a liberal dose? health and wellbeing – the role of the stateuser-raw]/11-06/rr.pdf · a liberal...

A Liberal Dose Health and Wellbeing ndash the Role of the State An independent report

February 2010

Richard Reeves

Contents Introductory letter 3

Executive Summary 4

Section 1 Context 7 1 Introduction Public Health Private People 7 2 The Public View 9

Section 2 Issues and Approaches 13 3 Some Recent Approaches Nudges versus Stewardship 13 4 What are the Key Issues 16

Section 3 Framework and Narrative 26 5 An Intervention Framework 26 6 A New Narrative 31

Annex A Test Cases Illustrating the Framework 33 Annex B Participants in the Expert Round Table 50

A Liberal Dose Health and Wellbeing ndash the Role of the State 1

Richard Reeves Richard Reeves is Director of Demos His principal areas of current interest are liberal political theory the economics and politics of wellbeing family policy trends in British politics and the future of the workplace His latest book is John Stuart Mill ndash Victorian Firebrand Richardrsquos former roles include Director of Futures at The Work Foundation Society Editor of the Observer principal policy adviser to the Minister for Welfare Reform Economics Correspondent of the Guardian and research fellow at the Institute for Public Policy Research

2 A Liberal Dose Health and Wellbeing ndash the Role of the State

Introductory letter Dear Andy

I enclose my report on the role of the state in promoting health and wellbeing You and your predecessor asked that this review be independently led in order to bring a fresh perspective to bear on this complex often controversial issue

Few would disagree with the idea that the state has a legitimate interest here For a wide range of economic social and ethical reasons the government of the day will be concerned with levels of health and wellbeing in the population To a considerable extent the health of a nation rests on the health of its people In particular the state has a legitimate role in promoting healthier behaviour because of the impact of ill-health on capability autonomy and life chances

The diffi cult question is how far a government should intervene in the choices and behaviour of individuals in order to promote their own health And this is the question with which my report is principally concerned Research conducted for this review shows that people want to be healthy and welcome government help to help make healthy choices easier But the majority of citizens ndash men and women rich and poor old and young ndash value their freedom to make their own decisions even if those decisions are unhealthy Good health is a key ingredient of a good life But so is freedom

The report makes a number of key points bull Ministers and offi cials should recognise that informed capable individuals have the

right to exercise free choice including if their choices cause harm to themselves The idea of lsquochoosing healthrsquo ndash which rightly animates much of government policy ndash only makes sense if the unhealthy choice is also available

bull Choices are not however made in a vacuum Government has an enabling role and should consider both individual capability and the social economic and physical environment in which individuals live Some groups may face higher hurdles to making healthier choices than others

bull The Government should pay particular regard to disadvantaged groups for whom the loss of freedom caused by ill-health may be greater and for whom healthy choices may be harder to make

bull Strong intervention to promote childrenrsquos health is justified Fears of intervening in family matters should not prevent action to support individual rights in this case the rights of individual dependent children not to suffer potentially life-long health problems

bull The grounds for interventions should be clearly articulated and government should ensure that messages have an appropriate tone treating adults as adults

I would like to record my thanks to you for supporting this independent review and for the opportunity to offer my refl ections I am also grateful for the support of Department of Health offi cials in the preparation of this report especially Lucy Ellis and Harriet Wallace Thanks are also due to the participants in the focus groups I would also like to record my gratitude to those who participated in a round table discussion on 16 July 2009 and especially to Julian Le Grand Richard Ashcroft and Mark Bassett for their detailed and helpful comments on a draft of the paper Any errors are of course my own

Yours

Richard Reeves


Executive Summary The role of the state in health and wellbeing is a complex and controversial issue A diffi cult question for any government is how far to intervene in the choices and behaviour of individuals in order to promote their own or othersrsquo health Good health is a vital ingredient of a good life ndash but so is freedom

This report

bull sets out evidence for what the public think about this question

bull explores the key issues at stake and clarifi es principles for state intervention

bull suggests a new framework to guide decision making and

bull proposes a new narrative for future state intervention

The state has a legitimate role in promoting healthier behaviour because of the impact of ill health on autonomy and life chances Health is a key capability for individuals in terms of their prospects of leading a fl ourishing autonomous life

But governments must recognise that people in free societies have the right to live in ways that may be harmful to themselves as long as they are not causing harm to others This is a stance that chimes strongly with the public attitudes revealed by research for this report Policy makers can legitimately encourage people to lsquochoose healthrsquo But by defi nition this allows the freedom for some people to choose otherwise

Choices are however not made in a vacuum and government can play an important enabling role considering both individual capability and the environment in which people live The social physical and economic contexts of peoplersquos lives deeply infl uence their everyday choices as demonstrated by recent work on behavioural economics Government can legitimately attend to the lsquochoice architecturersquo within which decisions are made as long as individual autonomy is not undermined

One of the differences between traditional public health problems such as communicable diseases and health problems relating to behaviour is that the goal is moderation of lsquogoodsrsquo rather than eradication of lsquobadsrsquo Most people derive some benefi t from alcohol or fatty food (and at least some smokers have no desire to quit) The goal is usually moderating and balancing consumption rather than preventing it altogether For some people especially those with stressful or diffi cult lives unhealthy behaviour ndash smoking or drinking to excess for example ndash may also be a coping mechanism So the best solution is not to coerce people away from unhealthy behaviours but rather to look at what is prompting this behaviour in the fi rst place to make healthy alternatives easier and more attractive and to provide support if people want to make changes

In particular government should have regard to disadvantaged groups for whom (for reasons of either capability or environment) healthy choices may be demonstrably harder to make But the dangers of paternalism do need to be guarded against here The principal way to improve the health and health behaviours of disadvantaged groups is to improve their broader life chances in terms of income employment skills and housing


And when targeting interventions on health behaviours at disadvantaged groups government should be careful not to simply assume that poorer people are intrinsically less able to make good choices or that they want the choice made for them The research for this report shows that freedom of choice is strongly valued across the socio-economic spectrum

This report discusses the principal issues at stake for public policies promoting healthier behaviour ndash capability choice harm responsibility children tone and disadvantage ndash and then sets out a framework for assessing government interventions The framework does not provide a set of lsquotick boxrsquo tests for every potential policy the issues and tradeshyoffs confronting policy makers are complex and nuanced But it does attempt to set out the key questions that need to be addressed when contemplating or assessing particular interventions

I propose that government should ask three sets of questions when considering interventions intended to change behaviour in terms of health and wellbeing

1 Legitimacy How strong is the case for intervention

The state can legitimately intervene to either prevent harm to the health of others or to lower barriers to informed choices on health

There is a strong case for intervention to prevent signifi cant direct harm to others Where no harm to others is involved informed choice should be the policy goal for capable individuals But if there are barriers (of either environment or capability) to individuals making an informed autonomous choice government may be justifi ed in intervening to reduce those barriers ndash while leaving the choice to the individual There is a strong case for intervention to reduce behaviour with no signifi cant intrinsic benefi ts but government should be more cautious regarding forms of consumption that in moderation may enhance wellbeing and are valued by individuals

2 Autonomy Given the strength of the case for intervention how can government respond in a way that protects (or increases) autonomy

Government should attempt to intervene in a way that enhances individual autonomy This is not only because autonomy and feeling in control of your life is strongly associated with good mental and physical health but also because personal agency is valuable in itself

Government should also consider on whose autonomy its policies have an impact In general restricting the freedom of corporations and institutions is more legitimate than restricting that of individuals Strong intervention to promote childrenrsquos health is justifi ed since children are not as capable as adults of making informed choices


The grounds for any intervention should be clearly articulated and government should ensure that messages have an appropriate tone Respecting peoplersquos ability to make trade-offs policy silos should be broken down so that people do not feel besieged by separate campaigns on different risk factors

3 Effectiveness Finally policy interventions should not be pursued unless there is good evidence of effi cacy and cost-effectiveness

Drawing on the work of Professor Julian Le Grand and Health England the report proposes some tests for assessing effectiveness including possible harm positive impact on health cost and feasibility

Debates around intervention to promote healthier behaviour have become stuck in a cul-de-sac about the reach of the so-called lsquonanny statersquo The media has a responsibility to allow for more nuanced discussion But the Government also needs to strike a different tone in its messages around health and behaviour with greater weight placed on informed choice and individual capability At the same time the Government can make a stronger case for intervention to protect children especially from harm caused by others There is also a strong case for offering additional support to the most disadvantaged for whom poor health compounds other obstacles to an autonomous life The Government has a responsibility to promote health but needs to recognise the limits of its own reach and the freedoms of its citizens in striving for a healthier freer society


Section 1Context

1 Introduction Public Health Private People In Aldous Huxleyrsquos Brave New World the Savage representing free will rejects the ordered world overseen by the Controller Mustapha Mond a world in which lsquoeverybodyrsquos happy nowadaysrsquo

ldquoBut I donrsquot want comfort I want God I want poetry I want real danger I want freedom I want goodness I want sinrdquo ldquoIn factrdquo said Mustapha Mond ldquoyoursquore claiming the right to be unhappyrdquo ldquoAll right thenrdquo said the Savage defi antly ldquoIrsquom claiming the right to be unhappyrdquo ldquoNot to mention the right to grow old and ugly and impotent the right to have syphilis and cancer the right to have too little to eat the right to be lousy the right to live in constant apprehension of what may happen to-morrow the right to catch typhoid the right to be tortured by unspeakable pains of every kindrdquo There was a long silence ldquoI claim them allrdquo said the Savage at last

The role of the state in the promotion of health and wellbeing is complex and controversial Governments and state agencies are clearly expected to invest heavily in the nationrsquos health for a wide range of social ethical and economic reasons These include protecting citizens from harms to health by others building capability in individuals to widen their life chances and promoting the health and sustainability or the society itself1 The diffi cult question for any government is how far to intervene in the choices and behaviour of individuals in order to promote their own ndash or othersrsquo ndash health Good health is a vital ingredient of a good life ndash but as the Savage reminds us so is freedom

The rationale for intervention in health and behaviour and the narrative to support it can become unclear The principles guiding state action and its limits are opaque

1 I am grateful to Richard Ashcroft for his thoughtful comments on the rationale for state action on health


Of course government ministers and offi cials are not helped by public debates typically framed by the absurd question of whether one favours or opposes the so-called lsquonanny statersquo Nobody seriously believes that the state should take responsibility for the diet and exercise regime of the entire citizenry Nobody sensible argues that the state should adopt a pure laissez-faire stance eschewing any responsibility for the health of the population The question is where on the spectrum between coercion and indifference the state can legitimately act and what form those actions might take

There are real issues at stake here and there is no hope of a complete consensus about the appropriate reach of state action Arguments about offi cial involvement in personal choices will be ongoing there is no fi nal answer to these diffi cult questions Indeed these arguments should be welcomed as part of the public reasoning necessary for securing democratic support for the actions government does undertake As the late philosopher Bernard Williams reminded us lsquodisagreement does not necessarily have to be overcomersquo2 But we should at least be clear what our disagreements are about The modest ambition of this report is to assist in this endeavour

