The Brewery | Health & Behaviour

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HEALTH & BEHAVIOUR

Editor in Chief EDWARD AMORY

Managing Editor JAKE EVANS

Assistant Editor ELLIE SPICER

Art Director JAMES FENTIMAN

Design MARGRIET STRAATMAN AND GARY REEDMAN

Illustrations & Infographics JAMES FENTIMAN

The Brewery at freuds is a strategic communications consultancy. We partner with corporations, brands, governments and individuals

to build and protect reputation and help them to better connect with the world around them. The brewery at freuds was founded on the

belief that good communications can make the world a better place. We exist to raise that bar.

THE BREWERY DIRECTORS

Managing Director DR ARLO BRADY

Client services EDWARD AMORY

TERI O’DONNELL

RUTH SETTLE

DAVID PAGE

Issues and Crisis JO LIVINGSTON

Insight ALICE CARTNER-MORLEY

Strategy ALEX HARRISON

Special Projects HANNAH PAWLBY

Chairman, freuds MATTHEW FREUD

CEO, freuds ANDREW MCGUINNESS

Director, freuds, Health JODY HALL

Associate Director, JULIA FLINT

freuds, Health

Director

Public Health England JODY HALL

Associate Director

Public Health England JULIA FLINT

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THE BREWERY JOURNAL

The Brewery Journal is published by The Brewery at freuds

Factor Five Alan Milburn | Former Secretary of State for Health

Editorial

The Cost Of LivingDavid Mobbs | Chief Executive, Nuffield Health Group

A Fitter PillMatt Regan | UK General Manager, AbbVie

Vital SignsDerek Yach | Chief Health Officer, Vitality

Gum ControlMartin Radvan | President, Wrigley

Needle WorkLuc Debruyne | President and General Manager, GSK Vaccines

In A StateSir Liam Donaldson | former Chief Medical Officer for England

We’ve Cut DownSheila Mitchell | Director of Marketing, Public Health England

Vital Statistics: freuds Insight

Tech TonicAli Parsa | CEO, babylon

Help In HandsDr. Suzanne Clough | Chief Medical Officer, WellDoc

Behavioural ProblemsDr. Angel Chater | Lecturer in Health Psychology and Behavioural Medicine, UCL Centre for Behaviour Change

End Of The LineBy Ruth Sutherland | Chief Executive, Samaritans

Play The FoolHeston Blumenthal | OBE

Road To RecoveryCharlie Howard | Founder, MAC-UK

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Good health, and how to achieve and maintain it, is

the most significant issue facing both governments

and individuals in the developed world. The concern

for individuals is that we are living longer, but many

of those extra years may not be healthy or especially

happy ones. Meanwhile, the state must balance the

unlimited need for sophisticated (and expensive)

healthcare treatments with a global trend towards

restraining the size of the state.

It is now widely accepted that the way

to square this impossible circle is through public

health; but our understanding of how to persuade

populations to make healthy choices is still evolving.

Until relatively recently, it was assumed that there

were two choices: dictatorial state intervention-

banning substances or activities; or rational choice

decisions by individuals to do the right thing

based on better information.

We now understand however, that humans

are not just rational but emotional. Many of us

prioritise short-term gratification over long-term

benefit. We don’t act in our own best interests. We

ignore information given to us by the state, and often

flout legal sanctions intended to protect us. We

are, in short, all too human.

So building a healthier society requires a

sophisticated understanding of human behaviour, a

far cleverer set of public health tools, and a coalition

of public and private sector organisations joining

together to create a movement for change.

freuds has for many years worked at this nexus.

This has included supporting Public

Health England in creating a series of campaigns,

EDITORIAL

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like Change4Life and Stoptober, which have

measurably impacted our country’s health

outcomes. It also encompasses our work with

London 2012, when as the lead agency involved in

the Olympic Games, and in particular responsible

for organising the torch relay, we worked to build

a health legacy from this key national event.

But it also extends to our work with

a series of private sector companies in the food,

drink and related sectors, where we have supported

their journey towards becoming partners in the

coalition working to ensure that consumers make

healthy choices. Nor does it exclude our work

with companies in other sectors who have used

their consumer engagement to make an impact on

healthcare outcomes, such as Sky and Nike.

This journal explores the current and

future development of health and behaviour. It

includes insightful and impactful public sector

contributions by Sir Liam Donaldson and Sheila

Mitchell, exploring the role of government in this

mix. It includes some really exciting thinking about

the role of the private sector, ranging from companies

in the health space like Nuffield, AbbVie and GSK,

to insurance firms with innovative models like

Vitality, to global food businesses like Wrigley.

It encompasses the latest thinking on

the role of technology from entrepreneurs like Ali

Parsa, founder of babylon and Suzanne Clough

from WellDoc, and includes a keynote contribution

from Alan Milburn, former UK Secretary of State

for Health and a think piece from a leading health

psychologist. It looks at new ideas in the mental health

space, with articles from Charlie Howard,

an innovative social entrepreneur, as

well as from Ruth Sutherland, the Chief

Executive of the Samaritans.

