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Health Incentives Scheme

Volume 815: debated on Thursday 28 October 2021


The following Statement was made in the House of Commons on Friday 22 October.

“Mr Speaker, with permission, I would like to give a Statement on our mission to help people live healthier lives. The Covid-19 pandemic has exposed so many vulnerabilities in our nation’s health and highlighted stark inequalities that we must work hard to put right. As a Government, we want to do everything in our power to tackle these disparities and to help people live in better health for longer.

We know that regular physical activity and a healthy diet are strongly linked to a higher life expectancy and a lower incidence of many chronic conditions. However, two-thirds of adults in England are currently living with excess weight or obesity, and obesity-related illnesses cost the NHS £6 billion a year. Not only this, but obesity is more prevalent among the most deprived areas, so a vital part of our mission to level up across the nation must be to level up the nation’s health and give everyone the tools and support they need to make a positive change to their daily lives.

Earlier this year, we announced £100 million of funding to help those living with obesity move towards a healthier weight, and this month, we have launched our Office for Health Improvement and Disparities, which has a relentless focus on prevention and tackling health disparities across the UK. Obesity policies cannot just be about sticks; we must also reward healthy behaviours. Today, I would like to update the House on the next step in our plans—our new health incentives scheme. The evidence shows that incentives can have an important role in improving rates of physical activity and encouraging healthier eating. For example, in Singapore, its national steps challenge has shown promising results, so we have been looking at what we can do here at home to encourage people to take the little steps that can make a difference and also to pursue a more personalised and data-driven approach to public health.

In England from next year, we will be piloting a new scheme to help people make positive changes to their diet, called Fit Miles. The six-month pilot will see users wearing wrist-worn devices to generate personalised health recommendations, such as boosting their step count, eating more fruit and vegetables, and lowering the size of portions. Users can collect points for making these healthy changes that will unlock rewards, which could include vouchers, discounts and gift cards. We will be making £3 million of government funding available for these rewards, and we will be releasing more information on the location of the pilot and how residents can take part in due course.

The app will be available to all adults within our pilot area but will have a particular focus on those who are not physically active and have poor diets, as well as traditionally underserved groups—for example, those in areas of high deprivation. I would like to reassure honourable Members that the app will have the strongest standards of privacy and security and we will make sure personal information is always kept safe. This ground-breaking new pilot offers a brilliant opportunity to explore how best to inspire people to make positive changes to their daily lives and it is a fantastic example of how government, business and the third sector can work together to make a difference.

I would like to thank HeadUp Systems for providing its international expertise in data science and health technology, and Sir Keith Mills, who has been advising the Government on how we can best make use of these incentives. We have been able to bring to bear his vast experience of working on reward programmes such as Air Miles and Nectar points, and I would like to thank him for his invaluable support.

There is no greater gift than the gift of good health and we are determined to make sure that people across the country can live in better health for longer. If we get this right, it will be good for our NHS, good for our economy and good for our society. This is a mission that the whole House can get behind and today’s important announcement is a great step forward for all of us. I commend this Statement to the House.”

My Lords, I thank the Minister for answering questions on the Statement, which was first made on Friday, before the Government began press releasing new—and some not so new—spending commitments, and eventually published their full Budget yesterday. I must admit to having been somewhat bemused when I read this Statement. It felt like being taken on something of a gentle canter around the issues. To put it mildly, it is more than unusual to see the announcement of an app and wrist-worn devices making the grade for the substance of a parliamentary Statement presented to both Houses.

I make this point because it is important to say that, on any measure, the Government have decimated the budgets necessary to tackle the underlying causes of poor health and the inequalities that arise from and contribute to its incidence and effects. As we know, poor health has many costs—social, economic and personal—and I regret that the Statement is a fig leaf for inaction. Although the Prime Minister and the Secretary of State have acknowledged that stark health disparities exist, the Government repeatedly fail to face the target, let alone hit it.

The pandemic has highlighted just how important it is to have a healthy and resilient nation. Preventing and treating disease is vital for reducing further unnecessary deaths from disease and lessening the burden on the NHS as it contends with the enormous backlog in healthcare caused by the pandemic. However, the Budget presented contradictions, as funding will be mostly focused on a curative rather than preventive approach, which would have prevented obesity and non-communicable diseases happening in the first place. Public health experts and practitioners alike agree that investment in the prevention of disease could make the single biggest difference to the nation’s resilience and health, so can the Minister explain the reason for this omission from the Budget? Does he agree that failure to invest in public health will harm the Government’s levelling-up agenda?

