Commissioning and behaviour change - The King's Fund (PDF)

Commissioning and behaviour Change Kicking Bad Habits final report Tammy Boyce Ruth Robertson Anna Dixon  © The King’s Fund 2008 First published 2008 by The King’s Fund Charity registration number: 207401 All rights reserved, including the right of reproduction in whole or in part in any form. ISBN: 978 185717 578 3 A catalogue record for this publication is available from the British Library Available from: The King’s Fund 11–13 Cavendish Square London W1G 0AN Tel: 020 7307 2591 Fax: 020 7307 2801 Email: [email protected] www.kingsfund.org.uk/publications Edited by Kathryn O’Neill Typeset by Peter Powell Printed in the UK by The King’s Fund The King’s Fund seeks to understand how the health system in England can be improved. Using that insight, we help to shape policy, transform services and bring about behaviour change. Our work includes research, analysis, leadership development and service improvement. We also offer a wide range of resources to help everyone working in health to share knowledge, learning and ideas.  © The King’s Fund 2008 Abbreviations v Executive summary vii Introduction xi Health policy – promoting personal responsibility for health xi Commissioning for health and well-being xi The Kicking Bad Habits programme xii Aims and structure of the report xiii 1 The scale of the public health challenge 1 Smoking 1 Alcohol misuse 2 Poor diet and lack of exercise 3 Understanding why people choose unhealthy behaviours 4 2 Identifying the target population 6 Segmentation and targeting 6 Geodemographics 7 Social marketing 9 Data analysis skills and capabilities 11 3 Designing effective behaviour change interventions 12 Using incentives to encourage behaviour change 12 Providing information 15 Providing individual support 16 Using a range of interventions 19 4 Evaluating behaviour change interventions 20 The evidence base 20 Improving evaluation methods 20 Evaluating cost-effectiveness 21 Funding 22 5 PCT commissioners and policy-makers leading the way 23 World class commissioning 23 Practice-based commissioning 23 Regulation and performance management 24 Engaging with new service providers 25 NHS staff contracts 26 Patient choice and empowerment 28 Contents  iv © The King’s Fund 2008 Commissioning and behaviour change 6 Conclusions 29 Appendix A: The Kicking Bad Habits expert seminar programme 31 References 33  v © The King’s Fund 2008 A&E Accident and emergency APMS Alternative Provider Medical Services BME Black and minority ethnic BMI Body mass index BNI Better Neighbourhoods Initiative CASA Centre for Advanced Spatial Analysis COPD Chronic obstructive pulmonary disease GMS General Medical Services GP General practitioner HHIM Household Health Improvement Managers JSNA Joint Strategic Needs Assessment LAA Local area agreement LSP Local strategic partnership NHS National Health Service NICE National Institute for Health and Clinical Excellence PBC Practice-based commissioning PCT Primary care trust PMS Primary Medical Services QOF Quality and Outcomes Framework SHA Strategic health authority TSIP Third Sector Investment Programme WCC World class commissioning abbreviations   vii © The King’s Fund 2008 What we set out to do The government has made it clear that it expects the NHS – and, in particular, primary care trusts (PCTs) – to take the lead on commissioning support that will encourage people to change their behaviour to adopt more healthy lifestyles. This report examines how the NHS can help people become healthier and, in particular, the role of commissioners in encouraging individuals to adopt healthy behaviours. Drawing on a series of working papers and seminars held in the first half of 2008, this report assesses existing and innovative methods the health service can use to persuade people to live more healthy lifestyles, including providing information and personal support and offering financial incentives. This report aims to help those within the NHS and beyond who are tasked with finding cost-effective solutions to the problems caused by unhealthy lifestyles and behaviour. It examines four bad habits; smoking, alcohol misuse, poor diet and lack of exercise. The current situation Recent government policy has placed a greater emphasis on the role and responsibilities of individuals in adopting healthy behaviours and lifestyles. As commissioners, PCTs have been made responsible for taking the lead on encouraging people to change their behaviour to adopt more healthy lifestyles. Unhealthy behaviours and the illnesses they cause represent a significant proportion of the disease burden facing the NHS. The financial cost to the NHS is huge and continues to grow. These unhealthy behaviours are estimated to cost the NHS in England more than £6 billion a year. What we found Helping people to kick bad habits such as smoking, alcohol misuse, poor diet and lack of exercise requires a long-term commitment to changing complex behaviours; it is an ambitious goal. Each type of behaviour has different characteristics, so it is unlikely that approaches that work for one behaviour will be easily transferable to another. This will also require greater efforts by local health services to assess, target and monitor public health needs at a local level. Behaviour change interventions and strategies should be clear about the nature of the behaviour they are tackling, as well as who they are targeting. Geodemographics – the science of profiling people based on where they live – and social marketing – the use of commercial marketing techniques to promote socially desirable outcomes – can give commissioners insights into the needs and behaviours of different kinds of people. Investment should be made in developing these skills among PCT staff and in improving both the quality and the quantity of data