Finally, there is an essay on

our relationship with food and how

that might be changed from Heston

Blumenthal, one of the world’s most

innovative philosopher-chefs. We have

also included some freuds insight and

research in this area, exploring how and

why we as individuals are reluctant to

take responsibility for the health impact

of choices that we make.

We hope you enjoy the journal,

and that it takes forward the discussion

about how to help human beings achieve

longer, healthier, happier lives.

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Factor FiveAlan Milburn | Former Secretary of State for Health

Wherever I go in the world, two words are virtually

synonymous: health and crisis. The National

Health Service is not the only healthcare system

under more pressure than ever before. It is true

in country after country. For some, the answer lies

in more cash. For others, it is in optimising more

value and driving greater efficiency. In this series

of essays, a distinguished panel of contributors

argues that whilst these incremental changes may be

necessary, they will not be sufficient to make modern

healthcare sustainable. Instead, the key that can

unlock sustainability is what individual citizens do

to improve their own health. That makes behaviour

change the next frontier in healthcare. Over centuries, healthcare worldwide has

had to adapt to new circumstances, new challenges

and new opportunities. In the last part of the

nineteenth century, progress in sanitation opened

a new frontier in public health. A century ago, the

discovery of new vaccines opened up a new frontier

in preventative health. In more recent times,

new treatments have opened up a new frontier

in interventional and in mental health. But each

of these new frontiers has been predicated on a

consistent philosophy about the relationship between

service and citizen - with an active role for the

former and a passive one for the latter.

Until recently, there has been too little

focus on the contribution that individuals can make

to better health and care. As our contributors explain,

that is now changing. An inflection point has been

reached with profound implications both for how

we think about healthcare and what it does. The

citizen-patient is emerging as the most powerful way

to improve health and care.

Five big factors are producing a platform

for change. Each is too often seen as a challenge

when it should be viewed as an opportunity.

First, demography. We live in an ageing society.

By 2030, one fifth of the population of Britain will

be elderly. But this will not be old age as we have

known it. There will be more very old people living

with more health problems - co-morbidities - than

ever before. And as the post-war baby boomer

generation grows old we are likely to want to live

out the end of our lives cared for in our own homes

by people we choose, with budgets we control. The

challenge is that the new generation of the old will

not tolerate a system of care that tells us what to do.

We will want to tell it what to do. The opportunity

An Introduction to Health and Behavioural ChangeIn the following article, the former UK Secretary of State for Health, Alan Milburn, introduces the concept of behaviour change in the health arena. He argues that the sustainability of healthcare systems, both in the UK and on a global level, rests on the ability of individuals to change their own behaviour and improve their health. As such, he asserts that behaviour change is ‘the next frontier in healthcare’.

‘Whether it is nano-technology or cloud computing,

technology is going to change what healthcare is able to do

and how it does it’

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is to refashion care so that it is aligned with the

mindset of this century rather than the last.

Second, malady. If the healthcare challenge

of the last century was to beat infectious disease,

the battle for this century is about tackling chronic

disease. It is responsible for 70% of NHS costs. This

change in the pattern of disease calls for less focus on

the state of the nation’s healthcare and more on the

state of each nation’s health. The focus needs to move

from treatment to prevention. What differentiates

diabetes or arthritis from other forms of illness is

that they become a permanent fixture of people’s

lives. So what patients do to manage their own

condition – their lifestyle, and diet and exercise – is

as important as what clinicians do. The challenge

is to find ways of treating patients less as passive

recipients of care in a system that denies them both

power and responsibility and instead empowers them

to take greater charge and more responsibility for

their own health. The opportunity is to bring patients

inside the decision-making tent – so they share the

day-to-day dilemmas clinicians and managers face –

rather than keeping them outside.

Third, changes brought by technology

also make likely the advent of more citizen-

controlled services. In the long-term, if the benefits

of pharmocogenetics can be realised, the next few

decades could see our whole model of healthcare

moving from one that has been about detecting and

then treating illness, to one that instead

predicts and prevents ill-health. In the

short-term the rising ride of chronic

disease means the focus has to shift from

episodic treatment – largely in hospitals

– towards earlier preventative action

and continuity in treatment – in the

community and peoples’ homes.

The world is on the verge of a huge leap

forward in how healthcare is delivered.

Whether it is nano-technology or cloud

computing, technology is going to change

what healthcare is able to do and how it

does it. The potential here is enormous,

but the challenge is to address the

mismatch between the services that are

provided – with an over-concentration on

hospital-based care – and those that are

needed – for more care in the community

and at home. The opportunity is to

harness technology – from big data to

patient-owned health records to mobile

health applications and wearable devices –

to help make that transition.

Fourth, expectancy. We live in

a world where people are more informed

and inquiring. They are demanding a

greater say. Ordinary people are getting

a taste for greater power and control

have mainly relied on structural and organisational

change to drive improvement in the NHS. Levers like

competition, transparency and incentives have been

deployed with some success but ‘patient power’ has

remained a marginal, rather than mainstream idea.

That now has to change both for health reasons

and financial ones.

