Financial incentives shape our daily routines – for example, if we do not work, we do not get paid – but to what extent should they shape our health choices and/or those of others? Asserting our autonomy entails behaving according to our individual preferences and values, free of both influence and coercion, and when Ashcroft (2011) sought to reconcile financial incentives with the concept of autonomy, he concluded that ‘they [financial incentives] may be in general or in specific instances paternalistic, coercive, involve bribery, or undermine the agency of the person.’ It seems reasonable to suppose that financial incentives may risk undermining the moral integrity of decision-making.
Financial incentives for health and negative outcomes
But what does the evidence show? When Korean mathematicians Lee et al (2021) devised an epidemic model to investigate the theoretical role of financial incentives to see how they might usefully address the COVID-19 pandemic, they found that ‘the larger the incentive budget is, the faster the epidemic will end’, but also included this subtle qualifier: ‘it is assumed that there is no moral hazard for rewards …’. In the real world, however, such an assumption might evince unwarranted optimism. For example, citing studies of negative outcomes of financial incentives – including reduced patient motivation and adverse effects on the trust that is intrinsic to a doctor-patient relationship – Hagoel et al (2013) reported that laypersons in an Israeli population they questioned ‘found administering incentives in exchange for colorectal cancer screening inappropriate on rational and moral grounds’; in a literature review by Tambor et al (2016), they found that ‘qualitative studies indicate limited trust of older people in the use of explicit financial incentives for health promotion and prevention’; a UK study by Judah et al (2018) concluded: ‘Financial incentives, particularly lottery-based incentives, attract fewer patients to diabetic eye screening than standard invites in this population’; and the title of a study by Moller et al (2012) – ‘Financial Motivation Undermines Maintenance in an Intensive Diet and Activity Intervention’ – summarises their findings.
A new Department of Health and Social Care initiative to address obesity will include a “fit miles” approach that will use incentives and rewards to support people to eat better and move more
Weight loss and incentives
Considering further the theme of financial incentives to encourage weight loss, Paloyo et al (2014) reported that ‘our study review casts considerable doubts with respect to the sustainability of any weight loss achieved through financial incentives’; a narrative review by Ananthapavan et al (2018) stated: ‘The evidence suggests that changes in weight, physical activity or diet are not maintained after the incentive is removed’; the title of a report by Patel et al (2016) – ‘Premium-based financial incentives did not promote workplace weight loss in a 2013-15 study’ – is self-explanatory; when Yancy et al (2018) undertook an internet-based randomised controlled trial to examine whether financial incentives can improve weight loss maintenance, they concluded: ‘Compared with the active control of daily texting based on daily home weighing, lottery-based and direct monetary incentives provided no additional benefit for weight loss maintenance’; and Molema et al (2016) are clear that ‘no solid conclusion can be drawn regarding the effectiveness of financial incentives on physical activity in the healthcare setting.’
A flawed initiative?
All of which invites the inference that the evidence favouring a useful role for financial incentives in several areas of healthcare, including weight loss, is far from overwhelming. Yet recently, in apparent contradiction of all this, the Department of Health and Social Care (DHSC) not only announced a £100 million funding initiative to address obesity (DHSC, 2021), but added that entrepreneur ‘Sir Keith Mills, who has pioneered reward programmes through Airmiles and Nectar points, has been appointed to advise on developing a new “fit miles” approach that will use incentives and rewards to support people to eat better and move more’, observing that ‘Sir Keith will support the government to develop innovative approaches with public and private partners that use incentives to help people make healthier choices.’
Wales-based obesity researcher Dr Zoë Harcombe, who has previously demonstrated that epidemiological evidence does not support the present dietary fat guidelines (Harcombe et al, 2017), is clear that the DHSC initiative is flawed (Harcombe, 2021). Dr Harcombe told Practice Nursing: ‘First, the focus is on exercise, but weight is about diet. Second,’ she explained, ‘people do not need incentives. The desire to be slim is immense. It is greater than any other desire, in my experience, and the COVID-19 association with high obesity provides even more incentive right now. People do not need to be paid to lose weight. They need better advice, and certainly not eat less/do more.’ This is supported by Grannell et al (2021), who state: ‘Many healthcare providers believe “eat less and move more” is the best treatment for obesity. This does not align with the current evidence base.’
Dr Harcombe also says that the literature backing the launch of the DHSC initiative confirmed that the ‘calorie in/calories out’ approach is at the heart of the scheme. Again, Harcombe's assertion that this strategy is mistaken is supported by fellow researchers. For example, Malhotra et al (2015) note that ‘shifting focus away from calories and emphasising a dietary pattern that focuses on food quality rather than quantity will help to rapidly reduce obesity, related diseases and cardiovascular risk.’ And Ludwig and Ebbeling (2018) are clear: ‘By asserting that all calories are alike to the body, the conventional model rules out the environmental exposure with the most plausible link to body weight control. What other factors could be responsible for such massive changes in obesity prevalence? The conventional model offers no compelling alternatives.’
‘People do not need to be paid to lose weight. They need better advice, and certainly not eat less/do more.’
An evidence-based approach is needed
It is possible that the government-promoted DHSC initiative, aided by Sir Keith Mills' incentive-based approach to weight loss might well appeal to health professionals in the primary care sector. However, if health professionals genuinely prize an evidence-based approach to healthcare delivery, perhaps part of their duty of care towards patients should entail critical reading and rigorous evaluation of the evidence base before schemes of questionable value are endorsed. Airmiles and Nectar points in commerce do not necessarily translate seamlessly into effective weight loss strategies in healthcare.