Specifically, we were disappointed not to see any further public health funding in the Budget to allow local authorities to deliver key prevention services, such as smoking cessation and weight management. It is well documented that locally provided public health services are highly effective and cost effective. Can the Minister tell your Lordships’ House why this was ignored?

We on these Benches have campaigned for many years against this Government’s short-sighted cuts to public health funding. A reduction in spending of a quarter in this area has led to growing obesity in our population, loss of smoking cessation services, a ticking time bomb of poor sexual health, and overburdened drugs and alcohol services. Of course, any savings made by those cuts has been hoovered up by the impact on the rest of the health service.

Obesity is at a crisis level in this country. Two-thirds of adults are above a healthy weight; half are obese. A new IPPR report says that multiple disadvantages were “conspiring” to drive down health outcomes and prevent life expectancy from growing across parts of England. Hundreds of thousands of children in England are growing up overweight or obese because of widening health disparities across the country. Their excess weight means that they will face a higher risk of serious conditions, such as type 2 diabetes, heart disease or cancer, later in life. The IPPR analysis found that as many as one in 12 cases could be avoided if health outcomes in the worst parts of England were improved to match the best. This does not make pretty reading.

We are of course not going to argue against measures that attempt to help the public improve their health, but like the obesity strategy that precedes it, the latest pilot announced in the Statement is tinkering around the edges. We need to acknowledge that tackling obesity is about tackling poverty. People in the poorest communities are twice as likely to be obese as those in the best off. This scheme is about encouraging people to make healthy choices, but the cost of living crisis will make that even harder for too many people. How is someone supposed to make healthy choices if they simply cannot afford to?

According to a report by Broken Plate, the poorest fifth of UK households would need to spend 40% of their disposable income on food to meet Eatwell Guide costs, as opposed to just 7% for the richest fifth. Therefore, if poverty limits someone’s food choices, their exercise choices and their time, can the Minister tell the House why this does not feature in the heart of the Government’s plan to tackle this scourge?

Whatever this pilot achieves, and whatever their obesity strategy achieves, it will be completely undermined by the £20 a week cut to universal credit, which, despite yesterday’s announcement, will push millions on to cheaper, less healthy alternatives. Can the Minister tell the House what will happen to the health of adults and our children? Will those who are invited to join this pilot come from the communities that will benefit most? They are the people who have suffered most from the cuts to public health. Will the Minister commit that this scheme and the obesity strategy will be followed by the restoration of moneys cut from the public health grant?

My Lords, from these Benches I thank the Minister for coming to answer questions on the Statement. These Benches welcome anything, including innovation, that targets the poor health and loss of life years that obesity brings. However, this is really the emperor’s new clothes, because it has to be set in the wider context of the detriment of poor health, public health budgets and poverty. Public health budgets have been decimated, so that many issues connected to the determinants of health cannot be dealt with. Low pay has become the norm for so many in our country. School budgets for extra activities, such as physical activity, and timetabling have caused problems, and food and drinks industry standards also have to be addressed. Tackling obesity is about tackling the lack of opportunity and tackling poverty. Innovation with a wristband is like asking somebody to learn the Green Cross Code they have a motorway to get across. It is not going to be successful.

As a country, we have to start early: we have the second-largest child obesity problem in the whole of Europe. So what are the Government doing to ensure that daily sport as an activity is available in every state school, so that every child has some daily activity? What is the Government’s response to the report by the Association for Physical Education with regard to children’s health and, in particular, with regard to swimming?

Diet at home and in school is important. The Jamie Oliver Foundation Bite Back report basically found that healthy options in schools were more expensive. What are the Government doing to ensure that fresh, healthy food is available at an affordable price in every school in the country? How are the pilots being chosen? The correct areas are the areas of deprivation, because that is where the highest incidences of obesity are. What are the criteria? How are they being selected? How are areas being offered the chance to become part of the pilot? This must be seen as a healthy eating and exercise approach, and not a weight-loss problem. There are far too many citizens in our country who suffer with eating disorder issues. So what are the Government doing to ensure that it is this framework of healthy eating and healthy lifestyles, rather than being seen purely as weight loss?

With regard to the wristband and the data, who will have access to the data? Where will it be stored? What precisely will the data be used for? Will any private sector organisation have access to the data and its interpretation, and, if so, what conditions are in place to ensure that we do not have the problem that we had with DeepMind, where it was used for purposes over and above what was anticipated?