This report commissioned by the Secretary of State for Health

bull sets out evidence for public opinion on the legitimacy of state activism on health and wellbeing

bull explores the key issues at stake in determining the scope of state action

bull clarifi es the principles that ideally should underpin state intervention

bull outlines a suggested framework to guide decision making underpinned by a focus on capability and

bull provides a narrative for future state intervention

This report does not address questions about the appropriate models for the provision of care or the future of the NHS It assumes the provision of care for the sick through a national tax-funded system free at the point of delivery The role of the state in promoting healthier living is the central issue not its role in treating sickness This report also touches only briefl y on behavioural sciences the considerable body of evidence on the factors driving behaviour change is tackled in another report prepared for the Secretary of State by Geoff Mulgan3

The focus here is on the grounds for and legitimacy of state intervention in the choices norms and behaviour of citizens as they relate to health This is now a central concern in health policy The proportion of health problems relating to personal behaviours such as smoking obesity and excessive alcohol consumption has grown considerably in recent years These are seen as lsquopublic healthrsquo problems but this labelling is not necessarily helpful A public health issue was previously one where an illness was directly communicable or where the health of the individual and the health of the population as a whole were directly and inescapably bound together In these cases the state can act strongly ndash through immunisation food standards or water quality controls ndash to support a clear public good or tackle a clear lsquocollective actionrsquo problem

2 Bernard Williams (1985) Ethics and the limits of philosophy p133 3 Geoff Mulgan (2009) Infl uencing public behaviour to improve health and wellbeing


But in the UK today many of the problems described as lsquopublic healthrsquo ones are in fact the cumulative effect of millions of private health problems with few direct consequences for others The deleterious health effects of smoking being signifi cantly overweight or drinking heavily are overwhelmingly felt by the individual concerned rather than by the population as a whole The danger with applying a traditional whole-population public health approach in these areas is an insufficient sensitivity to the unique values and desires of each person The individual can get lost in the crowd The question then is how the state meets its share of responsibility for the nationrsquos health and protects citizens from harm by others without eroding individual autonomy

The views of a number of experts and leading thinkers in the fi eld have been drawn on in the preparation of this report But the fi rst step was to gauge the views of members of the public

2 The Public View There are some tensions in public opinion on the role of the state in promoting healthier behaviour4 On the one hand there is an apparent desire for the state to do more but on the other resistance to being lsquoregulatedrsquo To explore further we commissioned a piece of robust qualitative research with a representative sample of the general public The research was carefully designed ndash with a mixture of group work creative stimulus and individual face-to-face interviews ndash to help respondents move from a discussion based in their personal experience of health and wellbeing issues to the more abstract debate about the state and its role in the lives of UK citizens Scenario options were offered (showing different levels and types of state intervention) in order to facilitate and explore the reactions of the public

Freedom of choice The statersquos role was instinctively conceptualised in terms of NHS hospitals and people were clear that the state had a duty to provide direct treatment to citizens who are unwell However thinking about the statersquos role outside direct treatment in terms of helping citizens stay well respondentsrsquo starting point was that the statersquos primary function was to protect freedom of choice

ldquoBritish people have their own mindshellip we like our freedomrdquo [Male 65+ C2 Birmingham]

Respondents valued being healthy and well But they also emphasised that many lsquounhealthyrsquo choices have a signifi cant positive impact on short-term wellbeing In protecting their own choices they wanted to be lsquotreated like adultsrsquo and to make their own trade-offs between lsquohealthrsquo and lsquopleasurersquo

ldquoYoursquove had a hard dayrsquos work and you come home You want a drink A nice cold beerrdquo

[Male 35ndash54 AB Manchester]

Ipsos MORI Real Trends report December 2008


4

Tone was important ndash lecturing people was counterproductive

ldquoI donrsquot knowhellip I donrsquot pay any attention to ithellip I donrsquot like being told you should and shouldnrsquot do thathellip even if some of them are rightrdquo

[Male 25ndash34 D Slough]

Across the board and across all socio-economic groups there was strong defence of freedom of choice from most respondents In terms of possible state intervention legislation was perceived to run the risk of penalising the majority for the actions of a reckless minority Mass intervention targeted at controlling the behaviour of the lowest common denominator was felt to signifi cantly and disproportionately erode the personal freedoms of the majority

In particular this argument was used to defend alcohol ndash where most respondents felt that the problem was not with the substance itself but with lsquothe drinkerrsquo and that the behaviour of the reckless minority in a town on a Saturday night was not to be taken as the yardstick for all

ldquoIt depends on what it is if they are encouraging people to eat healthy food and exercise then fair enough but if they ask us to stop smoking or drinking then it is a negative way to talk about thingshelliprdquo

[Male 18ndash25 C2 Birmingham]

Children however were felt to constitute a special case Freedom of choice was not seen as a principle that could be defended for those who did not have the capacity or resources to make an informed choice Adult freedoms had to be balanced against the protection of young people

ldquoIt is different with the children You have to try and steer them in the right direction I thinkrdquo

[Male 35ndash54 C2 Slough]

That said respondents largely favoured interventions that left the control and freedom of the parent in respect of their children Blanket interventions applied to young people that signifi cantly undermined parental responsibility were not favoured

Intervention welcomed if evidence is believed to support it When discussing principles respondents were wary about giving a carte blanche mandate to government to intervene in their private health behaviours to a large extent The challenge ndash to manage the lsquoreckless minorityrsquo while differentiating them from the lsquoreasonable majorityrsquo ndash was felt to be too hard to achieve

However when allowed to consider specifi c health behaviours and issues people were more willing to accept proportionate government intervention The level of intervention and the degree of proactive government action were accepted in proportion to the extent to which they believed there was evidence of harm from the behaviour in question


Most respondents for example felt that the argument for the health risks of smoking had been made fairly strongly and so felt that the state had a stronger legitimacy to act to limit smoking harm

As mentioned above the picture on alcohol was very different adults were broadly in favour of being allowed to drink what and when they choose Interventions were less welcomed although lighter-touch interventions centred around communication of information were seen as an important part of the statersquos role

Unlike smoking and despite evidence to the contrary alcohol per se was not seen as the root of a health problem for the majority Public disorder ndash caused by lsquoirresponsible drinkersrsquo ndash was felt to be the main problem arising from alcohol Once the issue had been framed around public disorder more felt that some state intervention targeted at the publicly disorderly would be appropriate

Help make healthy choices easier People talked about the barriers to being healthy lsquoWorking to liversquo was seen as the key barrier to working for a healthier life lack of time in busy stressful modern life forcing shortcuts in food (content and portion size) and encouraging a lsquotreatingrsquo or lsquosnackingrsquo mentality drinking and sedentary activity

ldquoI occasionally exercise I used to run marathons but when I started full-time work I got too tired and drained got into the routine of getting home and going for a drinkrdquo


There was a strong desire for help from the Government in this space to make healthy choices easier A key issue was balancing the unhealthy choices pushed by companies pursuing a commercial interest Respondents felt that the mandate for government on industry regulation was fi rm It was felt to be an essential element of the state protecting its citizens protecting their freedom of choice by helping them to choose equally between healthy and unhealthy options by ensuring that both are offered and promoted fairly

ldquoI do get a bit cross at my local shop that sells six cans of Strongbow ndash my husband will come home and say lsquoI got six cans ndash they were only pound5rsquo ndash to a certain degree shops and supermarkets are to blamerdquo

[Female 25ndash34 D Slough]

ldquoWhy do they let you have massive boxes of popcorn when you go to the cinema They just want your money They should make them make smaller onesrdquo


ldquoI think they do have more scope to remove fi zzy drinks and chocolate barsrdquo [Female 65+ C2 Birmingham]

ldquoThe Government should target people who sell alcohol because who do you think young people get it from Some shopkeepers check their IDs but some donrsquot They should be stricter on thisrdquo

[Female 16ndash18 C2 Birmingham]


Wellbeing as well as health The other key fi nding from our research was the importance of terminology Talking about lsquohealthrsquo moves respondents into a familiar discourse about illness and hospitals that does little to motivate them to take positive action They were able to reel off the problems with alcohol smoking junk food and lack of exercise and to identify them as the key elements that affect health adversely However there seemed to be a large disconnect for most between what is known generally (in terms of cause and effect) and what is practised personally (as lsquoa way of living in the worldrsquo) lsquoHealthrsquo is a slightly distant abstract idea

The term lsquowellbeingrsquo moves individuals into a more lsquopersonalrsquo space where they are thinking about their own personal stake in the outcome ndash positive feelings of happiness comfort and lack of stress However for many wellbeing was achieved in the short term through what might be termed lsquounhealthyrsquo behaviours


Section 2 Issues and Approaches

3 Some Recent Approaches Nudges versus Stewardship A number of publications in recent years have considered the role of the state in health and wellbeing Two approaches in particular stand out and have been taken into account in preparing this report and the framework in Chapter 5 This section provides a brief summary and critique of libertarian paternalism and the stewardship model

Libertarian paternalism was originally developed by University of Chicago professors Richard Thaler and Cass Sunstein5 and expanded in their popular 2008 book Nudge Improving Decisions About Health Wealth and Happiness6 It is based on behavioural economics literature which is discussed more fully in Geoff Mulganrsquos report7 Its application specifi cally to the public health fi eld has since been explored by others including Julian Le Grand8

Thaler and Sunstein portray the lsquorational economic manrsquo of traditional economics as a myth They point out that real people are inconsistent ill-informed weak-willed and lazy They want to help real fallible people make better choices without removing their right to choose So the libertarian paternalist approach aims to preserve freedom of choice but authorises private and public institutions to steer people in directions that promote their welfare Its great strength is that it builds on the fact that defaults matter that governments are choice architects and so cannot be neutral ndash there is not a lsquodo nothinglsquo option Something has to be placed next to the till in shops ndash and whether it is fruit or chocolate makes a huge difference to peoplersquos health behaviours as does whether the stairs or the lifts are signposted more clearly at the entrances to buildings

5 Richard Thaler and Cass Sunstein (2003) Libertarian Paternalism American Economic Review 93(2)175ndash9 6 Richard Thaler and Cass Sunstein (2008) Nudge Improving Decisions About Health Wealth and Happiness 7 Geoff Mulgan (2009) Infl uencing public behaviour to improve health and wellbeing 8 Julian Le Grand (2008) The giants of excess a challenge to the nationrsquos health Journal of the Royal Statistical

Society Series A 171(4)843ndash56


Small differences in the choice environment can make quite signifi cant differences in the choices people make

The lsquonudgersquo approach preserves freedom of choice hence the apparently oxymoronic term lsquolibertarian paternalismrsquo but it is unashamedly interventionist in framing those choices This is not libertarian according to any sensible use of that term and actually not even very liberal The most honest description offered by the authors of their approach is lsquoa relatively weak soft and non-intrusive type of paternalismrsquo However Thaler and Sunstein offer a persuasive argument for this soft non-intrusive paternalism in areas where people are very often lsquotheir own worst enemyrsquo the key being that this is about increasing easy opportunities to make healthy choices It does not remove the unhealthy choice altogether