It is time for citizens to own greater

responsibility for improving their own health.

That will not happen without a better understanding

about what drives certain behaviours and what

incentivises others. Nor will it happen without the

participation of both health professionals and new

providers. Above all else, it will mean thinking of the

public less as outsiders and more as insiders – as

part of the decision-making process rather than

by-standers to it.

Change will have to happen not just

because the cash is running out but because time is

running out for a system that was designed to deal

with yesterday’s challenges, not tomorrow’s. Meeting

these challenges will be daunting but it opens up

an enormous opportunity - to reshape how care is

delivered so that we optimise resources, empower

patients and improve outcomes.

in their lives. People today want choice and expect

quality. It is not that the public wants surgeries or

hospitals to behave like supermarkets or salesrooms.

The relationship people desire is not merely a

transactional one. They want a personal one. The

challenge is to find new ways of treating each patient

as an individual rather than as just another number.

The opportunity is to harness the modern citizen’s

appetite for knowledge and control in order to

make self-care a reality.

Fifth, and most potently of all, money.

In the last three decades, health budgets have been

growing faster than the economy has grown. In 1960

developed nations spent on average 4% of GDP on

healthcare. Today it is closer to 10%. We have been

spending more than we have been earning. The

global financial crisis and a squeeze on government

spending have brought those good times to an

end. The problem is that resources might slow but

pressures won’t. So the accent will be on finding new

ways of getting more out of healthcare for what is put

in. That is a challenge. But it is also an opportunity.

None of these challenges are unique to our

country. They affect every healthcare system in every

country. Their combined effect is to break the old

assumption that improvements in performance could

only be created by large increases in investment.

That is no longer sustainable. A new holy grail in

global health policy has emerged – how to get better

outcomes for lower costs. That relies on moving

people from being passive by-standers as patients to

active participants as citizens in healthcare.

The explosion in chronic conditions we are

now witnessing across the world calls into question

the whole paradigm of how we have traditionally

delivered healthcare. Clinicians have prescribed and

patients have received. But if you have diabetes, what

the patient does – the food they eat, the exercise they

take, the lifestyle they choose – has a huge bearing

on their health. Better still would be the adoption of

behaviours that prevent conditions like obesity in the

first place. The contributors to this journal suggest a

multitude of ways that can happen.

For decades there has been much talk

about giving patients more power. But policy-makers

‘Change will have to happen, not

just because cash is running out, but

because time is running out for a system that was

designed to deal with yesterday’s

challenges, not tomorrow’s’ 13

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The Cost of Living

Employee Wellbeing: the New Corporate Responsibility

By David Mobbs | Chief Executive, Nuffield Health Group

David Mobbs is the former Chief Executive of the Nuffield Health Group – a non-

profit group which operates a range of health and wellbeing facilities including

Nuffield Health Hospitals and Nuffield Health Fitness & Wellbeing Centres. The

charity was established in 1957 and has established 31 hospitals and 77 gyms

across the UK, delivering a comprehensive network of healthcare and wellbeing

services. In this article, David Mobbs explores the need for Corporate Britain to

increase its responsibility for employee wellbeing.

The Cost of Living

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It’s time to come to terms with the fact that while

on the surface the UK offers free health care, we in

fact run a co-funded system. Your health is free at

the cost of recovery, but there is a cost to stay well.

It is a cost nobody is taking responsibility for, which

lumbers the NHS with higher bills as more people

become ill due to poor lifestyle decisions.

The question is, who should pay to look

after the population’s wellbeing? In a world where

corporate responsibility implies supporting local

communities and looking after the health of the

planet, why would it not also extend to keeping your

workforce happy and healthy?

After the individual, UK businesses are

next in line to reap the benefits of a well workforce.

In 2012, Nuffield Health launched a joint research

project with Ashridge Business School to discover

sustainable wellbeing initiatives that would result

in real benefits. Judith Parsons, Business Director

for Ashridge Business School, said at the time: “The

costs of not attending to employee wellbeing are

enormous – both at an individual level and to the

company bottom line. Ill health and absence costs the

UK economy £100 billion per year. Poor nutrition

is estimated to cost 97 million working days in the

UK per year and a staggering 50% + of workers are

dehydrated. However, only half of UK employers

have an employee wellbeing strategy.”

Further, the World Economic

Forum’s Global Competitiveness Report

2010-2011 identified the health of the

workforce as one of the four pillars

of global competitiveness. They link a

country’s competitiveness and productivity

to having a healthy workforce. Illness

impacts not only attendance but also

productivity and so they make it clear that

investment in efficient health services is

critical to on-going economic success.

The link between everyday

wellbeing and avoiding health

breakdowns is so intrinsic, in 2008 we

made the decision to transform Nuffield

Health from a provider of recovery

services into an organisation which covers

the whole journey, from prevention to

cure and recovery.

It needs to be up to the

individual, ultimately, to make the decision

to improve their wellbeing – but this can

be a symbiotic relationship with work. An

employer can influence their employee’s

environment to promote a better lifestyle,

and at the same time an individual will be

tempted to work for a company who take

their wellbeing seriously.

