare is actually
‘sick care’. We wait until we’re ill then spend a lot
of time and effort trying to get better, meanwhile
50% of the world’s population have almost no
access to healthcare.
One look at your car will tell you why it
needn’t be like this. It has so many sensors now, that
we can intervene before anything goes wrong.
Within just a few years it will be the
same with your own body. Right now, I know my
cholesterol, my temperature, my heart rate, what’s
happening in my liver. I have my medical records
on my phone and I can speak to my doctor from
wherever I am in the world. But in a few years’
time, we will no longer need to prick your finger
to take a test to know what is happening in your
blood stream. We will be able to collect all of your
health information automatically and intervene
when the first warning signs occur. This can have
profound effects. For instance, we lose more people
to suicide in Britain than any act of terrorism or
war. It’s proven that if you are clinically depressed
you’re more likely to suffer a depressive episode if
you’re using your phone more and not leaving the
house. Analysis of phone use and location can flag
these warning signs enabling us to intervene before
anything happens.
You will also be able to analyse your health
in far more detail than we ever thought possible.
We already do something similar today with our
weather forecasts. The Met Office doesn’t have a
scientist studying a map, all the analysis is done with
computer modeling. In the same way, we can analyse
trends and information to predict what’s wrong with
you before you are even ill and then intervene to
keep you healthy.
Only a few years ago, access to information,
music or books was dependent on where you lived
or how rich you were, and today it doesn’t matter
who you are or where you are, everyone has near
equal access to everything that is digital. In the same
way, a very different model and means of delivery
of healthcare is unfolding, and it should make the
future of healthcare significantly better and accessible
to all.
Here are the four major trends that are
melting all that is solid in medicine into air, and
transforming the industry:
Diagnostics
The cost of diagnostics has already fallen by an
incredible 99% in the past decade and is projected to
be near free in the next five years.
Ten years ago, it would have cost over a
million dollars for full physiological and genetic
diagnostics. Today, the same can be done for less
than ten thousand dollars, including full genome
sequencing.
But something even more transformational
is about to take hold: an avalanche of new
applications, mobile devices, bio-sensors, biological
and imaging technologies, wearable and soon
embeddable devices, which are making it possible to
virtually track any of the body’s bio-signals in real
time, and if we wish, transmit them for continuous
analysis.
For the first time in medical history, we
will have the “check engine” capability that we are
accustomed to in our cars but never had for our
bodies, leading to real prevention possibility.
Information
While healthcare has been slow to adopt information
technology, patients have not. Healthcare is now
the third largest web activity across all generations.
Patients are already able to read and watch the
entire world heritage of medical libraries. Ever more
sophisticated symptom checkers are distilling these to
offer diagnosis on every condition.
But this is just the start: Machines
like IBM’s Watson are beginning to use artificial
intelligence to cope with the new scale of knowledge
and data being generated by the said biosensors in a
way that was never possible for a human brain. Soon,
IBM is hoping that Watson will be able to examine
a patient’s data, search the medical literature, and
make a recommendation for treatment in specific
specialties. As the technology matures, significant
companies are being formed with the aim of putting
a personal avatar doctor in everyone’s pocket.
Smartphones and “The
Internet of Everything”
What a smartphone can do today is only 3% of what
it will be capable of in just five years time, and a mere
thousandth of its ability in ten years.
Today, the vast majority of people on the
planet are connected by mobile phones. These are
increasingly becoming smart with a remarkable
number of devices from video recorders to sensors,
rolled into one, creating a personal gateway to the
world’s collective knowledge.
More importantly “The Internet of Everything”, will
soon make cheap smart sensors that will connect every
aspect of our lives from our environment to our bodies.
Armed with intelligent apps and
loaded for medicine, these will collect and
send much of one’s vital signs in real time
for continuous analysis by bio-algorithms.
In the short term, they will alert and
allow a face-to-face virtual consultation
with a doctor anywhere, anytime. In the
medium term, much of it will be done by
artificial intelligence.
Intervention
From nanotechnology, to laser and
ultrasound manipulation, embedded smart
devices, organ replication, bio-molecular
engineering, robotic surgery and electro-
biology, we are re-inventing almost every
aspect of intervention in health care.
The breadth of what is
happening in clinical intervention is so
expansive that it requires a lot more space
than what is available here, but with the
help of synthetic biology, for the first time
in history, it is not evolution (or creation)
but humans who are capable of creating
new forms of molecules, and even life.
So where will all these changes
come from? From government or even big
corporations – not at all. Just ask yourself
- why did M&S not do what fashion
brand ASOS did so successfully? Why
did Sainsbury’s not do what Ocado did?
Because there is a disincentive for big
companies to divest from what they have
already. They have tremendously bright
people, but the mind share and the brain
power is all engaged in what they do each
day. Instead it will be new firms and start
ups who will create this change.