The stewardship model as proposed in the World Health Organizationrsquos World Health Report 20009 was developed in the Nuffi eld Council on Bioethicsrsquo 2007 report Public health ethical issues10 It sets out a framework for encouraging healthier behaviours starting from a perspective that governments have a responsibility to protect the nationrsquos health and to serve in the public interest and for the public good It believes that libertarian paternalism does not go far enough ndash that sometimes people should not be given the possibility of opting out lsquoAlthough full-blown paternalism would be an inappropriate basis because it is insuffi ciently sensitive to the need for a mandate libertarian paternalism is not suitable as it may allow too much choice and it might also absolve the state from some important responsibilitiesrsquo11

The stewardship model sees government as having an active positive role in particular in addressing health inequalities It proposes that sometimes authoritarian measures are justifi ed if the collective interest outweighs the individual It lsquorecognises that the state should not coerce people or restrict their freedoms unnecessarily but also that the state has a responsibility to provide the conditions under which people can lead healthy lives if they wish The stewardship state in addition to protecting its citizens from harm caused by others sees itself as having a particular responsibility for protecting the health of vulnerable groups such as children and in closing the gap between the most and least healthy in societyrsquo

However we should not overstate the differences in these two approaches They start from different perspectives and the stewardship model at times advocates going further than libertarian paternalism would but they share a lot of common ground A summary of the stewardship model is set out below

Concerning goals public health programmes should

bull aim to reduce the risks of ill health that people might impose on each other

bull aim to reduce causes of ill health by regulations that ensure environmental conditions that sustain good health such as the provision of clean air and water safe food and decent housing

9 World Health Organization (2000) The World Health Report 2000 Health Systems Improving Performance 10 Nuffi eld Council on Bioethics (2007) Public health ethical issues 11 Ibid p25


bull pay special attention to the health of children and other vulnerable people

bull promote health not only by providing information and advice but also with programmes to help people overcome addictions and other unhealthy behaviours

bull aim to ensure that it is easy for people to lead a healthy life for example by providing convenient and safe opportunities for exercise

bull ensure that people have appropriate access to medical services and

bull aim to reduce unfair health inequalities

In terms of constraints such programmes should

bull not attempt to coerce adults into leading healthy lives

bull minimise interventions that are introduced without the individual consent of those affected or without procedural justice arrangements (such as democratic decision-making procedures) that provide adequate mandate and

bull seek to minimise interventions that are perceived as unduly intrusive and in confl ict with important personal values

The Nuffi eld report proposes an lsquointervention ladderrsquo which ranks interventions in terms of their impact on individual autonomy lsquoThe higher the rung on the ladder at which the policy maker intervenes the stronger the justifi cation has to be A more intrusive policy initiative is likely to be publicly acceptable only if it is clear that it will produce the desired effect and that this can be weighed against the loss of liberty that will resultrsquo12

The stewardship approach provides a useful tool to compare alternative approaches But while it includes autonomy as an important value it tends towards an overly paternalistic approach There are two principal diffi culties with the model in this regard First lsquopublic acceptabilityrsquo should not be the only check against excessive intervention as suggested in the Nuffi eld model Even if a total ban on alcohol or smoking became publicly acceptable ndash in the sense of having majority support ndash it would still be wrong to enact one because of the loss of freedom entailed (this is why Mill warned against lsquothe tyranny of the majorityrsquo13) A democratic mandate for government action is important But a policy attracting majority support is not automatically legitimate We live after all in a liberal democracy

Second the main justifi cation for intervention offered by the Nuffi eld model is the effectiveness of the policy So if a policy is highly effective it can be highly intrusive This is to put the cart before the horse A total ban on smoking might be highly effective at lowering rates of smoking and therefore rates of cancer and heart disease However policy makers must first determine whether the intervention is legitimate ndash given a clear commitment to freedom of choice ndash and then assess whether it would be effective This is not to say that effectiveness should not be taken into account of course it is a signifi cant issue Many perfectly legitimate interventions will be avoided or abandoned on the (hopefully) non-controversial grounds that they do not work

12 Ibid p42 13 John Stuart Mill (1859) On Liberty


4 What are the Key Issues Building on insights from the approaches discussed above in this section I examine a number of key issues that have a bearing on state intervention on health and wellbeing

bull the capability perspective

bull freedom of choice

bull the harm principle

bull the locus of responsibility

bull the special case of children

bull striking the right tone and

bull inequalities and disadvantage

Capability Good health matters because it is a crucial ingredient in a good autonomous life The philosopher and economist Amartya Sen has constructed an approach to social policy based on lsquosubstantive freedomsrsquo or capabilities defi ned as lsquothe power to do somethingrsquo14 Senrsquos approach has signifi cantly infl uenced policy and practice on international trade aid policy and human development In Senrsquos view a person is not free simply because they are left to their own devices but because they enjoy a real lsquoopportunity setrsquo of possible life choices It is a positive notion of freedom echoed by the ambition of one government minister for a lsquosociety of powerful peoplersquo15

It is not surprising that Sen ranks health very highly in his capabilities approach since health underpins not just life expectancy but life chances too16 In one of his most famous examples Sen describes three people who might be considered for a new job and the different grounds on which of them might be seen as the most deserving In Senrsquos view social justice would indicate that the job should not go to the one whose income or happiness will be most improved but to the one whose health ndash and therefore capability ndash will be most enhanced17

The state has then a legitimate and signifi cant role in nurturing health as a capability But Senrsquos work shows additionally the need to attend carefully to the impact on freedom of choice From a capability perspective it makes no sense for a government to coerce healthier behaviour In part this is because autonomy is itself associated with higher levels of wellbeing and mental health but principally because personal agency is valuable in and of itself

The value of individual agency does not rest on an assumption that people will automatically rationally pursue their own interests Individuals are often irrational and they often pursue perfectly reasonable goals that are not related to their own gain As Sen writes lsquoThe freedoms and capabilities we enjoy can also be valuable to us and it is ultimately for us to decide how to use the freedom we haversquo

14 Amartya Sen (2009) The Idea of Justice p19 15 Liam Byrne and Demos (2009) Powerful People 16 Amartya Sen (2009) The Idea of Justice 17 Amartya Sen (1999) Development as Freedom


Nor does the capabilities approach presume that individuals make their choices in a vacuum uninfl uenced by their social surroundings In making their own valuation of what constitutes a good life people draw on the views norms and values of the people with whom they share a community As Sen concludes lsquoUltimately it is individual valuation on which we would have to draw while recognising the profound interdependence of the valuations of individuals who interact with each otherrsquo18

The capabilities perspective is a liberal one acknowledging and embracing the right of individuals to make their own valuations and choices But it also recognises that peoplersquos life trajectories will be shaped by the norms ethics and opportunities in the society of which they are a part

Choice People rightly value the freedom to make their own choices as the qualitative research summarised in Chapter 2 demonstrates Freedom of choice is also a moral good in its own right as Senrsquos work demonstrates Previous government publications ndash especially Choosing Health (2004) ndash have correctly described the goal of adults being free to make lsquoinformed choicesrsquo about their own health But this choice aspect of the Governmentrsquos agenda is often not as explicit as it could be

Few people could argue with the principle that informed adults should make their own choices about their own health But there are a number of points worth making on choice

bull Freedom of choice is not straightforwardly in opposition to healthy behaviour indeed there is good evidence that as well as being an ethical imperative freedom is benefi cial to health Autonomy and feeling in control of your life is strongly associated for example with good mental and physical health This is not to say that free choice is always ndash and everywhere ndash good for health food rationing would almost certainly halt the rise in obesity But policy makers should recognise that choice does bring intrinsic benefi ts

bull People are free to make bad choices as well as good ones Even armed with all the facts about the consequences of a certain behaviour or act they may choose the less healthy option Of course most people want to be healthy and are glad of help from the state in achieving this goal But health professionals and policy makers should keep close to the front of their mind the right of each of us to make a different set of choices Governments cannot coerce healthier behaviour in the name of liberty

bull People are not rational utility-maximising ndash or health-maximising ndash machines Few of us manage to consistently and stoically balance our desire for immediate gratifi cation and wellbeing with our long-term interests Most of us struggle to do the right thing by our bodies all of the time Geoff Mulganrsquos report shows the myriad ways in which people act irrationally in terms of maximising their own health19 Behavioural psychology also tells us that many people regret past decisions for example wishing they had given up smoking But this is based on averages the Government cannot presume to know each individualrsquos future desires on this basis There are plenty of decisions that adults might fairly

18 Amartya Sen (2009) The Idea of Justice p244 19 Geoff Mulgan (2009) Infl uencing public behaviour to improve health and wellbeing


predictably come to regret ndash marrying too early say or dropping out of college There are however no legitimate grounds for preventing people from making these choices in part because for some people it will prove to be a good choice and in part because even if we often make choices we come to regret they remain our choices and our regrets

bull Information is obviously critical to informed choice and public health education is intended to provide it The marketing budget of the Department of Health is therefore not a lsquosoftrsquo area of spending but a vital contributor to a well informed citizenry on health issues The goal of informed choice has signifi cant implications in some consumer markets too for example through food labelling

bull Choices are not made in a vacuum The social physical and economic contexts within which a decision is made deeply infl uence everyday choices Peer pressure price and availability all impact on the chances of an individual choosing one course over another It is harder to quit smoking when all your friends are lighting up We are more likely to buy fruit or chocolate if it is placed right in front of us at the till But lsquochoice architecturersquo is broader than what is placed within reach in the supermarket The broader circumstances of peoplersquos lives ndash their life chances in terms of education income employment housing and so on how stressful and busy their lives are whether they are in good mental and physical health ndash have a huge impact on health risk behaviours such as smoking or overeating Simply acknowledging that choice can be profoundly infl uenced by the surrounding environment does not in itself provide suffi cient grounds for intervention ndash but it is certainly a factor

bull Personal economic or social circumstances may make it harder for some adults to make healthier choices (the question of children is tackled separately below) Most obviously an adult with serious learning diffi culties or with a disease such as dementia that impacts on their capacity to make autonomous choices cannot be assumed to be making an informed choice and will require much greater support and intervention For the general population there may be less extreme examples where people will fi nd it harder to make healthy choices Somebody on a low income for example may face higher barriers to choosing a healthier diet or less peer support in giving up smoking (smoking rates are very much higher among low-income communities) This justifi es the targeting of state help and advice on those groups who face higher hurdles to better health But governments should not simply assume that poorer people are less able to make better choices or that they want their choices made for them The qualitative research in Section 1 shows that they donrsquot And it is important to remember that while a particular choice may be harder to make for some than for others it is still a choice

bull People can have preferences about their own desires Most people who smoke want not to smoke So in the short term the lsquochoicersquo is to have a cigarette in the longer term the choice would be to not want the cigarette in the fi rst place These are called lsquosecond-orderrsquo preferences and have some purchase on the role of the state in health It is legitimate for the state to help people actualise their second-order preferences by making it easier to quit smoking


for example or cheaper to go swimming But it is not legitimate for the state to simply assume that everyone has the same second-order preferences Think for a moment about the fact that after decades of health education on the dangers of smoking 26 of smokers still want to carry on smoking20