‘Ill health and absence costs the UK economy £100

billion per year’

supermarkets employing a compulsory 5p fee for

plastic bags.

While the state can attack the bigger, more

obvious issues impacting our health (e.g. smoking

indoors, minimum alcohol costs) it is impractical and

unwanted for the government to interfere in our day-

to-day lives. There’s no platform for the government

to enforce a more granular approach – more balanced

diets, increased exercise or even just better posture.

A business, however, has the perfect

platform to address these within its own workforce.

This is where the idea of a Wellbeing Levy comes to

play. Just like a tax aimed at promoting the cutting

of carbon emissions, a wellbeing levy would tax

organisations not providing the right environments

and initiatives to make sure their employees are

looking after themselves.

In effect, such a wellbeing levy would be

an incentive to businesses to offer proactive solutions

to the future health problems of their staff (and, as

a result, the UK). The levy would be offset when a

business offered routes for their staff to achieve a

better wellbeing.

This would create a wedge-shaped fund,

offering a large amount of money now while the

NHS needs to reform, with that amount of money

decreasing over time as UK businesses offer more

wellbeing solutions to their staff (and thus decrease

their workforce’s demand on the NHS).

In 2013 Nuffield Health published a

study in collaboration with the London School of

Economics titled ‘12 minutes more’, highlighting

the impact increased physical activity among Britons

could have on their health, their finances and their

impact on the NHS.

For instance, we found that if each obese

person were to engage in moderate activity for five

days a week, there would be a 7% decrease in the

likelihood of that person continuing to be classified

as obese, which would imply a cost saving to the

NHS of £360 million per annum. Highlighting the

link between wellbeing and impact on the NHS,

there would also be a 6% decrease in those suffering

from psychological distress, yielding £6.3 billion in

potential savings overall (taking in to account loss of

The modern work week, despite the

digitalisation and the rise of remote working, still takes

up the lion’s share of our time. According to the ONS,

from May to July in 2015 people working full-time

worked, on average, 37.3 hours per week in their main

job. That gives an employer a significant opportunity to

make a difference.

It can be argued then, that the solution

to the major challenges that NHS faces lay outside

of NHS and indeed beyond real state control. That

means Corporate Britain has got a responsibility to

help UK plc with its health issues.

Ill health prevention and wellbeing is

territory Nuffield Health knows well. We know

what it takes to bring wellbeing benefits to

corporations - we service 60% of the FTSE 100

and 40% of the FTSE 250.

We’ve been working with corporations

to improve the health and happiness of their

workforce. A happier and healthier workforce

is reward in itself, but those corporations don’t

work with us out of their own benevolence – they

recognise what wellbeing brings to their bottom

line. Productivity goes up, those who were flagging

stop flagging and those who were already high

performers sustain their output longer. Then

there’s the obvious benefit of a well workforce –

the reduction of ill-health provision needed. In

short, less sick pay and better continuity in the

workplace.

Employee wellbeing will be at the centre

of a war for talent, which will become increasingly

apparent as millennials enter the workforce in

higher numbers. This new breed of employee arrive

with the desire to choose an employer based not on

salary, but on the impact on their own happiness

and health, as well as the organisation’s other

corporate responsibility credentials. Consumers

will also feel loyalty to organisations that clearly

look after the wellbeing of its people and the UK.

Sometimes the state is forced to do

something bold, something that will influence a

company’s corporate responsibility. So we have

organisations focusing on their use of renewables

and green energy, or for a more recent example

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‘Corporations don’t work with

us out of their own benevolence – they recognise

what wellbeing brings to their

bottom line’

earnings, associated treatment and welfare costs). If

businesses were able to help implement these changes

to their workforce, the benefits are obvious.

A Kings Fund report last year identified

that we are currently spending 8.5% of GDP on

health. If this continues without change, in 20

years time providing a similar level of service

would require more than 30% of GDP. Even

without the current pressure on public

finances, this would be unaffordable.

It’s a massive problem for

the NHS that the NHS is powerless to

solve. It’s time for Corporate Britain

to enter the battle, redefine corporate

responsibility and help improve

Britain’s wellbeing.

The future of our NHS depends on the decisions

we make today. We need to ask ourselves – as

individuals, patients, healthcare professionals,

industry and Government – what can I do to ensure a

sustainable future for the NHS?

Turning the vision of a sustainable NHS as

set out in the ‘Five Year Forward View’ into a reality

demands a new approach, with behaviour change on

all sides. We need fresh thinking about what each of

us – as individuals and in our professional roles – can

bring to the table.

The need for change is obvious and urgent.

The NHS deals with a million patients every 36

hours. Over a quarter of our population – some 15

Beyond Medicine: Why Patient Self Management is the New Frontier of Healthcare

By Matt Regan | UK General Manager, AbbVie

A Fitter Pill

Matt Regan is the UK General

Manager of AbbVie, the global

biopharmaceutical company. In the

following article, Regan explores

how shared decision-making and

improved patient self-care are

essential for the long-term survival

of the NHS.

million people – have a long-term health condition,

like arthritis, diabetes or asthma. As the ‘Five Year

Forward View’ puts it, the NHS must “evolve to meet

new challenges: we live longer, with complex health

issues, sometimes of our own making.”

