Exercise or lose benefits idea fails friends and family test

Last week saw two healthcare policy ideas discussed. One sounds fairly promising, the other is fairly silly. Fortunately, the former is the one that is likely to prevail.

The pretty good idea is an extension of the friends and family test, which last week the prime minister said he wants to extend to GP surgeries and community hospitals – acute hospitals in England are introducing this in April. It is open to criticism on cost grounds, which is likely to be higher for many thousands of GP surgeries rather than just a few hundred hospitals. However, a lot of the arguments against have focused on such a test being simplistic.

Asking whether you would recommend something to your friends and family is simple, but that doesn’t necessarily make it simplistic. The friends and family test looks fairly hard to game (unlike the way that waiting list targets can be gamed by, for example, treating patients just before a deadline). NHS services are already measured in more rigorous ways (mortality rates, waiting lists, infection levels), but asking whether you would be happy to tell your loved ones to use a service – not the same as whether you were personally satisfied with it, as it asks you to consider what other people would think and whether you would be happy to stand by that opinion through a recommendation – can, as David Cameron described it on BBC Radio, “act as a flashing light and I think that would avoid problems like we saw in Stafford” (and pointed out it is used at Salford Royal, which has been a trailblazer for NHS innovation in several areas).

Much will be heard about the terrible problems at Mid Staffordshire NHS foundation trust in the late 2000s (and hopefully a little about its recent improvements) in a few weeks’ time, when the Francis Inquiry into the trust’s past failings is published. It’s fair to say that if a friends and family test caught just one such situation early on, potentially saving many lives, it would be worth introducing.

Andy Burnham, responding to Cameron’s comments last week for Labour, focused on cuts to nursing numbers (a partial picture of the NHS jobs situation, given the equivalent rise in the number of doctors and technicians – and the far steeper cuts in NHS manager numbers, who no-one ever wants to defend). There’s a danger for Labour if it focuses purely on the producer interest, as it could allow the Conservatives to take the role of patients’ champion – something the Economist notes that health secretary Jeremy Hunt is working hard to do.

If the friends and family test looks like a reasonably good idea, the idea of docking benefits for overweight people failing to carry out prescribed exercise plans – floated by Westminister City Council and the Local Government Information Unit think-tank last week – looks bonkers, or as the British Medical Association’s Dr Lawrence Buckman described it, “draconian and silly”.  On a practical one, how would you ensure people had done the exercise? They might swipe into the leisure centre then head for the café. Perhaps the staff would have to confirm exercise had taken place? But given there’s real money at stake, how would you guard against bribery, or gym bunny ringers (perhaps wearing padding so as not to attract attention)?

Joking aside, the bigger issue is that people rarely respond well to being threatened. The better way to tackle obesity is through long-term education, in the fashion of anti-smoking and drink-driving campaigns, of the value of healthier living – to the extent that social attitudes change. The process is already underway with obesity, which the government is attempting to advance through the cartoon-based Change4Life campaign (including a gross-out advert showing a wine glass full of the fat in a pizza, to be first shown tonight during Coronation Street), although it’s a long road.

Such healthy living campaigns are partly about convincing those whose behaviour needs to change, but at least as much those around them. Social pressure works a lot better than state regulation – if the latter worked, the ‘war’ on drugs would have been won decades ago. The friends and family test for public health campaigns should be, will it recruit the friends and family of those targeted, or will they come out in sympathy against it? ‘Exercise or we cut your benefits’ would probably manage the latter.