Clearly this fi gure covers a wide range of reasons for wanting not to quit And nicotine is incredibly addictive more so than heroin But many people do give up Others recognising that they are addicted and aware of the risks choose to continue smoking These are not people who need help quitting these are people who know the risks but nonetheless do not want to quit They are making in public health parlance an lsquoinformed choicersquo just not the one the Government would prefer them to make

Harm One of the central insights of liberal philosophy ndash that people may be free to harm themselves but not to harm others ndash is a commonsense position with signifi cant purchase as the insight work discussed in the previous section shows A person is free to drink alcohol even at a greater risk of killing themself But they are not free to drink-drive because of the greater risk of killing someone else The capability perspective enriches this classical liberal approach by recognising that somebody can be harmed by a lack of resources by capability deprivation But it does not take away the right of informed capable people to make choices that damage their own health

John Stuart Millrsquos famous maxim published a century and a half ago in On Liberty remains a useful starting point in discussions of state power lsquoThe only purpose for which power can rightfully be exercised over any member of a civilised community against his will is to prevent harm to others His own good either physical or moral is not a suffi cient warrantrsquo

Harm to others underpins intervention in a range of areas most obviously in criminal law but in some health matters too such as smoking Harm principle arguments also provide solid grounds for state intervention in immunisation as well as laws on food and water safety limits on pollution radiation and so on These are not generally controversial issues

But there are three points worth making on harm principle arguments as they relate to health and behaviour

bull First there is an issue of consent or choice An adult might knowingly consent to run a degree of risk from the behaviour of another (for example by freely choosing to live with a heavy smoker) As long as the risks associated with the decision are known this is a perfectly legitimate individual choice

bull The second issue is the lsquoNHS costsrsquo argument Interventions to change behaviour are sometimes justified on the grounds that ill health harms every taxpayer by raising the costs of the NHS Of course potential savings to the health service from interventions to promote healthier behaviour should be measured and weighed in terms of calculating the cost-effectiveness of

20 Offi ce for National Statistics (2008) Smoking-related Behaviour and Attitudes 2007 wwwstatisticsgovukdownloadstheme_healthsmoking2007pdf


particular interventions But doubtful arguments about lsquoharmrsquo imposed via higher government spending tend to weaken rather than support the case for intervention To take one example there is good evidence that smoking is good news for the public fi nances since smokers pay lots of tobacco tax and die younger (which saves on pension provision) Reducing rates of smoking may then worsen the public fi nances But this is no argument against health education campaigns highlighting the risks of tobacco Smoking is a problem because it worsens health and life expectancy thereby damaging capability not because it adds to the Treasuryrsquos tab It is hard to use lsquofi scal harmrsquo arguments when they appear to support intervention for example on alcohol but turn a blind eye to them when they point in the other direction for example on smoking

bull The third and most diffi cult issue relating to harm principle arguments is how far it is the responsibility of the state to intervene in lsquoprivatersquo spaces as against lsquopublicrsquo ones Smoking provides the most instructive example here Smoking has been banned on buses but not in cars (except those being used for business purposes) in pubs but not in living rooms As far as adults are concerned there is an important line between public and private spaces ndash even if it is not always easy to draw with precision But children are another matter Since they cannot realistically be said to consent to their treatment or environment there is a strong philosophical justifi cation for protecting children from harm infl icted by their parents even in lsquoprivatersquo spaces in part to shift cultural norms towards making harm to children less socially acceptable

Applied properly harm principle arguments are still useful in contemporary debates about health They do not intrinsically support either the lsquopaternalistrsquo or lsquolibertarianrsquo position they may lead to lighter intervention in some areas and heavier intervention in others But governments must recognise that people in free societies have the right to live in ways that may be harmful to themselves Policy makers can legitimately encourage people to lsquochoose healthrsquo But by definition this allows the freedom for some people to choose otherwise Otherwise it is no lsquochoicersquo at all

Responsibility One of the key issues of principle raised in discussions about the role of the state in health and behaviour is the locus of responsibility From a pure libertarian perspective responsibility for healthy behaviour rests with individuals On a strict paternalist view people cannot be expected to take responsibility for their own health and an external agency ndash usually the state ndash has to act on their behalf with strict rules and sanctions

But this is an area of policy and politics where responsibility cannot be straightforwardly assigned Is the obesity of a young child the responsibility of the parent the state the community or the corporations marketing unhealthy food and drink The answer is all of the above Discussions about healthy behaviour and the state would benefi t from what the philosopher Susan Hurley called an lsquoecologicalrsquo model of responsibility Responsibility is shared across a set of complex agents and relationships rather than simply sitting in one place As Hurley put it


It is a serious mistake to assume that if an individual agent is responsible for what he does and rightly held responsible for harmful effects of his action then no further questions arise about how others might also be responsible and how those harmful effects can most effectively and should be avoidedhellip Responsibility for certain effects is not exclusive nor is there a fi xed quantity of it which once allocated to an individual agent is somehow used up21

In particular institutions ndash including corporations ndash have a responsibility for the impact of their activities Governments have often been more wary of curbing the behaviour of companies than of citizens But in liberal societies it is the freedoms of people rather than institutions that counts most Of course institutions ndash private public and civic ndash are made up of infl uence and serve individuals But institutions do not have the same fundamental rights to freedom of operation as individuals Human rights attach to people not organisations Institutions can be subject to rules and regulations that could not be legitimately applied to individuals in their private decision making employment law health and safety legislation legal protections against discrimination fi nancial transparency and so on There is a considerable difference between banning tobacco advertising and banning individual consumption of tobacco

Senrsquos capability approach to freedom also has implications for responsibility lsquoFreedom to choose gives us the opportunity to decide what we should dorsquo he writes lsquobut with that opportunity comes the responsibility for what we do ndash to the extent that they are chosen actionshellip Since a capability is the power to do something the accountability that emanates from that ability ndash that power ndash is a part of the capability perspective and this can make room for demands of dutyrsquo22

Children Children cannot be expected to take the same responsibility as adults Especially at a young age they do not possess the necessary information skills and autonomy to make decisions about their own health They are economically and socially dependent on adults But the life chances of an adult are shaped by their childhood and childhood health relates strongly to adult health in Wordsworthrsquos terms lsquothe child is the father of the manrsquo There is therefore a much stronger case for intervening to protect and promote childrenrsquos health Few would oppose a ban on vending machines in schools while few support a ban on vending machines in workplaces

Children especially in the fi rst few years of life are most profoundly infl uenced by their parents One of the most diffi cult questions is how far the state can legitimately intervene to protect children from the decisions and behaviour of their parents There are obvious concerns about the state crossing into lsquofamily mattersrsquo But equally individual children are entitled to protection from harm by others ndash even if the lsquoothersrsquo are their parents The issue then becomes what level of harm justifi es what level of intervention There may also be straightforward questions of enforceability It may be philosophically justifi able to ban parents from smoking in enclosed spaces with dependent children but impossible to put into practice

21 Susan Hurley (2004) Imitation Media Violence and Freedom of Speech Philosophical Studies 1171ndash2 22 Amartya Sen (2009) The Idea of Justice p19


lsquoChildhoodrsquo is not of course a simple category There is no clear line at which a wholly dependent child suddenly becomes an entirely independent adult There is a wide age range across which cognitive ability knowledge self-awareness and responsibility are all growing Adulthood is generally assumed in state policies to come in the late teens typically 18 There are inevitably oddities in policy approaches currently the age of consent for sex is lower than the age at which alcohol or cigarettes can be purchased But the broad principle holds that children especially young children are a legitimate focus of state intervention in health

Striking the right tone One of the additional challenges for framing policy towards healthy behaviour is that many of the choices that can lead to poorer health can also bring real benefi ts especially in moderation Fatty food can taste great A beer or glass of wine with friends is enjoyable Interventions in these areas have to be sensitive to the fact that at least in moderation these are lsquogoodsrsquo not lsquobadsrsquo Many of the choices that policy attempts to counter are ones that bring real wellbeing benefits to the person choosing them This means that attempts to shift choices in a healthier direction are often concerned with moderating consumption of certain items such as high-fat food and alcohol rather than stopping consumption altogether There are other forms of consumption such as smoking that are lsquomonotonicallyrsquo bad ndash one cigarette a day is worse than not smoking at all But even here it is necessary for policy makers to recognise that in the view of some smokers at least they are deriving some benefi ts from their smoking

For most people the question is also one of balance between our various indulgences We might drink a bit too much but manage to keep our weight down and cycle to work or keep our alcohol intake down to BMA-accepted levels but fail to give up the takeaway food But because policy on different risk behaviours tends to operate in silos these trade-offs are often not acknowledged With separate campaigns on alcohol exercise salt lsquo5 A DAYrsquo of fruit and vegetables smoking weight gain and so on individuals can start to feel besieged No normal person can meet the goals of all these campaigns at once and the danger is that they react by crying lsquonanny statersquo and ignoring it all Rather than coming at healthy behaviour from all sides it may sometimes be better to promote a generally balanced life allowing for lsquoa little of what you fancyrsquo rather than what might come to seem a fairly spartan existence

State agencies and politicians also need to work harder to strike an appropriate tone when delivering messages ndash both of encouragement and discouragement ndash around health behaviour People want information but they dislike being lectured as our qualitative research confirmed Over-zealous health messages can backfi re by making people bloody-minded (and there is perhaps a risk of this happening on alcohol at the moment) There are plenty of people who react to inappropriately delivered medical lsquoadvicersquo like Charles Lamb who when ordered by his doctor to walk on an empty stomach every day replied lsquoBut whose stomachrsquo

There can be a tension between creating simple memorable messages and fully setting out the evidence on risks which may be more complex This is a diffi cult balance to strike to make messages clear but not oversimplifi ed There can also be a tension between giving the most accurate advice based on current evidence and taking a


precautionary approach to advice where the evidence base may be less certain These tensions can be seen for example in the current abbreviated messages on alcohol consumption during pregnancy

The full CMO advice is

bull Pregnant women or women trying to conceive should avoid drinking alcohol

bull If they do choose to drink to protect the baby they should not drink more than 1 to 2 units of alcohol once or twice a week and should not get drunk

This message seems along exactly the right lines in communicating risks to people in an intelligent and evidence-based way equipping people to make an informed choice There is a strong argument for precautionary advice since the current evidence base does not rule out that drinking could cause harm to a baby But (as current NICE guidance also makes clear) neither is there any evidence of harm to the unborn baby from drinking at low levels (one or two units once or twice a week) after the fi rst three months of pregnancy23

The advice can currently be abbreviated (for example on alcohol labels) to ldquoavoid alcohol while pregnant or trying to conceiverdquo Current voluntary labelling arrangements allow this message to be simplifi ed still further through the use of the pregnancy alcohol logo (a line with a circle with a picture of a pregnant woman drinking)