on local public health needs that they use in their work. Understanding how to use social marketing tools and having reliable data on local needs are vital first steps to finding solutions. executive summary  viii © The King’s Fund 2008 Commissioning and behaviour change Innovative interventions, such as financial and non-financial incentives and those designed to increase an individual’s motivation and confidence, are increasingly viewed as effective ways to change behaviour. Currently, the Department of Health in England invests heavily in information-based programmes to promote healthy lifestyles and behaviours. In 2007/8, it spent more than £50 million on publicity and advertising. But providing information, on its own, has little effect on people’s health behaviour. Health behaviour is complex, and is determined by more than just an individual’s level of knowledge. Providing information has much greater impact when it is part of a wide range of activities that promote healthier choices. Similarly, the use of financial incentives is likely to be most effective when used as one element of a wider programme to promote long-term behaviour change. Commissioners need to be innovative and committed to developing programmes that draw on existing evidence as to what works. This will often mean implementing several different activities. Commissioners’ responsibility to collect and use evaluation data There is little systematic evidence to help determine which interventions or combinations of interventions are most effective in changing particular behaviours in various population groups. To facilitate evidence-based commissioning, PCTs need good-quality evidence on the impact and cost-effectiveness of behaviour change interventions. There is a lack of good-quality evidence, and investment needs to be made in developing a stronger evidence base to evaluate the impact of behaviour change programmes. The National Institute for Health Research, the NHS Service Delivery and Organisation Research & Development Programme, the Medical Research Council and other research councils all have a role to play in investing in evaluations of behaviour change programmes. PCTs and providers might also consider establishing partnerships with local universities, who can help to develop evaluation tools. What the NHS needs to do For PCTs and strategic health authorities (SHAs) to deliver a true ‘health service’ rather than a ‘sickness service’, health promotion must be fully embedded in national policies, commissioning priorities, care pathways, standards and performance indicators, and staff and service contracts. The NHS needs to invest in interventions and programmes that provide effective support to help people change their behaviour, in the short term and the longer term. The case for change is clear. Not only are there personal costs in terms of ill health but significant and rising costs to the NHS and to society as a whole. Encouraging healthier lifestyles is the job of all staff working within the health service, not just those working specifically on public health projects. All interactions between patients and health care professionals – including hospital staff, GPs and pharmacists – present opportunities to deliver messages about healthier lifestyles and behaviours. Primary care contracts should be used to further encourage health promotion activities. GPs have responded to Quality and Outcome Framework incentives before, and financial incentives should be added to encourage them to undertake health promotion in their everyday contact with patients. World class commissioning (WCC) and practice-based commissioning (PBC) are also opportunities for PCTs to improve the way they commission behaviour change interventions. Local ‘vital signs’ indicators can be used to assess the impact of their behaviour change interventions. Local area agreements are another opportunity for PCTs, local government and other partners to identify local health priorities and build policies to tackle wider determinants of health into the agreement.  ix © The King’s Fund 2008 Executive summary Finally, good practice needs to be shared. This report contains case studies from some individual projects from around the country. The NHS and SHAs need to take a lead in spreading information and best practice so that successful interventions for tackling smoking, alcohol misuse, poor diet and lack of exercise can be rolled out to as many people as possible as quickly and efficiently as possible.   xi © The King’s Fund 2008 Since it was set up 60 years ago, the National Health Service (NHS) has predominantly focused on treating people when they are sick. This has prompted criticism that it is a ‘sickness service’ rather than a health service. Yet the current Secretary of State for Health, Alan Johnson, is keen to steer the NHS in a different direction, stating that ‘Promoting health and well-being is the raison d’être of the NHS’ (Johnson 2008). Furthermore, Lord Darzi’s High Quality Care For All: NHS next stage review final report (Department of Health 2008d) called for the NHS to focus as much on promoting good health as on treating illness and managing disease. Do these statements suggest a real shift in priority for the NHS? Or are they simply political rhetoric? Will the NHS continue with business as usual – that is, treating the consequences of unhealthy lifestyles and behaviour, but not tackling their causes? Health policy – promoting personal responsibility for health Since the Labour government came to power in 1997, it has introduced a number of policies that may help to reduce inequalities in health such as the minimum wage (to reduce inequalities in income); programmes such as SureStart, which aim to improve the life chances of children born into poor households and communities; and the ban on