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OPINION

'Forget nudging, the public health strategy doesn’t work'

  • 116 Comments

I took some solace from a news report last week saying that search engines such as Google may be to blame for my failing memory.

I was getting worried about my inability to remember certain words, or where I put my shoes or the fact that I had an appointment with a sadistic former Polish special forces assassin now employed as a dental nurse last Thursday.

Fining the parents of children not wearing a sun hat isn’t a vote winner

Anyway, scientists are suggesting that we are adapting our memories because so much information is so easily available to us. So that’s all right then.

My wife has a different explanation. She says we need a holiday. She has been saying this since 1997 and has even been known to say it while we are on holiday. But paradoxically, if you go on holiday, there is so much to remember. Not least suncream.

I was reading last week about an uproar over primary schoolchildren getting sunburnt on sports day. “Why didn’t the teachers smother them in suncream?” sobbed one mother. Well, the fact that there are 300 kids, one tube of suncream and some teaching to do may explain it. But, outrage being outrage, it wasn’t long before a charity was demanding that all UK schools develop a comprehensive sun safety policy to protect children from skin cancer.

Who is to blame for sunburnt kids? Parents? Schools? The law? The government? Legislation has brought about the biggest recent changes in public health, from banning smoking in pubs to making the wearing of seat belts compulsory. But, for every law banning something, there is a pressure group protecting civil liberties.

The alternative to legislation is “nudging” and involves us being persuaded to make life-improving changes through social cues. The traffic light system on food is an example. But it seems people need more than cues and information to make better choices, as any nurse working in health promotion would probably testify.

We can’t over legislate. Fining the parents of children not wearing a sun hat isn’t a vote winner and, anyway, maybe legislation diminishes our sense of personal responsibility. Yet prompting people to try to stay healthy doesn’t make much difference. One could even argue that, for many people, small acts of recklessness - a ciggie behind the bike sheds for example - are the most potent expressions of personal power or “freedom” they have.

It is largely about economics, can we afford to manage avoidable or long-term illnesses? Maybe we could increase income tax. But that doesn’t win votes either.

And so it goes on. We wander around in the space between nudging and legislation, persuading and enforcing until, as the Wanless report on public health told us, the consequences of our choices become simply unmanageable.

Don’t you think it is interesting that often we simply don’t care about ourselves? Why is that? Are our choices psychological and personal? All about the struggles in our inner world? Or are they socially constructed? All about coping with the external pressures of modern life? And, whichever one of those it is, what on earth can health professionals do about it?

It may be that trying to do anything about how people live is absurd and invasive. If people want to smoke or take drugs, then that is their business and the only reason we even talk about it is because it costs us all money.

But whatever your position - libertarian, legislator, health educator or taxpayer - it is apparent that public health strategy is as muddled up as we are. Will that ever change? And, if it doesn’t, where will the NHS be in 10 years’ time?

  • 116 Comments

Readers' comments (116)

  • I have no clue as to why people choose to willingly ruin their own health or do not look after themselves, I probably never will.

    However, I do also have a sneaking suspicion that a lot of it has to do with the fact that the concept of personal responsibility has been all but removed in this country. Why should people look after themselves when the NHS will always be there to pick up the pieces?

    I am a great believer in personal choice, if people want to smoke or take drugs or drink until their kidneys melt in a seething mess of vodka and bodily fluids, then that is their choice. However, I am also a great believer in personal responsibility and they should take responsibility for their own choices.

    Some thinks NEED legislation, smoking and drug use for example. I fervently believe tobacco should be banned immediately.

    However with other long term conditions and lifestyle choices, drinking to excess and obesity for example, I think that there is a strong case for 'heavy nudging', and by that I mean forcing people to live with the consequences of their decisions and removing the safety net. For example, if you CHOOSE to eat and eat and eat until you are obese, then why should the NHS fund all your extra treatment of the conditions that are caused by that?

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  • I really don't understand it at all. the government can make laws at a whim on more or less whatever they want - democracy or not. there are some very silly petty laws on all sorts of things and spying on individuals to ensure they are not broken.
    for instance if your Mummy and Daddy had a tv licence and you inherit your family home and cancel it because you never watch the telly you are haunted by reminders and warnings forever after with wording suggesting that you are a potential law breaker just because some others unfortunately are. if you respond to them, their advice is to ignore them! if your parents used a hosepipe in the garden the installation of a water meter is forced upon your property without any choice and then the garden suffers as water becomes to costly!
    worse than these minor irritations, are the effects this has on people whose livelihood depends on their small business. many have been put out of business following health and safety inspections enforcing sudden new regulations requiring changes which may be unreasonable and affordable although their business had been functioning perfectly well, sometimes hundreds of years prior to this intrusion. small business in the Highlands and Islands are a prime example: b&bs who could not afford to meet the regulatory requirements of new installations and purchasing the extra bed linen and crockery, etc. or the case of the government providing a ferry at the cost to tax payers of over £20,000 a year for a ferry to take a small boy to school on a neighbouring island as they no longer deemed it safe for his father to row his son across a narrow stretch of water to school each day, a practice which had been carried out for several generations.
    if the government has the time, money and intelligence for all such trivialities why can they not impose stricter laws on habits which are known to be detrimental to health and do not provide any benefits such as drugs and tobacco and excessive alcohol intake. one problem might be that if tobacco was outlawed it would probably lead to widespread illicit use which would also cost a lot to control and punish but at least the government would still get its revenue and costs to the health service would be reduced but they may then have higher administrative costs to implement the law and control the law breakers. but then they are already specialists in this field and in wasting our money on offices full of armies of administrators carrying out investigations simply by ticking a few boxes, writing reports which are already out of date before they are published and filing them in the archives before any action has been taken on them!