Clearly the summarised version of the advice is well-intentioned aiming to present a short clear message (and stemming from a concern that while the majority of pregnant women drink below or at the recommended low level a small minority are drinking heavily putting their unborn babies at serious risk of harm from fetal alcohol syndrome)

But there is a tension between accuracy and simplicity and between the best current evidence and a precautionary approach While it is very diffi cult to fi nd the balance my concern is a risk of confusion over differing messages and for some groups a risk of feeling patronised

Inequalities and disadvantage The current Government has an explicit goal of reducing health inequalities Many of the experts consulted during preparation of this report also suggested that an explicit lsquosocial justicersquo principle ought to be included in the principles and model regarding state intervention in health and behaviour

Health inequalities are a legitimate concern of the state not least because of how they feed into life chances life expectancy and quality of life An inequality in health is an inequality in capability Health inequalities overlap with and fuel other kinds of inequality as the work by Jonathan Wolff and Avner de-Shalit on disadvantage demonstrates24

23 The full NICE 2008 Clinical Guideline Antenatal care routine care for the healthy pregnant woman is available at httpguidanceniceorgukCG62GuidancepdfEnglish Alcohol advice is at p16

24 Jonathan Wolff and Avner de-Shalit (2007) Disadvantage


The central importance of health as an ingredient of a good capable life means that all governments should have an abiding concern with groups whose health capabilities are less than the norm The UK has a reasonable record in this regard health inequalities in the UK are narrower than other forms of inequality (the Gini coeffi cient for health inequality is 01 compared with 035 for income25) and lower than in many other similar nations Nonetheless gaps in mortality and life expectancy remain ndash and in some cases are growing Inequality is most marked in relation to the number of years a person can expect to live free from disability

But the relationship between health inequalities and state intervention in personal behaviour is complex On the one hand differences in personal choices and behaviour explain an increasing proportion of the health gap Half of the class difference in heart disease for example is explained by the different rates of smoking (In 2007 26 of people from lsquoroutine and manualrsquo households smoked compared with 15 in professional and managerial households26) There is also a social gradient although not as steep in rates of obesity and in harms from alcohol consumption (but not in alcohol consumption itself) Further reductions in health inequalities then will almost certainly require a closing of the gap in personal behaviour But one of the challenges is that health education programmes very often widen the gap at least initially because more affl uent groups change their behaviour the quickest Policy makers will frequently refer to the need to reduce lsquounfairrsquo health inequalities But unless this is taken to mean that all inequalities are by defi nition lsquounfairrsquo it can be quite diffi cult to establish which inequalities result from unfairness

It is clear however that the principal concern of policy makers ought to be the most disadvantaged rather than health gaps across the whole population The key question is how far the Government should therefore focus its attention on the behaviour of particular groups There are some grounds to suggest that it should For instance if lower-income individuals can be shown to face higher hurdles to healthier behaviour there is a case for the targeting of voluntary initiatives towards them If access to affordable healthier food or sports facilities is narrower for some groups there is a good liberal case for interventions that attempt to make access more equal Similarly if low-income pregnant women fi nd it more diffi cult to stop smoking because of social norms and greater negative peer pressure there is ample justifi cation for targeted assistance ndash including fi nancial incentives which recent pilots suggest appear to work27 (Here there is also a strong harm principle argument for intervention because of the deleterious consequences of smoking on the unborn baby)

But it is important to keep a clear distinction between policies to make healthier choices easier for those facing genuinely higher obstacles and policies that simply put greater pressure on lower-income groups ndash often referred to in public health literature as lsquovulnerablersquo ndash to follow health advice in order to reduce observed health inequalities Interventions to help lower-income groups make healthier choices are usually framed in terms of helping to lsquolower the barriersrsquo that they in particular face But while

25 The Gini coeffi cient is a measure of inequality where a value of zero indicates perfect equality and one indicates complete inequality

26 General Household Survey 2007 wwwstatisticsgovukStatBaseProductaspvlnk=5756 27 See Geoff Mulgan (2009) Infl uencing public behaviour to improve health and wellbeing for more information and

also wwwnsmsorgukpublicCSViewaspxcasestudy=72top


this may justify extra encouragement or incentives it does not justify additional discouragement It would be absurd to introduce for example different rules on pub opening or fast-food outlets in poorer areas Policy makers must never lose sight of the fact that poor people have the same rights as the affl uent including the right to make bad health choices

Infl uential work by Michael Marmot and others has shown the strong relationship between social status and health across a range of dimensions Marmotrsquos work suggests strongly that much of the poorer health of lower-income groups is related to lower expectations more stressful lives and narrower life chances rather than specifi c behaviour For a disadvantaged person the willingness to make a short-term sacrifi ce for a longer-term reward is likely to be less The principal way to improve the health and health behaviours of disadvantaged groups is to improve their broader life chances in terms of income employment skills and housing People are more likely to invest in their own health if they have got more to lose

Meanwhile for many people in diffi cult circumstances unhealthy behaviour ndash smoking or drinking for example ndash may be a form of coping mechanism or a small comfort in an uncomfortable life The solution is not to coerce people away from unhealthy behaviours but to give them more reason to give them up


Section 3 Framework and Narrative

5 An Intervention Framework There is no magic equation for when and how the state should intervene But there have been fruitful efforts to provide some criteria for action including important work by Julian Le Grand and Health England which is discussed further below28

Building on the discussion in the previous section there are ten principles that can usefully guide policy makers and that underpin the framework outlined in this chapter

bull The state has a legitimate role in promoting healthier behaviour because of the impact of ill health on autonomy capability and life chances

bull Informed choice is the goal of policy for adults where no harm to others is involved recognising that people are free to make lsquobadrsquo health choices as well as good ones

bull Interventions can be targeted at individuals for whom healthy choices are demonstrably harder to make

bull Strong intervention to prevent harm to others is justifi ed

bull Regulation of institutions is more legitimate than lsquoregulationrsquo of individuals

bull Strong intervention to promote childrenrsquos health is justifi ed

bull Health messages should be delivered with the appropriate tone especially for adults

bull Intervention on behaviour with no signifi cant intrinsic benefits can be stronger than on choices that may have personal benefi ts ndash where moderation is the goal

bull The grounds for any intervention should be clearly articulated by ministers and offi cials

bull Interventions should be both effective and cost-effective

28 wwwhealthenglandorg


These principles are of course not exhaustive and they will sometimes be in tension but they give policy makers a way of weighing up particular interventions In the next chapter a framework for decision making based on these ten principles is presented

The principles summarised above animate the following framework which is intended for use by policy makers considering or evaluating interventions in health and behaviour It is important to be clear that the framework is not intended to give a simple hard-andshyfast answer to whether any specifi c intervention ought to be pursued There will be few interventions that tick every box but this is not the point It is designed to ensure that the relevant questions are taken into account in considering options

Proposed interventions should be examined against three criteria

Legitimacy How strong is the case for intervention on a given issue

Autonomy How can the state respond in a way that protects (or increases) autonomy

Effectiveness Will it work

Legitimacy The legitimacy of state intervention on a given issue will depend on three critical factors

1 Does this issue have benefits to some or is it an unwanted harm to all

If something is an agreed unwanted harm to all ndash for example health protection issues such as radiation or infectious disease ndash government should not hesitate to intervene However on many other issues ndash smoking drinking using UV sunbeds ndash some individuals may see benefi ts to themselves regardless of whether government or public health doctors regard them as healthy If people see benefi ts to themselves or society from a particular behaviour government should be more cautious in how it intervenes

2 Does it cause significant direct (health or other) harm to others

The greater the direct (health or other) harm a specifi c behaviour causes to others the stronger the case for intervention

3 Are there significant barriers to individuals making an informed autonomous choice ndash either in the general environment or in the individualsrsquo capabilities In particular are there demonstrably higher barriers for some individuals than for others


Where an activity or behaviour harms only the individual concerned the state should consider whether there are obstacles to the individual making an autonomous choice

bull environmental barriers including commercial infl uences social norms and wider social economic or environmental factors or

bull capability barriers including lack of information resilience and rationality or ability to make decisions in their long-term interest

If there is good evidence that people face signifi cant barriers to making an informed choice there are grounds for intervention to lower these barriers without restricting choice

Autonomy If there is a legitimate case for intervening the impact of the proposed intervention on autonomy has to be assessed given the overarching goal of lsquoinformed choicersquo There are four important questions policy makers should ask here

1 How much does intervention impact on individual autonomy

Regardless of how strong a case there is to intervene the state should always attempt to intervene in a way that enhances individual autonomy Good health is a vital ingredient of a capable autonomous life which is one of the principal grounds for intervention

It is also worth noting that the autonomy of an individual is in general threatened less by a policy that promotes healthier choices than by one restricting unhealthy ones Of course this is not always clear-cut a healthier diet for example consists of less fat sugar and salt and more fruit and vegetables But it is both more legitimate and usually more effective to promote the positive Change4Life is a promising example

2 Whose autonomy is most impacted

a Institutions or individuals Regulating institutions is greatly preferable to lsquoregulatingrsquo individuals Free markets are usually effective at promoting choice but especially through advertising and marketing companies also have a profound infl uence on the choice environment There is often a case then for tough market regulations to counteract unhealthy infl uences caused by commercial interests especially in terms of marketing and advertising

b Children or adults Since children are less capable of making an autonomous choice government should tend to intervene for children and be more wary regarding adults Clearly this is a sliding scale taking account of the abilities of older children and teenagers And there are special cases in adulthood including learning disability where more support may be needed Early years (0ndash5) intervention should be a particular priority as this is key to building resilience and capability for later life chances


3 Does the intervention ndash especially in terms of message and tone ndash engage honestly with adults about the grounds for intervention and encourage deliberative public debate

Policy makers should be clear about the grounds for intervention Health messages for adults need to treat them as adults be scrupulously honest about the evidence and avoid sounding as if they are preaching At the same time the overall message needs to be better coordinated in order to promote sensible moderation rather than perfection

Effectiveness A policy intervention should only be pursued if there is good evidence for its effi cacy and cost-effectiveness These are questions that lie beyond the scope of this report and have been dealt with elsewhere There is a robust set of criteria in Julian Le Grandrsquos Health England report No329 Of course it is not possible to answer these questions before pilot programmes and thorough evaluation have been carried out ndash but the general point to be made here is that the need for evidence-based policy is even stronger in areas where individual behaviour is concerned Drawing on Le Grand there are four relevant questions for policy makers to ask (only the fi rst is not taken directly from Le Grandrsquos report)

1 Are there potential health harms from the intervention that need to be weighed against the potential benefits

2 What is the proven effectiveness of the intervention in improving health outcomes

3 What is the cost relative to effectiveness

4 Is the suggested policy feasible (in terms of both implementation and public acceptance)

The diagram overleaf summarises the three tests and the questions posed under each test Annex A addresses three areas of topical concern ndash smoking alcohol and obesity ndash using the framework