Finally, talking of the private sector, HeadUp Systems is noted in the Statement. This is a company that has a £30,000 turnover and made an £11,000 loss last year. So how, and on what criteria, was HeadUp Systems chosen? What role will it have? Which other private sector organisations were asked to provide the support that HeadUp Systems is doing? What Ministers or officials did members of HeadUp Systems approach or have access to? If there is a contract, what is its value and on what basis was it given to HeadUp Systems?

My Lords, I start by thanking the noble Baroness and the noble Lord for their questions. This is a good story in terms of how we tackle health in the modern day. The noble Baroness mentioned the IPPR. I am not sure how well the name “Tony Blair” goes down on the Benches opposite these days—

I am pleased to hear that, because the Tony Blair Institute has actually recommended more of these schemes using wearable tech to ensure that we have a healthier population. So this is not politically motivated in any way; it is led by a desire to do the right thing, and to learn lessons from previous schemes about what works and what does not work. One problem, as many noble Lords have said in the past, is that some of these schemes have not worked. We need to make sure that we have evidence, and that anything that we roll out is evidence-based. On that basis, it is absolutely right that we pilot a scheme rather than do a one-size-fits-all scheme, only to find where the errors are.

Also, as Hayek has said, we have limited knowledge. Some people express the conceit of knowledge and think they know everything, and sometimes—in economics and in politics—quite often we become aware of consequences, both intended and unintended. It is important that, when piloting a scheme such as this, we are able to identify potential unintended consequences that would not have been foreseen. I know that the noble Lord, Lord Scriven, can already predict the outcome and has infinite knowledge, but what is really important is that we see what works and what does not work, rather than predicting in advance that something will fail—and I acknowledge that the noble Lord, Lord Scriven, was asking a question, as he is entitled to do.

I will try to answer a few of the specific questions. One of the things that we are seeing is that obesity is costing our health service and healthcare system more than £6 billion a year. Clearly, schemes have been attempted in the past, and some have worked and some have not. We looked around the world to see what we could learn from the rest of the world. In particular, we looked at the Singapore health challenge, and also the Amsterdam programme, to see what we could learn. One of the things that I noticed when I worked on projects in the past in one particular area was that, just because they worked in one area, it did not mean that they would necessarily work in another area. We have to understand the local factors that might make a project a success or not.

In addition, it is really important that we do tackle disparities, and I am very pleased that many noble Lords have brought up the issue of disparities. We now have the Office for Health Improvement and Disparities: the clue is in the title. “Disparities” means that we want to identify these disparities—all sorts of disparities: sometimes they are gender disparities; sometimes they are based on ethnic minorities; and sometimes within communities there are different disparities. It is always far more complex than we can predict in advance. One of the best ways of tackling things is to look at pilot schemes.

Let me see if I can now answer some of the specific questions. This is based on understanding what incentives people respond to. Many noble Lords will have read of schemes in the past that simply have not worked. We need to work out what works with certain communities and certain demographics. One of the bits of academic research that has been found to be quite helpful is that, quite often, people from lower-paid communities respond better to price incentives or reward systems, and we are going to put that to the test. We are not saying that this is definitely the case: we are saying that we are going to pilot this to see if what we think is going to happen will happen—and, if it does not happen, why does it not happen and what can we learn from that in the future?

The noble Baroness, Lady Merron, asks what assessment the department has made of the changes in the level of the public health budget. Public Health England has monitored and published data on trends, with a wide range of indicators of public health, set out in the Public Health Outcomes Framework. That function has now transferred to the Office for Health Improvement and Disparities, which shows the fact that we want to identify those disparities and see how we can tackle them.

The ring-fenced grant that we have provided to local authorities to spend on public health services comes with a condition that they consider the need to reduce health inequalities in their areas. The grant’s distribution is heavily weighted towards areas facing the greatest population health challenges. Per capita grant funding for the most deprived decile of local authorities is nearly 2.5 times greater than that for the least deprived.

What is the breakdown, as we go over this? The publicly available information will contain the contract value, inclusive of £3 million to be spent on rewards for participants. The budget will be managed through standard contract procedures and there will be provisions in place to prevent overspend.