smoking in public places. These policies have focused on social, economic and environmental factors, all of which are important in delivering improvements in public health. But recent policy documents have signalled a greater emphasis on the role and responsibilities of individuals in adopting healthy behaviours and lifestyles. The Wanless review of health care funding (2002) suggested that greater public engagement with health (and more ‘self-care’) could help to reduce overall health care costs. It presented three different scenarios, the most desirable being a ‘fully engaged’ population that is proactive in avoiding sickness and choosing healthier lifestyles. Choosing Health: Making healthy choices easier (Department of Health 2004) continued this theme, emphasising the role and responsibilities of individuals in maintaining their own health. This White Paper set out recommendations to create a ‘health-promoting’ NHS, and suggested there was a role for retailers and advertisers to make healthy lifestyles ‘an easier option’ for people. Our Health, Our Care, Our Say (Department of Health 2006) stressed the need for health and social care services to support individuals to take more responsibility in managing their own health and health care. So although it is important that the government continues to implement policies to address the wider determinants of health, there is also an important role for the NHS to play in addressing the personal factors that influence lifestyle and health. Commissioning for health and well-being The government has made it clear that it expects the NHS – and, in particular, primary care trusts (PCTs) – to take the lead on commissioning support that will encourage people to change their behaviour to adopt more healthy lifestyles. The Commissioning Framework for Health and Well-being (Department of Health 2007a) encouraged commissioners to incentivise the promotion of health, well-being, dignity and introduction  xii © The King’s Fund 2008 Commissioning and behaviour change independence for all and to commission for outcomes. However, the framework lacked detail about what commissioners were expected to do in practice. ‘Adding life to years and years to life’ is the tagline of world class commissioning (WCC) (Department of Health 2007c). Its statement of intent – ‘to deliver long-term improvements in the health and well-being of local communities’ – puts better preventive care at the heart of what it wants to achieve. However, to date, it appears that PCTs have continued to focus on commissioning in the acute sector. If the vision of WCC is to become a reality, PCTs need to give equal priority to commissioning for health and well-being. The requirement to keep people well, improve overall health and reduce inequalities was also included in the 2008/09 Operating Framework (Department of Health 2008f). The Department of Health is providing more specific advice to commissioners and PCTs to tackle the problem of obesity. In November 2008, Healthy Weight, Healthy Lives was published, and was specifically aimed at helping to improve commissioning of weight management services (Department of Health 2008c). ‘Staying healthy’ is one of eight clinical pathways1 that each strategic health authority (SHA) had to address as part of Lord Darzi’s High Quality Care For All: NHS next stage review final report (Department of Health 2008d). Every primary care trust will commission comprehensive well-being and prevention services, in partnership with local authorities, with the services offered personalised to meet the specific needs of their local populations. Our efforts must be focused on six key goals: tackling obesity, reducing alcohol harm, treating drug addiction, reducing smoking rates, improving sexual health and improving mental health. (Department of Health 2008d, p 9) These policy documents all signal a greater emphasis on the promotion of health. To turn this policy into reality, the NHS has to play a significant role in finding and implementing cost-effective interventions to change habitual and deeply rooted behaviours such as smoking, alcohol misuse, poor diet and lack of exercise. The Kicking Bad Habits programme This report is based on the findings of a series of working papers and expert seminars held between February and July 2008 as part of the Kicking Bad Habits programme. The programme was launched by The King’s Fund in 2007 and focuses on four ‘bad habits’ in particular: smoking, alcohol misuse, poor diet and lack of exercise. It aims to find out how the NHS can help people become healthier – and, in particular, to identify effective interventions that encourage individuals to adopt healthy behaviour. The working papers and seminars aimed to bring together leading public health practitioners and academic researchers, government officials, and representatives from the private sector and third sector organisations that are involved in innovative approaches to behaviour change (see Appendix 1 for the full list of participants). We wanted to find out how existing approaches (such as educating and informing the public) can be made more effective – for instance, by tailoring information to individuals – and whether some approaches are more (or less) successful with certain target groups, such as people on low incomes. We also wanted to look at newer, more controversial approaches (such as financial incentives), and whether providing support to improve an individual’s motivation and self-confidence is more likely to bring results. 