29 Julian Le Grand (2009) Health England Report No 3 Incentives for Prevention


Health and wellbeing an intervention framework

bull The state has a legitimate role in promoting healthier behaviour because of the impact of ill health on autonomy and life chances

bull Informed capable individuals have the right to exercise free choice including if those choices cause harm to themselves

bull However government has an enabling role and should consider both individual capability and the choice environment in which individuals live

bull Government should have particular regard to disadvantaged groups for whom healthy choices may be harder to make


bull Does this issue have benefits to some or is it an unwanted harm to all

bull Does it cause signifi cant direct (health or other) harm to others

bull If the issue causes only harm to self are there significant barriers to individuals making an informed autonomous choice ndash either in the general environment or in the individualsrsquo capabilities

bull In particular are there demonstrably higher barriers for some individuals than for others

2 Autonomy

bull How much does intervention impact on individual autonomy

bull Whose autonomy

ndash Institutions or individuals

ndash Children or adults

bull Does the intervention ndash especially in terms of message and tone ndash engage honestly with adults about the grounds for intervention and encourage deliberative public debate

Given the strength of this case

how can the Government respond in a way that

protects (or increases) autonomy

3 Effectiveness

bull Are there potential health harms from the intervention that need to be weighed against the potential benefi ts

bull What is the proven effectiveness of the intervention in improving health outcomes

bull What is the cost relative to effectiveness

bull Is the suggested policy feasible (in terms of both implementation and public acceptance)


These detailed

questions are outside

the scope of this report

6 A New Narrative The following is a suggested narrative to underpin future government interventions on health and behaviour

People want to be healthy and they want the Government to do its part in promoting a healthier society Having good health is a key ingredient of having a good life ndash a vital capability that all citizens deserve The principle of lsquoinformed choicersquo will continue to guide policy But it is clear that the aspiration that people will lsquochoose healthrsquo is coherent only if we recognise that this means they might choose differently Greed sloth and drunkenness are not sins of recent human invention and few of us are consistently immune to them As policy makers we will be careful not to assume that just because someone is not making the lsquorightrsquo choice from a health perspective they must be either ill-informed or incapable

If a particular choice or behaviour directly harms others however ndash and especially if it harms children ndash the state has a responsibility to step in A liberal state does not insist on saving people from themselves But it does have an obligation to protect people from each other Children in particular deserve protection from health harms resulting from the bad choices of others ndash including sometimes their own parents Fears of intervening in family matters should not prevent action to support individual rights ndash in this case the rights of individual dependent children ndash not to suffer potentially life-long health problems Perhaps we need to lsquonannyrsquo adults a little less but children a little more

We see an important difference between the freedoms of citizens and the freedoms of corporations Interventions to lsquoregulatersquo the behaviour of individuals are in principle less justifi ed than those applied to institutions If a policy that promotes informed choice for citizens imposes regulations on companies so be it We will be wary of telling people what to do but less wary of telling fi rms what to do or sometimes what not to do

If some people face higher barriers to healthier behaviour than others we will give them extra support This forms part of our efforts to reduce health inequalities and direct the most help to the most disadvantaged But here as elsewhere the focus will be on encouraging healthier behaviour rather than on clamping down on unhealthy choices We will always prefer policies to make the healthier choice the easier choice rather than policies that attempt to remove unhealthy choices altogether

Even when a policy is justifi ed we will be careful to make sure that it is also effective especially when the public fi nances are tight all our interventions will be subject to stringent tests for both effi cacy and cost-effectiveness

Lastly we fi rmly believe that adults should be treated as adults We recognise that some people will choose not to follow offi cial advice and their right to do so Our health messages will set out the risks and benefi ts of particular choices or behaviours clearly and honestly Where the evidence is mixed wersquoll say so


Modern affl uent societies have a new set of challenges in terms of creating a healthier society because of the growing importance of individual choices and behaviours for health outcomes The balance we have to strike is between support for people to make informed healthy choices and their right to lead lives of their own choosing There is no magic formula we can apply We welcome debate on all aspects of our thinking and policy But we are clear about the principles that guide us and our ambition for a healthier freer society


Annex A ndash Test Cases Illustrating the Framework Three areas of current concern ndash tobacco alcohol and obesity ndash have been considered using the new framework

Test case 1 ndash tobacco

1 How strong is the case for intervention

Does the issue have benefits to some or is it an agreed unwanted harm to everyone

Approximately 20 of adults in England smoke Some 74 of those say that they would like to quit30 However this means that up to 26 of smokers (around 5 of the total adult population) say that they want to keep smoking

Clearly these fi gures cover a wide range of reasons for wanting to quit or not Some people may say they donrsquot want to quit although they wish they did not smoke because they have tried before and just canrsquot manage it government should offer as much support as possible to these people

Nicotine is incredibly addictive more addictive even than heroin But many people do give up Some others recognising that they are addicted and aware of the risks choose to continue smoking However clearly that health evidence shows that smoking is harmful the state should still take this minorityrsquos preference ndash their view that smoking benefi ts them ndash into account

Does it cause signifi cant direct (health or other) harm to others

The evidence is absolutely clear that second-hand smoke kills as confi rmed by bodies including the World Health Organization and the UKrsquos Scientifi c Committee on Tobacco and Health

This includes both the increased risk of cancers from long-term exposure to second-hand smoke and the acute increased risk of heart attack when non-smokers inhale cigarette smoke (due to a rapid impact on the blood-clotting mechanisms involved in triggering heart attacks) Children of smokers in particular can be exposed to high levels of second-hand smoke in homes and cars

Smoking during pregnancy causes signifi cant harm to the unborn baby

Does it cause harm to self

The evidence of harm to self is clear half of all smokers will die of a smoking-related disease But as set out in our starting principles this alone is not a reason for coercive government intervention

30 Offi ce for National Statistics (2008) Smoking-related Behaviour and Attitudes 2007 Offi ce for National Statistics wwwstatisticsgovukdownloadstheme_healthsmoking2007pdf



Are there signifi cant barriers to individuals making an informed autonomous choice

Are there bull Commercial The story of the overwhelmingly powerful role environmental that the tobacco industry has played in persuading people to barriers to smoke is well known31 Over the last decade the Government autonomy has taken signifi cant action to restrict opportunities for tobacco

companies to market their products notably through the advertising ban and the display ban which will come into force in 2013 However tobacco companies continue to fi nd ways to circumvent the existing ban on advertising for example using pack design as an advertising tool or through lsquoTrojan horsersquo products such as cigarette papers Through promotional activities too numerous to list here including viral techniques and product placement in fi lms there are still huge commercial infl uences at work persuading people to take up smoking

bull Social norms In some segments of society social norms provide pressure to smoke In some of the most disadvantaged socioshyeconomic groups 70 of all adults smoke This provides a case for government to consider how it could redress the balance in these groups specifi cally

bull Socialenvironmental factors These are what Sir Michael Marmot has called the lsquocauses of the causesrsquo poor education poor housing worklessness and crowded urban environments can all make people value longer-term abstract ideas such as lsquohealthrsquo less and the short-term wellbeing and stress relief that smoking can provide more Further there is a generational effect children who grow up in a household where someone smokes are four times more likely to become smokers themselves

Are there Information is not the problem here Everyone knows in theory capability that smoking kills The problem is peoplersquos inability to adequately barriers to weight their long-term interests against their short-term interests autonomy Nicotinersquos highly addictive properties make this signifi cantly worse

The most serious issue of capability here is that the vast majority of smokers (80) start before they are 19 ndash ie while they are still children This is a crucial factor in considering how far adult smoking can be considered a matter of lsquofree choicersquo The lsquofreestrsquo choice is starting to smoke After that addiction blurs the picture Psychology and recently neuroscience both tell us that teenagers are particularly ill-equipped to make good rational trade-offs between short-term pleasure and long-term risk

31 See for example Brandt A (2007) Cigarette Century The Rise Fall and Deadly Persistence of the Product That Defi ned America Basic Books USA

Summary There is a strong case for intervention on the basis of harm to others through secondshyhand smoke There is a particularly strong case for intervention in the case of smoking during pregnancy on the basis of direct harm to the unborn baby

There is also a strong case to rebalance the many environmental factors that make it easier for some to smoke than to not smoke

Government should in particular focus on rebalancing the choice environment in disadvantaged areas where social norms to smoke are much stronger for example through tackling smuggling and the supply of smuggled hand-rolling tobacco


2 Autonomy How should government shape its response in order to protect peoplersquos freedom to make decisions

How much The only state intervention entirely eliminating choice is the does minimum age (18) for smoking and purchasing tobacco products intervention This is entirely appropriate given the case above and should be impact on rigorously enforced individual autonomy The ban on tobacco advertising and the shortly-to-be-introduced

display ban reduces individualsrsquo ability to choose between brands However it also reduces the commercial pressures on children to take up smoking A trade-off needs to be made here and the importance of protecting children justifi es these measures

Clearly smoke-free legislation has a signifi cant impact on individual autonomy Smoking has not been banned altogether and smokers are still free to go outside to smoke or to smoke at home But it is a signifi cant restriction of personal freedom to no longer have the choice to smoke in enclosed public places even when other adults present consent

An explicit aim of tobacco duty is to restrict choice through decreased affordability

Other elements of current policy focus on enabling healthy choices (through the offer of smoking cessation programmes and nicotine replacement therapy) and providing information (education campaigns and pack warnings including picture warnings)

Whose Much of this Governmentrsquos highly successful tobacco programme autonomy is has focused on companies Advertising and marketing bans restrict impacted ndash companies while leaving individuals free to choose However as institutions or described under lsquoenvironmental barriersrsquo above there are still many individuals ways in which tobacco companies promote their products and

government should continue to tackle these

Smoke-free legislation has had some impact on various companies removing their freedom to allow their customers to smoke in enclosed spaces However the impact on citizensrsquo autonomy is more marked A choice has been removed


Whose As discussed above minimum-age legislation targets children autonomy is However many under-18s are still experimenting with tobacco and impacted ndash becoming addicted regular smokers Government should focus children or its efforts on stopping more children from starting particularly by adults preventing tobacco companies from targeting their multi-billion

pound budgets to fi nding new ways to recruit young people to smoking

Smoke-free legislation targets adults however often in environments where they are with other adults It is arguable that a domestic smoking ban would be more appropriate to protect smokersrsquo children on autonomycapability grounds

Given the strong evidence of harm from smoking during pregnancy government should particularly look for ways to help pregnant women quit Geoff Mulganrsquos32 report looks at pilots on offering fi nancial incentives to pregnant women in particular circumstances where the social norm is to smoke which have had promising evaluations

Does the The smoking debate is much more mature than debate around intervention other behavioural risk factors There is much more consensus about ndash especially the evidence So for most tobacco policy government can be very in terms of straightforward about its aims message and tone ndash engage On smoke-free legislation the Government was insistent publicly honestly with that its purpose was to protect people from second-hand smoke adults about However in my view the stronger argument for smoke-free the grounds for legislation is about changing the choice environment to one which intervention makes the default healthier This should have been made clearer and encourage deliberative public debate