Certainly there is more that each of us

can do for ourselves. If we make small changes every

day – moving more, eating well, not smoking – we

can avoid some of the preventable conditions that

thousands of people already live with. As an employer,

AbbVie want our people to be healthy and to have

a good work-life balance. Through our Vitality

programme, we’re encouraging our team to get their

health checked and supporting them to make positive

lifestyle changes where they feel the need.

But our person-centred approach isn’t only

about our workforce. It’s also about the people we

serve – individuals living with long-term conditions

– understanding their needs and working to improve

their care and quality of life.

As a pharmaceutical company, our mission

is to bring breakthrough medicines and innovative

medical approaches to patients across the globe. The

traditional view of what companies like ours can

contribute has been focused on the medicine: efficacy,

risk/benefit profile and cost. But we have decided

we can do more than discover and manufacture. We

are committed to a partnership approach that goes

beyond medicine.

Our approach is three-fold. First, work in

partnership with patients, healthcare professionals,

academics, Government and beyond to understand

the challenges and find solutions. Second, focus on

the interventions that have been shown to be most

effective. Third, get them to patients early, when they

have greatest chance of working.

‘Our partnerships are taking us into non-traditional territory

for a pharmaceutical company’

Collaboration is critical. We are

partnering with a wide range of different

organisations and individuals. We each

have different expertise. What unites us is

the belief that our NHS is precious and,

by harnessing our collective insights and

ingenuity, we can find practical solutions

to the urgent challenges it faces.

Our partnerships are taking

us into non-traditional territory for a

pharmaceutical company. For example,

one of our key areas of focus is around

the interventions that can support people

with a long-term condition to get back

to work as early as they can. Sickness

absence costs our economy a massive

£100 billion every year. Musculoskeletal

conditions – such as lower back pain,

osteoarthritis, rheumatoid arthritis and

ankylosing spondylitis – are the biggest

cause, accounting for around 31 million

days of sick leave each year in the UK.

Here, we’ve put our

international experience to use. We’ve

taken a model of care that we’ve seen

working in Spain and put it into action

in the UK. The model shows that by

supporting people to get specialist help

quickly, they can often manage their

condition effectively, improving their

experience and helping them stay in

work. We’re now partnering with the

Leeds Community Healthcare NHS

Trust to create the UK’s first Early

Intervention Clinic for people with

musculoskeletal conditions.

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addressing their hepatitis C can be an important step

towards their overall recovery from addiction. As one

former drug user put it, “getting tested and treated

for Hepatitis C can be the first positive thing you’ve

done for yourself in a long time.”

But people who use drugs often find it

difficult to access traditional health services. The two

charities came to us to help them bring information

and testing into the drug service. The initiative we’ve

co-created includes workforce development for drug

service key workers, peer-to-peer education delivered

by former drug users and a buddying scheme to

support people through testing and treatment.

Just four peer educators in Cornwall have reached

236 service users, busting myths around risky

behaviours, testing and treatment. Specialist nurses

based in the drug services will be tracking how many

people decide to get tested and go on to complete

treatment successfully.

Ultimately, the goal is to eliminate hepatitis

C as a public health problem and reduce the burden

of liver diseases on patients and on our hospitals. It’s

ambitious, but achievable. If we can contribute to this

by improving the whole care pathway for people with

hepatitis, we’ll be very proud.

This example also illustrates what can be

achieved when you change the traditional hospital-

dominated model of care. By moving services – in

this case the specialist nurses – into the community

and closer to the patient, we can release capacity

and get better outcomes. By treating people in their

homes and supporting them to self-manage where

possible, we can keep them out of hospital and help

them stay where they want to be.

Here, Government needs to change its

behaviour too. It needs to recognise and invest in

the interventions today that have a future payoff.

Preventable disease, lower disability, avoidable

mortality and lower costs – all of these will ease the

burden on stretched health and care services at a

time of financial pressure. It’s easy to talk the talk,

but the Government needs to walk the walk.

At AbbVie, we believe we can make

medicines work better for patients, services work

better for the NHS, and investments in health and

The aim is to cut the many weeks people

signed off work can wait for a specialist appointment

to just five days. Six clinics over three sites will

serve a population of 750,000. Over the next year

we will track the clinics’ impact on improving

people’s health, experience of care and ability to

work. Estimates suggest that, if the scaled-up model

works for the UK, we could reduce temporary work

disability by 25% – the equivalent of having nearly

40,000 additional workers available for work each

day. We’ll also have a proof of concept that may be

transferable across different locations, populations

and disease areas.

We believe that a true partnership

between patients and professionals can transform

outcomes and experience. “Doctor knows best”

may have satisfied the patients of yesterday, but

it’s not going to cut it today. As a group of experts

brought together by AbbVie to examine healthcare

sustainability wrote: “individuals will be able to

make a transition from being a passive recipient of

advice and treatment to increasingly directing their

own care [in a sustainable system].”