Whether it is our company
or another, I seriously believe it must
happen, as it always has historically with
disruptive innovation.
HEALTH&BEHAVIOUR|TECHTONIC
59
31. How Innovation and Digitalisation Can
Better Manage Chronic Disease
By Dr. Suzanne Clough | Chief Medical Officer, WellDoc
Help In Hands
Dr. Suzanne Clough is the Chief Medical Officer of WellDoc, an American
healthcare company she founded in 2005 that develops digital and mobile
health technology solutions to support chronic disease management. As an
innovative physician, Suzanne sought a better way to help patients manage type
2 diabetes between doctor visits. The company launched BlueStar, the first mobile
prescription technology that delivers automated personalised and adaptive
feedback and guidance to patients and health care providers, enabling them to
better manage their disease within the demands of everyday life.
61
decision is made as to whether or not an action should,
or will, be taken. While this way of moving through
the world holds true for some, it is not the lens
through which the rest of the population views the
world, or their healthcare choices. That’s because life,
rather than being linear, is often complex, dynamic,
and chock-full of apparently random events. Many of
our decisions come from quantum, rather than linear,
events driven by a surge of motivation or inspiration
that “is greater than the sum of its cognitive parts.
It is not so much a planned decision, but something
that arrives beyond cognition.” Motivation arrives
versus being planned. So, it is not surprising that the
complexity of human behaviour cannot be adequately
addressed or supported via the traditionally autocratic
healthcare paradigm that was built to serve patients,
not people all within a 12 minute clinic visit.
As it currently stands, a 12 minute clinical
meeting must covers all aspects of the patient’s care.
It’s clear that pills and injections and overall
treatment plans are critical for the management of
chronic disease and acute illness. It is also clear that
any treatment plan is only as good as how well it
is understood, tolerated, and adopted by the person
for whom it was designed. This has led to incessant
debate about how and why poor patient compliance
to treatment plans is one of the largest drivers of
healthcare costs. And herein lies the problem: we talk
about patients instead of people. The result is that we
have built behavioural frameworks that don’t consider
the complexity of the human. This complexity of an
individual cannot be accounted for by interventions
and guidelines built for populations.
Historically, as evidenced by behavioural
models based on the cognitive-rational paradigm,
health professionals have assumed rational, linear
behaviour by patients: the pros and cons of a situation
are assessed by the patient, and at some point, a
HEALTH&BEHAVIOUR|HELPINHANDS
In those 12 minutes the physician must establish the
scope of the symptoms, be it a cold or cancer; offer a
full medical investigation, mitigating any bias from a
patient’s symptom story; and should ultimately offer
a series of clear and manageable directives to assist
the patient in moving forward in their day-to-day life.
Simple in theory. Crude in practice. This top-down
healthcare structure has indeed come to create a
gulf in patient care, falling short of contemporary
healthcare demands, and failing to contend with
the huge paradigmatic shifts occurring in the way
people choose to live their lives. Now, more than
ever before, we need insight into the moments that
really matter: that is, those occurring within the
8700 hours a year that people living with chronic
disease are experiencing their dynamic and chaotic
lives outside of the healthcare system. We need a big
picture view of the patient’s life that helps a doctor
create a treatment plan for that one individual,
rather than offering one that is simply a copy and
paste from the population guidelines. A contemporary
healthcare framework must work within an
ecologically grounded framework, acting reflexively
to the everyday nature of healthcare concerns and
responding with the delivery of adaptive, dynamic
and individualised behavioural support.
We can get there, to this state of delivering
adaptive, dynamic and individualised behavioural
and clinical interventions, by leveraging the multi-
faceted, multi-media capabilities of digital and mobile
technologies. The ubiquity of these products are
never in doubt: on average we look at our phone 150
times a day. Smartly designed digital health products
have combined behavioural and clinical algorithms
with features already built into phones, like GPS,
to deliver anytime, anywhere behavioural feedback
to people on their mobile devices.
Additionally, digital health products can
glean what information from the patient’s
digital data is relevant for the health care
team to optimize the treatment plan at the
next visit. On this basis, we can develop
personalised digital health solutions
that offer a level of ongoing support to
people living with chronic disease that
has not existed before. Additionally, done
right, digital health products, can and
should, improve healthcare outcomes and
decrease health costs.
Ultimately the marriage of big
data, data science, and the digital and
mobile health industries will make it
possible, for the first time in the history
of medicine, to deliver highly scalable but
highly personalised healthcare that have
a demonstrable ROI to the healthcare
system. Technology, in this form, bends
time and seamlessly and smartly connects
the 8700 hours people are away from
their health care team to the 12 minutes
they are with them. The time to act is
now to ensure we empower individuals
to make accurate healthcare choices for
themselves, in their personal lives, and in
their own time.
‘We have built behavioural
frameworks that don’t consider
the complexity of the human’