3 Effectiveness How should interventions be evaluated and prioritised

Potential to All proposed interventions should be evaluated for effectiveness do harm using these criteria In particular the impact on different groups effectiveness should be taken into account cost feasibility

When smoke-free legislation was proposed evidence from other countries already suggested that it would be a highly effective policy Its impact will continue to be monitored One potential harm is the possibility of smokersrsquo children being more exposed to passive smoking if people smoke more at home due to the legislation This should also be monitored

32 Geoff Mulgan (2009) Infl uencing public behaviour to improve health and wellbeing p26


Conclusions England has a world-leading anti-tobacco strategy which the Government can be proud of in achieving its aim of reducing smoking prevalence Considering it through this framework I would make three points

Companies Subtle marketing by the tobacco industry continues to present a major environmental barrier to individuals making informed autonomous choices Government should continue to focus on tackling this

Children There are three main issues to focus on

Unborn babies Given the strong evidence of harm the Government is justifi ed to intervene strongly to help pregnant women stop smoking This could include the use of fi nancial incentives

Young children To protect children from the harms of passive smoking the Government would also be justifi ed to consider domestic smoking bans (although noting the potential complexity of implementation)

Older children Given that 80 of smokers become addicted before they are 19 the Government should in particular focus on stopping children from starting to smoke in particular through continuing to tackle tobacco marketing aimed at children

Grounds for intervention There is a question of whether the Government got the balance right in how it communicated the reasons for smoke-free legislation Changing the choice environment to a healthier (non-smoking) default was a stronger argument than harm to others More emphasis on this might help move us towards a more sophisticated public debate about policy


Test case 2 ndash alcohol The Department of Health segments drinkers according to the amount consumed

bull lsquoLower-risk drinkersrsquo Those who do not regularly drink more than the Chief Medical Offi cerrsquos guidelines ie men not regularly drinking more than 3ndash4 units a day (2ndash3 units for women)

bull lsquoIncreasing-risk drinkersrsquo Those who regularly drink above the lower-risk guidelines (but less than double the guidelines) estimated at 76 million people in England

bull lsquoHigher-risk drinkersrsquo Those who regularly drink more than double the lower-risk guidelines There are 26 million adult higher-risk drinkers in England drinking one-third of all the alcohol consumed Some 11 million of these are estimated to be dependent on alcohol



Does the issue Alcohol is a toxic psychoactive and dependency-producing product have benefits that people like to drink However this public health defi nition

to some or is can appear divorced from peoplersquos everyday experience as it does it an agreed not adequately recognise the benefi ts that many people feel they unwanted derive from alcohol There are clear societal benefi ts from moderate harm to consumption of alcohol and drinking is something people enjoy everyone Further for example after a hard week at work an individual may

feel that they derive short-term wellbeing benefi ts from a few drinks

Does it cause On the basis of current evidence for the vast majority of lower-risk signifi cant drinkers consumption of alcohol causes no harm to others direct (health or other) harm However clearly there are cases in which alcohol does cause harm to others to others Up to 13 million children are adversely affected by family

drinking and around a quarter of child protection cases involve alcohol Some 37 of all domestic violence cases involve alcohol

Social harms include injury through drink driving alcohol-related violence (around 80000 facial injuries each year are related to alcohol) and anti-social behaviour

Drinking during pregnancy risks harm to the unborn child



Hangovers are the least of the health risks of alcohol Consumption increases the risk of injury through accident and can cause fatigue depression weight gain memory loss disturbed sleep and impotence

People who regularly drink above the lower-risk guidelines increase their risk of a range of serious conditions including heart disease liver disease stroke hypertension neuropsychiatric conditions cancers of the mouth neck throat liver and breast

For female breast cancer there is a linear relationship between consumption and risk of harm For a woman drinking 5 units per day the risk of getting breast cancer over ten years is 19 compared with 119 in non-drinkers33

However some people may judge the increase in some of the other disease risks to be relatively low For example the average baseline lifetime risk of mouth cancer is 10234 A man drinking 5 units of alcohol a day would have a 25 times increased risk of mouth cancer ndash taking his lifetime risk to 25535

Alcohol is the third-biggest cause of death in under-25s


Are there environmental barriers to autonomy

bull Commercial There are a range of powerful commercial infl uences including marketing by the alcohol industry price promotions happy hours two-for-one offers etc There is also the increasing availability of higher-strength lagers wines and ciders and the provision of large measures as standard Licensing conditions do not include a public health objective and alcohol is available increasingly cheaply from a wide range of outlets ndash in some cases 24 hours a day

bull Social norms There is a strong social norm to drink socially and particularly for young men to drink to excess This has changed dramatically in a generation Thirty years ago public drunkenness was broadly viewed as unacceptable outside of university unions and working menrsquos clubs and women drank differently and less This has also become more visible through the concentration of on-trade premises in town centres and the closure of rural pubs The availability of affordable (and higher strength) new world wines in the last 20 years has led to a new middle-class norm of opening a bottle of wine at home in the evening with little understanding of the amount of alcohol being consumed

33 Source DH Alcohol and Drugs Team 34 Source US National Cancer Institute SEER Cancer Statistics Review 1975ndash2006 wwwseercancergov 35 Source DH Alcohol and Drugs Team

bull Socialenvironmental factors Marmotrsquos lsquocauses of the causesrsquo ndash ie poor education poor housing worklessness and crowded badly maintained urban environments ndash all make people value longer-term ideas such as lsquohealthrsquo less and short-term wellbeing from drinking more Evidence suggests that people in deprived communities suffer more harm from alcohol without necessarily drinking more There is emerging evidence that patterns of drinking in these communities also make a contribution not just the overall amounts that are consumed

Are there bull Addiction or dependence varying from slight to severe is a capability factor for most higher-risk and some increasing-risk drinkers barriers to autonomy

bull For higher-risk and dependent drinkers there is the issue of untreated mental health problems Alcohol can cause reveal or exacerbate mental health problems Note that (for this small number of drinkers) this may suggest interventions should be targeted at the underlying problem (eg emotional resilience stress and anger management)

bull For lower-risk and increasing-risk drinkers there may be a lack of full information about long-term health risks and lower-risk drinking guidelines and people may be unable to make the trade-off However we should note that some people may rationally value what they see as the short-term wellbeing benefi ts above the longer-term health risks

bull On the issue of drink-driving there is the possible inability to judge whether the legal level of alcohol has been consumed

Summary Working through the questions above reveals that there are a number of different risks related to alcohol consumption and the case for intervention is different on each There is a strong case for intervention where harm to others is involved In cases of alcohol dependency there is a strong case for the NHS to provide support in order to help people overcome their dependency

However the majority of the population are lower-risk drinkers who cause no harm to others and are trading-off a low lifetime risk of disease from alcohol against the short-term benefi ts to wellbeing that they consider they derive

Government should keep this large population in mind when considering alcohol policy to ensure that policies that are aimed at changing the alcohol behaviour of higher-risk drinkers do not have an inappropriate impact on the autonomy of lower-risk drinkers



How much The only area of current government alcohol policy that entirely does eliminates choice relates to children ndash the minimum ages for intervention consumption and purchase For adults licensing laws restrict choice impact on to some extent but we should note that these are more liberal than individual they have ever been with alcohol available from a wide range of autonomy outlets in some cases 24 hours a day

Prices due to alcohol duty may restrict choice for some

Other elements of current policy focus on enabling healthy choices (through the offer of advice or specialist treatment) or on providing information (alcohol education campaigns and work with the industry on responsible promotion voluntary labelling agreements etc)

Particular ways of enabling lower-risk drinking without overly restricting choice could include the following

bull Regulating for smaller standard measures of alcohol (eg 125ml measure of wine) People may choose bigger measures but behavioural economics suggests that this reduction in the standard measure would enable people to choose to drink less

bull Allowing local authorities more freedom to control the environment in town centres eg by limiting the concentration of pubs and clubs which may help to reduce alcohol-related problems given that we tend to respond subconsciously to cues in our wider environment

bull The NHS providing brief advice has been shown to be effective for drinkers with an associated health risk Identifying those suited to brief advice early and ensuring that it is offered in all areas would also be recommended

bull Through the education system building childrenrsquos resilience and ability to choose for themselves despite social norms may have a number of benefi ts including weakening the social norm of binge drinking that is currently particularly prevalent among younger people


Whose Government should look to regulate companies to make it easier for autonomy is individuals to drink at lower-risk levels before restricting individual impacted ndash choice This may point to stronger restrictions on advertising and institutions or marketing including price promotions The Home Offi cersquos recent individuals consultation on a mandatory code of practice for alcohol retailers

looks promising proposing restricting promotions that encourage people to drink too much and looks at the principle of restricting lsquobelow costrsquo selling such as retailing alcohol for less than the cost of its duty and VAT

Government should monitor closely the alcohol industryrsquos compliance with voluntary labelling agreements and if information provided is not adequate then it should consider regulation

Whose It is currently illegal to give alcohol to a child under 5 for children autonomy is under 16 to have an alcoholic drink in a pub or for any under-18 impacted ndash to buy alcohol It is legal for 16ndash17-year-olds to drink beer wine children or or cider with a meal if bought by an adult This sliding scale looks adults reasonable on the basis of childrenrsquos increasing autonomy and

health profi le during adolescence

Government should ensure that the current law is adequately enforced in particular on retailers adhering to the minimum age of purchase It should also ensure that alcohol industry advertising is not targeting young people including alcohol advertising that is targeted at adults but seen by children


Does the intervention ndash especially in terms of message and tone ndash engage honestly with adults about the grounds for intervention and encourage deliberative public debate

For higher-risk or dependent drinkers evidence suggests that targeted individualised programmes are effective

For the lower-risk population government could build capability by having a wide and consistent conversation Current government policy is to provide information rather than to lsquolecturersquo ndash however communications should be reviewed to ensure that this is being consistently achieved

As happens in Australia the Government could provide people with much more information in a readily comprehensible form on the risks associated with different levels of drinking and allow people to make an informed choice Learning from behavioural economics it could try to make this more salient to people and easier to understand by providing examples of activities with comparable levels of risk ndash as the Australian government has done by comparing the risk associated with its recommended level of alcohol consumption with the lifetime probability of dying in a road traffi c accident This is particularly apt because most people are happy to trade-off this risk against the benefi ts of being able to use a car

While providing risk guidelines is helpful government should recognise that people may have different levels of risk tolerance and that in the end people are free to make an informed choice

As discussed in the main body of this report government should carefully consider the balance between accuracy and simplicity regarding abbreviated advice to pregnant women on alcohol (see pages 22ndash23)



Potential to All proposed interventions should be evaluated for effectiveness do harm using these criteria In particular impact on different groups should effectiveness be taken into account cost feasibility

Conclusions Much of Government alcohol policy is appropriate and the Government is looking for ways in which to rebalance the choice environment in order to make lower-risk alcohol choices easier

In terms of the alcohol industry government should not be afraid to regulate if companies are not complying with voluntary agreements It should ensure that it is adequately prioritising health with other policy objectives