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  • I agree with Mike. People are given the information they need about lifestyle choices after that its up to them.
    But they should be prepared to take responsibility for the consequences.

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  • I am not condoning people making bad life choices, but taking responsibilty of your lifestyle is relatively new, and it will take a generation or two to become embedded in our culture.

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  • I do not think there is anything new in adults taking responsibility for their own health. nobody has ever been able to do that for anybody else.

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  • Where do all the concerns that people should be responsible for their actions (for which I assume other commentors mean 'pay for the consequences of their actions' end)?

    I go rock climbing. If I fall and break a leg should the NHS charge me for treatment? What about people who cycle at the weekend with their family? It's a dangerous activity and leads to many admissions each year. How about someone who takes the car a mile down the road to visit a friend, they could have easily and more safely walked and so does their taking of that needless risk disqualify them from treatment in an accident?

    If the NHS is going to follow the principle of 'to each according to their need' and provide care that is 'free at the point of need' then you cant begin to exclude people based upon their life choices. All life choices entail some degree of risk, be it greater or lesser.

    As to whether the government should ban tobacco, I tend to agree. I do wonder if the NHS would survive the huge loss in tax revenue from cigarettes.

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  • John Spashett, I'm sorry but that is a ridiculous argument that never holds any water.

    First of all, activities such as rock climbing, sports, etc do inherently have a risk, I agree. But they also inherently keep you fitter and healthier far longer than those who do not do those activities, (and I speak as one who indulges in a number of sports and training activities) so the cost of repairing a broken leg or whatever due to an unforseen ACCIDENT (and that term is crucial) is far, far, far outweighed by the billions saved in not treating long term conditions caused by lack of fitness, etc. Secondly, I also go mountain climbing, usually abroad, as well as indulging in many other activities that people may consider 'risky'. However, when I do go abroad for these activities, I also have personal health insurance which covers any cost.

    Also, activities such as driving, again, entails some risk, yes, (you could also say you run the risk of being run over when walking to the same destination, but hey ho) but they are also safe for many people who are not the victim of an unfortunate ACCIDENT. ie the victim of circumstance entirely out of their personal control.

    These activities, these normal everyday acts of living in a modern society are generally safe and fine, and treatment caused by accidents or unforeseen circumstances within these activities can never be compared to the treatment of damage caused by negative lifestyle choices such as smoking or drug taking or excessive and repetitive alcohol consumption, etc, where the detrimental health effects are well known by everybody.

    So you CAN begin to exclude some people based on life choices.

    Oh, and I tend to think that the NHS WOULD survive the loss in revenue, as would the government, from banning tobacco, whether they have the WILL to do so however is another matter. Personally I would ban tobacco just on a moral stance, since I think it is a disgusting, selfish and deplorable habit and would love to live in a society where it did not exist.

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  • Time to get off that high horse of yours Mike. I sometimes find it hard to believe that you are a nurse. How cosy it must be living in your black and white world with no grey or shady areas.
    These are people we are talking about with sometimes either very difficult lives or very monotonous boring lives. Many do not have your luxury of a reasonable wage derived from a job you enjoy (so you say, allthough your comments often suggest otherwise) many are semi illiterate scraping by with no real prospects of any meaningful life changes in sight. Spending what little money they have on drink, tobacco, junk food and drugs is obviously not a good thing but your attitude of writing them off as worthless idiots because they don't conform to your personal ideals is sad, unfair and not worthy of a so called professional nurse.
    Did you miss the session on empathy during your training?

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  • Time to get off that high horse of yours Mike. I sometimes find it hard to believe that you are a nurse. How cosy it must be living in your black and white world with no grey or shady areas.
    These are people we are talking about with sometimes either very difficult lives or very monotonous boring lives. Many do not have your luxury of a reasonable wage derived from a job you enjoy (so you say, allthough your comments often suggest otherwise) many are semi illiterate scraping by with no real prospects of any meaningful life changes in sight. Spending what little money they have on drink, tobacco, junk food and drugs is obviously not a good thing but your attitude of writing them off as worthless idiots because they don't conform to your personal ideals is sad, unfair and not worthy of a so called professional nurse.
    Did you miss the session on empathy during your training?

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  • What about me then? I have danced all my life and played badminton for many years. Now I've worn out the joints (got osteoarthritis) and heading rapidly towards obesity as I can't take much exercise. Still working at 61 though!
    As nurses we are not supposed to be so judgemental.

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