1 The eight clinical pathways are: staying healthy, maternity and newborn, children, acute care, planned care, mental health, long-term conditions, and end of life.  xiii © The King’s Fund 2008 Introduction This led us to focus on five key questions: to what extent do financial incentives help individuals change their behaviour? ■ (Jochelson 2007) what behaviour change interventions are most effective for individuals in low- ■ income groups? (Michie et al 2008) how effective are information-led strategies? (Robertson 2008) ■ to what extent does increasing an individual’s motivation and self-confidence help ■ them change their behaviour? (Dixon 2008) how can behaviour change interventions best be targeted and tailored to secure the ■ desired health outcomes? The case studies featured in this report are based on presentations made at the seminars; others have been identified during the course of the programme. They provide examples of a range of behaviour change programmes, although many of them have not been formally evaluated, and their inclusion here should be read in this light. As well as being discussed at the expert seminars, each discussion paper was posted on The King’s Fund website, where visitors to the site were invited to post comments and responses. Some of these comments and discussion from the seminars have been included, to illustrate the issues and debates raised. Aims and structure of the report This report aims to help those within the NHS and beyond who are tasked with finding solutions to the problems caused by unhealthy lifestyles and behaviour. It will be useful to PCTs and others seeking to commission services to promote healthy lifestyles and behaviour. It will also be useful to their partners in local government and the voluntary sector, providers of health and wellness services, NHS providers committed to supporting health improvement, and to policy-makers who are responsible for shaping the environment in which these organisations operate. Section 1 describes the scale of the public health challenge for each of the four behaviours – smoking, alcohol misuse, poor diet and lack of exercise – and discusses the importance of understanding the full range of reasons why people choose unhealthy behaviour. Section 2 discusses a range of tools that can help commissioners identify and understand the target population, which is crucial for effective behaviour change interventions. Section 3 looks at a range of behaviour change interventions to find out ‘what works’. It summarises the results of a number of interventions, including information, individual support and financial incentives. Section 4 discusses the difficulties of evaluating behaviour change interventions, and suggests ways to strengthen the evidence base in future. Section 5 examines the policy levers that are available, and the extent to which they can be used to support behaviour change interventions. Section 6 sets out recommendations for PCTs, commissioners, providers and policy-makers.   1 © The King’s Fund 2008 In this chapter, we describe the scale of the challenge facing the NHS as a result of people choosing unhealthy behaviours (smoking, alcohol misuse, poor diet and lack of exercise). We also discuss the complexities of understanding the reasons why people choose to adopt unhealthy behaviours (aside from the simple fact that they are often pleasurable or even addictive). Unhealthy behaviours and the illnesses they cause represent a significant proportion of the disease burden facing the NHS. Treating smokers costs the NHS in England £2.7 billion a year, compared with £1.7 billion a decade ago (Action on Smoking and Health (ASH) 2008). Alcohol misuse is thought to cost the NHS around £2.7 billion per year (National Audit Office 2008). Alcohol misuse also has wider costs for society, such as crime and disorder, social and family breakdown, and absenteeism. In total, alcohol- related ill health and crime and disorder is estimated to cost around £20 billion each year (Department of Health 2007b). The cost of treating obesity was approximately £47.5 million in 2002, a big increase from £9.5 million in 1998 (largely due to the increase in drug costs). The costs of treating diseases caused by obesity (such as coronary heart disease and type 2 diabetes) were estimated at between £945 and £1,075 million in 2002 (Information Centre for Health and Social Care 2008a). By 2007, the cost of prescriptions for all diabetes-related drugs had increased to more than £594 million, up 7 per cent on the previous year (Information Centre for Health and Social Care 2008c). If action is not taken, the financial cost to the NHS will grow and, according to Sir Derek Wanless (2004), could make the NHS itself unsustainable. This is why investing in effective behaviour change interventions is more important than ever. Smoking Smoking is the biggest cause of preventable deaths in England. In 2007 there were 82,900 smoking-related deaths among adults aged over 35, 18 per cent of all deaths. In England in 2006 were smokers: 23 per cent of men and 21 per cent of women. The highest prevalence of smoking was among 20–24-year-olds (31 per cent) and the lowest among those aged 60 and over. Overall the trend is moving in the right direction; with prevalence down from 39 per cent in 1980, smoking rates in England are currently the lowest on record (Information Centre for Health and Social Care 2008b). Who is more likely to smoke? We’ve either got to motivate low-income people to try to stop more often than high- income people to even things out, or we’ve got to give them greater assistance to quit. And since people are already trying to stop at quite a high rate, then the first of these is not very likely. (Seminar participant) People on low incomes are more likely to smoke. People in social grade E (casual or lowest grade workers, pensioners and others who depend on the state for their income) are more than twice as likely to smoke as people in social grades AB (administrative or professional staff). Smoking remains one of the biggest causes of the substantial and The scale of the public health challenge 1