Yet, when we reviewed the tools available to

support shared decision-making, we found that not a

single one mentioned work. We’re now working with

a team at the University of Cardiff to close that gap.

The team is developing a shared-decision making tool

that specifically supports better conversations around

work – whatever the individual’s long-term condition.

We’ve helped the Cardiff team find testing sites for

the tool to be piloted in hospital out-patient clinics

and in general practice.

With shared decision-making and a

supported self management approach, we can also

unlock the potential of individuals to change their

own lives.

One of the most inspiring examples I’ve

seen is through the initiative we’ve set up with The

Hepatitis C Trust and Addaction in the South West,

working with people who use intravenous drugs.

Around half of people who use intravenous drugs

are thought to have hepatitis C, putting them at

increased risk of liver cirrhosis and liver cancers.

With the right treatment hepatitis C is curable, and

‘By treating people in their homes and

supporting them to self-manage where

possible, we can keep them out of hospital and help them stay where they want to be’ 21

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care work better for society. We’re committed to

playing our part to meeting the tough challenges

and choices that we face.

It will take all of us – patients,

the public, professionals, national and local

government, industry. We’ll all need to change our

behaviour, think creatively, work in partnership.

It will take time. But if we start today, we’ll have a

healthier tomorrow.

How Health Insurance Can Ensure Healthier Living

By Derek Yach | Chief Health Officer, Vitality

Vital Signs

Derek Yach has focused his career on advancing global health. He is the Chief

Health Officer of Vitality, and leads the Vitality Institute. The organisation

offers health and life insurance and is one of the first of its kind that rewards its

customers for choosing healthier lifestyles. Here, Derek shares his perspective on

how companies are able to pursue profit but in a way that is beneficial to society

as a whole.

and making healthy choices the easy choice. They

were filling a gap in what was then a widespread

failure to apply the work of Nobel Prize winning

behavioural economists like Daniel Kahneman and

Robert Shiller to public health issues.

Kahneman focused on the critical insight

that we are imperfect in how we make decisions, in

the sense that the short-term often dominates our

thinking and actions at the cost of our long-term

health and wealth. We act irrationally in terms of

daily behaviors. Other thinkers, like Robert Thaler

and Cas Sunstein, suggested that it might be possible

to “nudge” rather than force consumers towards

behaving in their own best long term interests.

Vitality is an insurance and finance

company, and they set out, well before I joined, to

answer a complex question: How do we persuade

people to do more exercise if they would rather lie

in bed, avoid sugary sweets when presented with

appetising treats, or go to the doctor even if they

don’t really feel like it?

My early career in public health in South Africa

was traditional. It focused on surveillance and the

use of government regulations and taxes, marketing

bans and advertising controls on harmful products

like tobacco. I took this view to the World Health

Organization (WHO), where for a decade I worked

on government-led approaches to addressing tobacco

use, unhealthy food consumptions, and a lack of

physical activity.

When I moved to the United States (US),

however, and went to work for PepsiCo, I observed

that in the private sector there was a far greater

intensity of interest in understanding what determined

consumption behaviour. What do consumers love

and dislike? What really mattered to them and drove

them in their daily life? It was clear to me that if

you understood this, you stood a far better chance of

guiding people towards healthier lives.

So it made sense to join Vitality (part of

Discovery Holdings) who were pioneering the notion

and excitement around incentivising better health

Vitality realised that it would be in their

interest as a company to have a positive impact on the

health of their clients, because as a health insurer

there would be lower healthcare payouts, and as a life

insurer they would get more premiums. Consumers

would also benefit, from longer and healthier lives.

At the start, they put in place a range of

rewards, including dramatic discounts at the gym,

intended to overcome the natural bias towards the

short-term. The results surprised even the programme

advocates, as hospitalisation rates fell and customers

became less likely to succumb to common diseases.

These results, which have been clinically proven,

have now been replicated in the US as well.

The longer clients stay with Vitality,

it turns out, the more substantial the decline in

their risks for heart disease and diabetes, and the

steeper the decline in healthcare costs due to such

conditions. Not that this is necessarily enough

to persuade people to stay with the programme

– which is why it has built-in safeguards against

backsliding. People don’t like losing rewards which

they have already unlocked, and will take actions

that improve their health to safeguard seemingly

unrelated rewards!

The programme has expanded

to allow for people who dislike going to

the gym, so we can track their activity

on a range of wearables devices like the

iPhone. People receive rewards based

on how much exercise they are doing,

regardless of whether they are walking

the dog or jogging to work.

The exponential expansion

of personal health technology opens up

whole new areas for health promotion.

For example, around 50% of people

over the age of 50 are on one or more

chronic disease medication, but in many

populations, only around 30% of those

people are taking it regularly. Using the

right technology in the right way can

boost that to 80%, a vast difference that 23

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freuds Case Study;

Sky Ride

In May 2010, Sky launched Sky Ride; a

series of 12 free, mass participation cycling

events in 10 cities across the UK. Participants

were offered the unique opportunity to cycle

around their city on traffic-free streets and

celebrity ambassadors, including Kelly Brook

and Sir Chris Hoy, took part to help promote

the events.