With regard to children government should ensure that minimum age legislation is rigorously enforced It should also continue work on building young childrenrsquos resilience to enable them to make informed choices later on in life

The diffi cult issue for government on alcohol appears to be one of tone and how to provide information without people feeling lectured Government has a duty to inform people about the health harms of alcohol The challenge is to do this in a way that does not become counterproductive ndash that people do not feel lectured and so switch off Part of the solution here may be around breaking down the current silos between policy on different risk factors (smoking alcohol diet etc) providing more targeted personalised advice that allows people to make their own trade-offs


Test case 3 ndash obesity



Does the issue The policy challenge of obesity is that while the physical cause of have benefits obesity is straightforward (an imbalance of energy in and out) the

to some or is underlying causes of this energy imbalance are immensely complex it an agreed unwanted However the key behavioural factors are diet and physical activity harm to Clearly food is vital for life Moreover anyone who has ever enjoyed everyone a full English breakfast or a chocolate brownie will know that there

are also signifi cant social and short-term wellbeing benefi ts from eating food high in fat sugar and salt (HFSS)

Sedentary lifestyles may have no health benefi ts but someone in a busy offi ce job whose interests can be enjoyed from the sofa might see signifi cant benefi ts in not wasting time doing physical activities that they do not enjoy

Does it cause For the majority of the population the answer is no However signifi cant parents are responsible for the diets and activities of their young direct (health or children If they allow their children to overeat and become other) harm to sedentary they may be harming them by allowing them to others become obese

Does it cause For diet this is a diffi cult question High-fat or sugary food will not harm to self cause health harm in moderation but it can do in excess Sedentary

lifestyles are more clearly harmful ndash physical activity has multiple health and social benefi ts and a lack of it can cause non-weightshyrelated health harms including poor mental health

However the answer is clear on obesity It carries signifi cant short-and long-term health risks including type 2 diabetes cancer heart and liver disease



There are huge environmental barriers to maintaining a healthy weight We live in what the 2007 Foresight report36 referred to as an lsquoobesogenic environmentrsquo in which commercial social and environmental factors combine to make overweight a likely outcome

bull Commercial These exist for food in particular ndash there is wide availability of cheap highly palatable calorie-dense food aggressively marketed

bull Social norms Shifting social norms making overweight lsquonormalrsquo and healthy weight lsquothinrsquo There is a shift away from home cooking and eating as a family due to the availability of alternatives and time pressures There is a shift to travelling to work and school by car rather than walking or cycling

bull Socialenvironmental factors Busy modern high-stress lives allow little time to prepare healthy affordable meals or to get suffi cient physical exercise There is a shift away from physical activity being part of routine daily life with less manual work and more energy-saving devices in the home and driving rather than walking Planning in some urban areas is a problem ndash there are too many fast-food outlets and not enough safe green spaces for exercise

Are there capability barriers to autonomy

The key barrier is our inability to make a good short-termlong-term trade-off The short-term benefi t of sitting in front of the telly with a packet of biscuits makes it very hard to take into account the potential long-term health risks

There may be more specifi c barriers for example a lack of cooking skills or a lack of confi dence in ways to exercise

Summary There is a strong case for government intervention on obesity on the basis of the major environmental barriers to individuals making informed autonomous choices

36 wwwforesightgovukOurWorkActiveProjectsObesityObesityasp



How much Current Government policy fi ts well with this principle does intervention The only element of current policy that eliminates choice relates to impact on children in schools ndash through school food and physical education individual (PE) policies autonomy

The ban on advertising HFSS food during childrenrsquos television programming is the most restrictive element and clearly this leaves choice available

Current physical activity policy focuses on increasing opportunities to exercise for example the provision of free swimming for under-16s

Change4Life is a very promising example of a programme of intervention focusing on enabling people rather than restricting choice The focus of Change4Life is fully on encouraging healthy behaviour by increasing confi dence and opportunities and changing defaults in the environment The programme includes some particularly interesting pilots for example the Change4Life convenience stores project Convenience stores (where children are more likely to shop rather than in supermarkets) are provided with an attractive display stand for fruit This is placed at the front of the shop next to the chocolate ndash and early evaluation suggests a positive impact on the sales of fruit

Whose The Governmentrsquos current obesity strategy has a strong focus on autonomy is working in partnership with institutions to rebalance the choice impacted ndash environment institutions or individuals Given the power of commercial forces on this issue however

government would be justifi ed in going further to regulate (or otherwise require) companies to make healthy choices for individuals easier if voluntary agreements do not have a substantial enough effect

Whose Current government obesity strategy places more emphasis on autonomy is children There are already tight standards for school food in place impacted ndash for example no confectionary or sweetened drinks may be sold in children or schools including tuck shops and vending machines (whereas the adults Government does not regulate to remove vending machines from

workplaces) Increasing physical activity in schools is also a focus through the two-hour PE requirement and fi ve-hour PE offer


Does the The Government is clear for example in policy documents such as intervention Healthy Weight Healthy Lives that the reason why government is ndash especially intervening is because we know it is hard to make healthy choices in terms of around diet and activity The Government sees its role as supporting message and individuals and making it easier for them to make healthy choices tone ndash engage honestly with adults about the grounds for intervention and encourage deliberative public debate


Potential to One of the major challenges in tackling obesity is the lack of do harm robust evidence on what works It is essential that interventions are effectiveness piloted and rigorously evaluated Change4Life is an example of best cost feasibility practice here and government should continue to ensure that all

major initiatives across the Healthy Weight Healthy Lives strategy are rigorously evaluated

Conclusions The Governmentrsquos current obesity strategy fi ts well with this framework It focuses on rebalancing the choice environment and does not take choices away from individuals It targets the behaviour of institutions before that of individuals It has a much stronger focus on children restricting unhealthy choices within schools The focus is on encouraging healthy behaviours

I would emphasise that the Government would be justifi ed in being tougher still on industry if that is what is required to more effectively rebalance the environment against their commercial interests


Annex B ndash Participants in the Expert Round Table As part of the research for this report an expert round table was held on 16 July 2009 at the Institute for Government chaired by Richard Reeves

Attendees Title

Richard Ashcroft Professor of Bioethics School of Law Queen Mary University of London

Tom Baldwin Professor of Philosophy University of York

Mark Bassett Group Director of Public Policy Group Development BUPA

Gwyn Bevan Professor of Management Science London School of Economics

Clive Blair-Stevens Director of Strategy and OperationsDeputy Chief Executive Offi cer National Social Marketing Centre

David Halpern Director of Research Institute for Government

David Hunter Professor of Health Policy and Management Durham University

Ann-Louise Kinmonth Foundation Professor of General Practice Cambridge University

Julian Le Grand Richard Titmuss Professor of Social Policy London School of Economics

Avner Offer Chichele Professor of Economic History All Souls College University of Oxford

Richard Wilkinson Emeritus Professor of Social Epidemiology University of Nottingham

Jonathan Wolff Professor of Philosophy University College London


A Liberal Dose Health and Wellbeing ndash the Role of the State

Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness

1 Introduction Public Health Private People

2 The Public View

Freedom of choice

Intervention welcomed if evidence is believed to support it

Help make healthy choices easier

Wellbeing as well as health

3 Some Recent Approaches Nudges versus Stewardship

4 What are the Key Issues

Capability

Choice

Harm

Responsibility

Children

Striking the right tone

Inequalities and disadvantage

5 An Intervention Framework

Legitimacy

Autonomy

Effectiveness


6 A New Narrative

Annex A ndash Test Cases Illustrating the Framework


Summary

Conclusions

Test case 2 ndash alcohol

Summary

Conclusions


Summary

Conclusions

Annex B ndash Participants in the Expert Round Table

Contents Introductory letter 3

Executive Summary 4

Section 1 Context 7 1 Introduction Public Health Private People 7 2 The Public View 9

Section 2 Issues and Approaches 13 3 Some Recent Approaches Nudges versus Stewardship 13 4 What are the Key Issues 16

Section 3 Framework and Narrative 26 5 An Intervention Framework 26 6 A New Narrative 31

Annex A Test Cases Illustrating the Framework 33 Annex B Participants in the Expert Round Table 50















Yours

Richard Reeves



This report


























Section 1Context





























4















































































































































































































2 Autonomy


bull Whose autonomy







3 Effectiveness






These detailed















































































































































































Attendees Title















Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness


2 The Public View

Freedom of choice






Capability

Choice

Harm

Responsibility

Children




Legitimacy

Autonomy

Effectiveness


6 A New Narrative



Summary

Conclusions


Summary

Conclusions


Summary

Conclusions















Yours

Richard Reeves



This report


























Section 1Context





























4















































































































































































































2 Autonomy


bull Whose autonomy







3 Effectiveness






These detailed















































































































































































Attendees Title















Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness


2 The Public View

Freedom of choice






Capability

Choice

Harm

Responsibility

Children




Legitimacy

Autonomy

Effectiveness


6 A New Narrative



Summary

Conclusions


Summary

Conclusions


Summary

Conclusions



This report


























Section 1Context





























4















































































































































































































2 Autonomy


bull Whose autonomy







3 Effectiveness






These detailed















































































































































































Attendees Title















Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness


2 The Public View

Freedom of choice






Capability

Choice

Harm

Responsibility

Children




Legitimacy

Autonomy

Effectiveness


6 A New Narrative



Summary

Conclusions


Summary

Conclusions


Summary

Conclusions

















Section 1Context





























4















































































































































































































2 Autonomy


bull Whose autonomy







3 Effectiveness






These detailed















































































































































































Attendees Title















Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness


2 The Public View

Freedom of choice






Capability

Choice

Harm

Responsibility

Children




Legitimacy

Autonomy

Effectiveness


6 A New Narrative



Summary

Conclusions


Summary

Conclusions


Summary

Conclusions
























4















































































































































































































2 Autonomy


bull Whose autonomy







3 Effectiveness






These detailed















































































































































































Attendees Title















Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness


2 The Public View

Freedom of choice






Capability

Choice

Harm

Responsibility

Children




Legitimacy

Autonomy

Effectiveness


6 A New Narrative



Summary

Conclusions


Summary

Conclusions


Summary

Conclusions
















































































































































































































2 Autonomy


bull Whose autonomy







3 Effectiveness






These detailed















































































































































































Attendees Title















Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness


2 The Public View

Freedom of choice






Capability

Choice

Harm

Responsibility

Children




Legitimacy

Autonomy

Effectiveness


6 A New Narrative



Summary

Conclusions


Summary

Conclusions


Summary

Conclusions














































































































































































Attendees Title















Contents

Introductory letter

Executive Summary

Legitimacy

Autonomy

Effectiveness


2 The Public View

Freedom of choice






Capability

Choice

Harm

Responsibility

Children




Legitimacy

Autonomy

Effectiveness


6 A New Narrative



Summary

Conclusions


Summary

Conclusions


Summary

Conclusions


a liberal dose? health and wellbeing – the role of the stateuser-raw]/11-06/rr.pdf · a liberal...

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