I shall go over the timescales. There was open procurement for the pilot, which closed on 16 August. The contract was awarded and unsuccessful bidders notified on 27 September. The pilot mobilisation period that we are looking at is 11 October to 31 December. The press release announcing the pilot provider was issued on 22 October. The pilot launches in January 2022 and closes in June 2022 with an evaluation report. That is critical. We want this to be evidence led; it is about time that we pushed for more evidence-led research. Before I came here, I had read reports from think tanks that had analysed government programmes, only to find that the evidence always backed it up. We want to make sure that this process is clearly evidence led and also to be aware of unintended consequences.

In terms of whether people can afford to eat a healthy diet, the Eatwell Guide represents government recommendations on a healthy, balanced diet to promote long-term health at the population level. Analysis by Scarborough et al in 2016—I shall not give a Harvard reference here—of the cost of achieving a diet in line with the Eatwell Guide concluded that in some cases it was 3p cheaper than the current diet.

In terms of audience and location, the pilot will target adults over the age of 18 in a chosen local authority. The approach will be tested to ensure that it combines wide appeal across the adult population with an ability to engage those who could get the most benefit from adopting healthier behaviours for physical activity and diet, such as those not meeting recommended guidelines. The pilot will take place in one local authority in England where there is a high proportion of our target groups. I hope that the information will become available publicly, or I will be able to update the House. We will be releasing further information in due course on the pilot location and on how residents can sign up to take part in the work. The scheme will be for England only but we will continue to work across the devolved nations to learn shared best practice. One of the things that we need to do is to make sure that we learn from what works well and what has not worked so well.

How will we safeguard data and privacy? I am sure that the noble Lord, Lord Scriven, will have recognised that I come to this post as a bit of civil libertarian, and perhaps civil liberties is one of the few things that we agree on. All data will be collected, stored, shared and used in alignment with all applicable law regarding the processing of personal private data and security standards, including the UK Data Protection Act and the UK General Data Protection Regulation. Full data collection and processing requirements will be shared with potential pilot users as part of the sign-up process. Consent to take part in the pilot is, I stress, voluntary. The Department of Health and Social Care is the data controller for the pilot, with HeadUp Systems as a limited data processor that collects data on the department’s behalf.

The noble Lord asked about the supplier. We contacted HeadUp Systems to deliver the pilot, and it has partnered with a number of organisations to deliver the requirements, including the Behavioural Insights Team. The advice of Sir Keith Mills who successfully launched and ran the Air Miles and Nectar programmes has also been sought. We are therefore trying to work with the best experts out there, including the Behavioural Insights Team, to bring knowledge and expertise on behavioural economics. I am sure that many noble Lords have read many interesting works on behavioural economics over the years. If the pilot does not work, we will work out why and how we can improve the scheme to make sure.

Given that obesity costs this country over £6 billion a year, surely it is worth a little investment, experimentation and discovery to see if we can make sure that we nudge our citizens, wherever they come from, whatever their background, towards healthier living.

My Lords, perhaps I may first apologise to the Opposition Front Bench for my confusing an Urgent Question with an Oral Statement. I thought that we had only 10 minutes for all of us.

My reaction is that this system will be quite easy to game. One cannot measure fruit and vegetables, and size of portions, by wearing a wristwatch; one can only use it to input data. That is the same for step counting, which, on a wrist counter, is well known as being not as accurate as elsewhere. I hope that the Minister and his officials will look carefully at the possibilities for gaming the system. If they are collecting the data remotely, they should be able to tell whether it is being gamed.

As a former president of the British Dietetic Association, I ask the department to look carefully particularly into the obese and overweight category. There is evidence that a BMI of around 26 does no harm to people, and I should like to see more medical evidence produced on that. I invite the Minister to ask the department to look at that.

Finally, will the department look at producing an app for all citizens, not with rewards attached but just an app of good practice that could be made available for free through the App Store so that we can all share in the wisdom of the department?

I thank my noble friend for those important questions, which are exactly those that I would have asked—and, in fact, did ask the briefing team when I was getting more details on this matter.

Of course, one of the most obvious things that we have to ask is: how do people game the system? Often, when one analyses a scheme, sometimes there are unintended consequences whereby people are able to game it. Someone asked me—I think and hope that it was in jest—“If I ate 75 cream cakes and blamed my metabolism, would I be able to get on to the scheme?” We have to make sure that our data is robust. The pilot will include robust anti-fraud measures in relation to users’ activity and access to incentives.

What is interesting about the scheme is that it is voluntary, but it will also make sure that the users input the data. There has been a lot of research around that, because it has seemed to be a potential weakness, if users were inputting the data, regarding whether they can game the system. We have been assured that measures have been put in place to avoid that sort of gaming but, once again, the evidence will tell. That is why the system is not national but is a pilot to test all these questions to the limit.