From Great Britain's success in the

Beijing Olympics in 2008, cycling had a new

fan base. Sky saw an opportunity to tap into

this cultural zeitgeist in order to highlight

the benefits of cycling to those that were not

engaged in the sport at an elite level. In order

to achieve this, freuds looked at different

consumer groups and created platforms that

would talk to them through a cycling lens

including fashion, music and lifestyle.

In year one, over 200,000 people

participated. freuds also managed consumer

communications around Sky Ride for the

successive 2011, 2012 and 2013 campaigns,

managing media relations and consumer

engagement at multiple locations across the UK,

with a total reach of 1.1bn people. Sky’s aim was

to get 1 million more people cycling by 2015 and

this was achieved by 2013.

will have real impact on death and hospitalisation

rates for diseases like strokes and diabetes.

New technologies bring new challenges.

Privacy is one. Individuals and society will need to

balance the benefits of data sharing with the need for

protecting people’s personal space. We have worked

proactively with technology companies, leading

privacy advocates, national regulators, and health

groups to develop guidelines to ensure the highest

privacy standards are built into our programs.

The future direction is clear – consumers need to

be aware of the bargain they are making at each

stage of the data transfer process, and have the

option to explicitly opt in or out of that transaction.

Ultimately, it is up to us all to convince people that

this is not about Big Brother watching them, but

Big Sister helping them.

Our company’s profitability depends

upon our clients living longer and healthier lives.

We call our model “shared value insurance”. We

are not alone in developing business models that

work for business and society. One example is

CVS, the pharmacy chain in the US. Last year,

they announced they were taking all tobacco

items out of their stores. The result was a short-

term profitability hit, and a massive long-term

profitability gain. They renamed themselves as CVS

Health, in line with their new direction. Another

example is Tesco, who I work with in the UK. They

took sweets and chocolate away from the immediate

area around checkouts. This has had a positive

business impact, mainly because of the indirect

effect of sending messages to mothers that they no

longer need to worry about “pester power” if they

shop at Tesco. So that has led to them asking what

else they can do to advance health! Leading food

companies are going through a similar process.

After many years of struggle we now see

that the financially healthiest part of Unilever,

PepsiCo, and many other food companies’ portfolios

is increasingly the healthiest products, with less

sugar, less saturated fat, and less processing. I see

the simple principle of advancing health through

better aligned business models having a critical

impact on tackling the major threats to health we

face today.

This is not just about finding easy ways

for companies to change. Furthermore, there

should not be any no-go areas when it comes to

public health, so we should be talking to alcohol

companies who are starting to think about the long

term profitability of low alcohol products including

‘This is not about Big Brother

watching them, but Big Sister helping them’

for profit which are also good for society.

To accelerate this, we need to move

away from a traditional view of health

as the province of the pharmaceutical

industry or the medical profession, and to

understand that the future will see firms

in technology and other sectors helping

individual consumers get healthier

and being rewarded for doing so. They

are effective because they understand

consumers and realise that government

regulation does not change behaviour.

That requires a far more subtle process

of nudges and incentives which private

companies are often better placed to

provide than the state. The future of

health is not solely in the hands of civil

servants, but with individual consumers

and those who provide for all of their

needs.

zero alcohol beers.

Even the tobacco industry is no longer the

clear-cut case that it was when I campaigned against

cigarette firms in my youth. In many nations, public

health professionals have taken a very hard line

on e-cigarettes and I think that is wrong for two

reasons. First, because it seems clear to me that

any means of ingesting nicotine without the tar

content of a cigarette could have major public health

benefits. Second, because if the tobacco companies

were encouraged to invest more in this area, that

would accelerate the decline of traditional smoking.

Philip Morris has already stated quite explicitly

that in a decade, the majority of their products will

be reduced risk. There are difficult issues here, but

nearly anything which brings down the death rate is

worth trying.

Overall, I believe that when major

corporations and corporate interests start looking at

their product portfolio through the lens of public

health, they will see more and more opportunities

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Gum ControlBy Martin Radvan | President, Wrigley

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Chewing Gum: No Longer A Sticking Point For Better Oral Healthcare

Martin Radvan is the President of Wrigley, a subsidiary of Mars, Incorporated.

As a recognised leader in confectionary, Wrigley has been involved in the

improvement of global dental care by promoting the benefits of chewing sugar-

free gum. Radvan believes Wrigley has a considerable role to play in educating

consumers, dental health professionals and policy makers on the health benefits

of chewing.

The consumer preference ‘why’ is simple to

understand – the flavor of sugar-free gum lasts much

longer. In short, it tastes better. That’s because in gum

it’s the sweetener that plays a big role in delivering

the flavor - when you think the flavor has gone it’s

actually the sweetener that has gone. So gum is one of

the few food categories where we can actually improve

product performance by taking sugar out.

Sugar-free gum is also very low calorie, but

the big bonus comes from what it does for your teeth.

Chewing gum stimulates the production of saliva –

and saliva is the body’s natural way of looking after

teeth and the mouth in general.

