Guy Rughani: A waist of money?

Guy Rughani“Cash for blubber” is how the Twitter community have dubbed the UK government’s latest bid to tackle obesity. As revealed in the Sunday Telegraph, plans have been made to pay GPs extra for giving their patients “weight management advice” and referring them to publicly financed dieting clubs. But will this nudge fatten wallets or slim waists?

There has been much written lately about the government’s passion for nudging. In case you haven’t read the book that Cameron told his coalition colleagues to read (“Nudge” by Richard Thaler and Cass Sunstein), healthcare nudging is essentially modifying the environment to make the healthiest choice the easiest option. It’s called “liberal paternalism.”

Cameron’s new scheme is a double nudge. Perhaps because obesity is so prevalent, paternalistic (but liberal) Dave has decided that he’ll use GPs to remind us that obesity is not “normal.” For dishing up this sound advice, GPs will be rewarded. Cameron’s second nudge will help obese individuals attend dieting clubs and gyms by removing the cost barriers.

Whilst nudge number two seems a reasonable attempt at boosting healthy behaviour (perhaps a nudge Thaler would be proud of), does paying GPs for something they should already be doing represent good value for money? Could it create a perverse incentive for patients to put on enough weight to qualify for free memberships?

The government presumably argues that prevention is cheaper than cure.  Many single anti-obesity nudges have been tried, but mostly on small scales. People have replaced sweets with fruit at cash tills, changed default side orders from chips to salad, and offered Topshop vouchers to kids who walk to school.

Unfortunately, the evidence for the long-term effectiveness of nudging (both clinical and financial) is pretty scant (BMJ 2011; 342:d2168), and the individual schemes are rarely wide-ranging enough to lastingly change behaviour.

You may offer free swimming sessions and tell people that they should lose some weight, but you can’t force them to comply. That is the problem with liberal paternalism. It’s too liberal. The authors of a recent BMJ head to head article described nudging as a “smokescreen for inaction” (BMJ 2011;342:d2177). Nudge policies appear to make sense, but they lack the bite to make a lasting impact.

Health promoters have long argued that legislative approaches are much stronger and more effective than nudging. Legislation can also target one of the major roots of the problem – the food industry.

Guy Rughani is a Clegg scholar and a 3rd year medical student studying at the University of Edinburgh.