My Ideas.

By

Ian Burbidge

·

May 23, 2024

Behaviour + Incentives, Outcomes + Evaluation, Systems + Complexity

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On buying behaviour change

I’m gaining weight. Deliberately, mind you. I’ve always found it hard, but I’m pretty dedicated. Once I reach a level considered clinically obese, I’ll have placed myself in the same category as around a quarter of the UK adult population^⁠1 and, when the new payment by results policy* is rolled out, I’ll be eligible for the reward once I shed the pounds and return to my usual weight. Easy money, right? Assuming, that is, I’m correct in my calculation that the financial reward more than covers the cost of the extra food I’m eating, and that the effect of playing with my weight doesn’t disrupt what has hitherto been a pretty stable metabolism.

A recent health trial reported^⁠2 that paying people a reward to lose weight was a successful public health outcome. For me it’s another of those ideas that simply won’t go away, on a par with the notion that the NHS should run parks^⁠3 in the UK because they are important for people’s health (on that logic should they not run every public service, from Jobcentre Plus to driving instruction?) or the introduction of performance related pay to motivate people in purpose-driven organisations.

I was first asked this question of ‘payment by results’ relating to weight in 2017 at a health conference; the Director of Public Health who spoke before me wanted to see the evidence from clinical trials as to the efficacy of paying people to lose weight. I guess he how has that evidence. In turn, I suggested that just because the idea may be proven to work (at the time there wasn’t such evidence), it doesn’t necessarily follow that it is the right thing to do. There are moral, ethical and political concerns and, as hinted at in my reference to financial rewards above, using extrinsic (financial) rewards for what is fundamentally an intrinsic issue is likely to make things worse. In my experience, to reduce a complex challenge to a simple intervention is not generally a successful approach.

Two critical challenges with this idea of ‘payment by results’ or financial bribery are the lack of clarity around purpose and the associated misalignment of incentives.

First, what is the true purpose? We know that health is a complex issue and so setting discrete goals or targets will both drive unhelpful behaviours and lead to unintended consequences. What is it we are trying to achieve here, and for whom? For health commissioners it will be to reduce demand and therefore costs. For epidemiologists it may be to reduce the rising trends of obesity prevalence in society. For the individual is it to lose weight? That’s not enough in itself, because to lose weight is only a means to an end. What’s the real outcome you’re motivated by, such that you are willing to do what it takes to lose weight? Is it be able to tie your own shoelaces, walk up the stairs, pick up your grandchild, look after the garden, run a marathon? Which objective is a strong enough reason for you? Or are you really only out to gain the cash reward?

Regarding incentives, there is so much research^⁠4 on the carrot v stick approach to behaviour, much of it focused on the use of rewards in the workplace, another topic I have explored in detail. Because intrinsic motivation is the most powerful behavioural driver, people with a strong purpose or reason why they are doing something are not motivated by financial rewards. We see time and again that their introduction in purpose-driven companies and sectors will have significant and disruptive consequences that not only undermine the original intent of rewarding and thus improving performance, but also have a whole slew of knock-on, unintended consequences. Just because you are financially incentivised to do something doesn’t make it the right thing to do, as we have seen through scandal after scandal and institutionalised failure:

Yet here we are throwing an extrinsic and apparently simple solution at the complex problem of obesity. If someone is only motivated to lose weight by a cash payout, what happens after the payout is received? Because the extrinsic motivation is now withdrawn. What’s in its place? Nothing, unless at the same time you’ve been working on your own psychology: developing your intrinsic motivation for change, telling new more positive stories about your health, creating a new identity as a healthy person, creating healthy habits, being more active, cultivating a support network, and so on. Without that strong purpose, habitualised changes, new ways of seeing yourself and support network you’ll just put on more weight again when the money stops.

I wonder how will this might work in practice. Do you have to return the funds if you go back above a trigger weight? What if you’ve already spent the reward and have no savings, will you be charged interest on the debt, driving you further into debt? Will you be pursued by a debt collection agency? Will you start eating comfort food to assuage the stress? Can you claim the reward twice if you put the weight back on? What about slim people with high cholesterol, does the same logic apply? Reduce cholesterol levels, reduce likelihood of a heart attack, gain a financial reward. Or smoking? So if I successfully lose wight, stop smoking and lower my cholesterol might I gain triple the reward? And at what point is all this automated as the quantified self through implants and data monitoring automatically updates my Health app and thus those in charge of handing out the rewards (or fines?).

When we seek to reward people for making positive lifestyle changes – stop smoking, reduce drinking, eat healthily – are we not in effect rewarding those with existing poor behaviours? Those who don’t have such unhealthy behaviours will not only receive any kind of extrinsic reward for those behaviours but will also, through taxation, be helping to pay those rewards. How we use the public purse for public good is a crucial component of our social contract, one which feels pretty broken at the moment.

A simple solution – pay people when they reach an agreed healthy weight – to a complex challenge – there are so many inter-related and dynamically changing aspects that could cause an individual to be obese – is doomed to failure. It’s one thing to do the research through randomised control trials where you are controlling for variables but not looking at the longer-term impacts – or spillover effects – on subsequent behaviours. But at their worst this anodyne approach^⁠5 can lead to insights that are interesting but don’t survive impact with the real world. We need instead to bring our humanity to the table and look at the wider socio-political and moral dimensions.

Perhaps we need to do more to challenge this practice by getting to our underlying beliefs about human nature that lead us to create these approaches in the first place. Payment by results (to achieve a specified outcome) is born of the capitalist paradigm that reduces everything to fiscally-driven decisions and incentives, regardless of their applicability to the specific context. What if, instead, we took a systems view of health and figured out together what might work for people given their own unique circumstances?

*this is anticipatory and not a fact (as of May 2024), made to illustrate the point of unintended consequences. The research paper can be accessed here^⁠6.