The noble Lord mentioned weight loss and obesity, which I shall come to. One of the things that we want to make clear is that the health incentives scheme is not a weight-loss programme; it is a programme for healthy living. It uses an innovative approach to rewards and incentives to help participants to adopt healthier behaviours for physical activity and diet. Of course, it will help those who are overweight. I have been on two diets in my life—no, really I have. What is interesting about this is that, when one looks at these issues, it is not just a question of consuming less but about burning off calories. That is why we want to encourage healthy living as opposed to purely tackling obesity. That is very important.

The other day, I met a young lady who was very slim. She said, “Why do you keep going on about obesity and type-2 diabetes? I am slim and I have type-2 diabetes”. So sometimes we have to make sure that we are clear about these connections.

Oh I see. I bow to the superior expertise in this House of the noble Lord, Lord Scriven, and I will sit down.

My Lords, I want to ask the Minister a question based on an answer he gave earlier. He said specifically that the Government’s “eatwell plate” was as affordable as any other meal. I would like to challenge that, in my role as a member of the Food Foundation. It points out that, if you are on a low income, eating the “eatwell plate” is going to take about 60% of your disposable income. The reality of the cost of healthy food is this: if you have a pound to spend, you could get three peppers, which add up to 65 calories; six apples, which add up to about 200 calories; or a packet of sweet biscuits, which would give you 1,000 calories. If you are a mother or father struggling on a low income, and you need to feed your kids, you are going to go for the high-calorie option; this is how the food system is worked. If the Minister has data that proves that the “eatwell plate” is affordable, on whatever income you happen to have in this country, I would be very grateful for that knowledge. If he does not have it now, please could he write to me?

I thank the noble Baroness for that important question. When I am being briefed, I test my officials and make sure that I am able to answer as many questions as possible. I am told the “eatwell plate” costs about 3p less per adult per day than the current diet in the UK, but I will write to the noble Baroness with more detail. If the noble Baroness is not happy, she can challenge that.

My Lords, I really think the Minister can afford to be less prickly about all this. No one is disparaging the idea of a pilot; there have been many hundreds of pilots in this space, to my knowledge, and probably many more that I do not know about. The easy thing is piloting it; the hard thing is rolling this stuff out and having an impact. It is just that we are rather underwhelmed with the scale of this pilot, given the scale of the challenge we face. But in the interest of being positive about all this stuff, a Parkrun practice pilot has been taking place in GP surgeries up and down the country—only about 20% of them are actually taking part. Early assessment looks incredibly positive. It does not actually cost anything to implement. I encourage the Minister to try to accelerate the rollout of this initiative and, if he does not already, to take part in his own local Parkrun.

I thank the noble Baroness. I would like to know on what basis she thinks I should take part—I hope I am not looking unhealthy. I also apologise to noble Lords if I have come across as prickly; maybe I just got too excited about this scheme. As someone who been quite critical in the past of schemes that do not work and who has looked at evidence behind such schemes, I am excited that this is a real pilot, as opposed to a one-size-fits-all national system. We can see what works and then roll it out. I also thank the noble Baroness for making me aware of the scheme in GP surgeries. Maybe the noble Baroness could do me a favour and send me some details, so I can look into it in more detail and see how we could roll it out.

My Lords, in giving his answer, the Minister failed to answer one of the questions from my noble friend Lord Scriven on school sport. So perhaps we can give the Minister a second go at responding. When will the Government throw their full weight behind reviving, revitalising and extending school sport?

I have responded to questions, including the noble Lord’s question about sport in schools, which is of course incredibly important—we all benefited from that. One of the things I have to be clear about is which department it falls under. As I understand it, some of this does fall under the Department for Education, so if the noble Lord does not mind, I will write to him.

I want to follow on from the question on sport. Since 2010, the Government have given authorisation for the sale of over 220 school sports fields. Does the Minister see any correlation between the sale of these school sports fields and the rise in health inequalities? I understand the Minister might not be able to answer this and may need to go back, so if we could get a response from the Department for Education, that would be great.

I thank the noble Lord for that question. It is an interesting data point to look at to see whether it is correlation, coincidence or there is a link. As the noble Lord acknowledges, I do not have the answer at my fingertips, particularly because some of this will fall under the Department for Education. If the noble Lord will allow me, I will go back and investigate this and write to him.