It’s simple science. When you eat food,

plaque acids form on your teeth and the acidity

in your mouth rises, damaging the teeth. Saliva

neutralizes these acids, reducing the damage done. It

also promotes the remineralisation of tooth enamel

and reduces ‘dry mouth’. In a nutshell - chewing

sugar-free gum after eating protects your teeth.

For Wrigley, our interest in getting more

people chewing more sugar-free gum isn’t just about

driving our sales. Poor dental care is a huge issue for

society: the World Health Organisation estimates that

nearly 100 per cent of adults and 60-90 per cent of

children have cavities globally. In the UK, the latest

NHS data shows that dental problems are now the

fourth most common reason that young people under

17 are admitted to hospital.

Wrigley has focused for some time on

promoting the individual benefits of chewing sugar-

Chewing gum has always been much more than

simply a fun confection. Women in classical Greece

chewed mastic gum to clean their teeth and sweeten

their breath. Early settlers in America were taught

by Native Americans to use gum from spruce trees to

quench their thirst.

During the 20th century, of course, gum

came to be seen as primarily about fun and fresh

breath. But in recent years, inherent and deeper

benefits of chewing gum have, once again, come to

the fore with widening recognition of the positive

difference it has on oral care. As a consequence,

at Wrigley we increasingly spend our time working

with dental professionals and public health experts

worldwide – because more people chewing more

gum will lead to better oral health and reduced

healthcare costs.

The beginnings of this breakthrough can

be traced to our continual search for better gum for

consumers. Older readers might recall the 1950s hit

for Lonnie Donnigan ‘Does your chewing gum lose

its flavor on the bedpost overnight?’ Well it wasn’t

just something he sang about. Indeed, for most of

our history, the search for longer lasting and better

flavored gum has been central to our R&D efforts

and that’s where sugar-free gum came in.

We launched EXTRA™ sugar-free gum

in the US in 1984, and now sugar-free gum is

available around the globe. It’s usually the gum that

consumers prefer and it accounts for over 80% of

global gum sales – indeed much more in the UK.

free gum, but recently we have also turned our

attention to the broader public health benefits. There

is now good research that is beginning to quantify the

impact that this can have on individual dental health

as well as health care costs across a whole population.

We recently commissioned a study that

looked at the impact of taking German consumption

of sugar-free gum to the levels of Finland. In

Finland, the government – and dentists – encourage

the very regular use of sugar-free gum to great effect,

with 202 pieces being chewed per person per year.

In Germany, by contrast, per capita consumption is

at 111. The research showed that if Germans chewed

like the Finns, not only would national health care

costs be 313 million euros lower per year, but over

a lifetime the average person would also have seven

more cavity-free teeth. Another study looking at the

UK has concluded that if every 12-year-old chewed

three times a day, there would be an estimated

annual saving of £8.1-8.4 million to the NHS.

As the world’s largest gum company there is

a clear convergence of our commercial interest with

that of public health. We want more people to chew

more gum – and that’s in the health interest of the

population as a whole.

Now we are not trying to say we are

an oral care company – and so don’t expect us to

launch Wrigley toothbrushes any time soon. But

we do believe we have a role to play in educating

consumers, dental health professionals and policy

makers on the health benefits of chewing.

The health benefits of chewing are

increasingly recognised in policy making circles. We

have strong support from national and international

dental federations. Several Governments explicitly

support the chewing of gum as part of their national

oral health care plan. At a European level, the body

that regulates health claims for food have supported

eight specific claims for sugar-free gum – and we are

one of the very few categories where health claims

are allowed.

Our understanding of what makes our

consumers tick makes us a valuable partner for

public health initiatives around the world. That’s

why we currently have partnerships with dozens of

dental associations around the world.

We work with these associations to help

them and their members educate patients

on an effective and enjoyable part of

good oral health. We also partner with

them through the Wrigley Company

Foundation to provide better access to

oral health in under-served communities.

One of our big challenges

as a business is chewing gum is an

impulse purchase – it rarely makes it

to the shopping list. That means our

business success is very dependent on

having our product on sale wherever

money (legally) changes hands. So as

checkouts change through technology

and some customers look to restrict

confections at checkout, it becomes even

more important to get across the health

message about gum.

It’s great to work in a business

that not only brings such great pleasure

to billions of consumers but also has

such a positive health contribution. It

is something that really motivates our

Associates. Plus it is a good example of

the principle of Mutuality that is at the

core to how Mars does business.

I believe that at Wrigley we

are demonstrating Mutuality in action –

illustrating how businesses can and must

be a positive, as a well as a profitable, part

of the societies in which they operate.

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‘More people chewing more

gum will lead to better oral health

and reduced healthcare costs’

GSK: Changing its Business Model to Change the World

By Luc Debruyne | President and General Manager, GSK Vaccines

Needle Work

Luc Debruyne is President and General Manager of Vaccines for GSK – a science-

led global healthcare company – and is based in Belgium. He is currently

a member of the Vaccines CEOs Roundtable convened by the International

Federation of Pharmaceutical Manufacturers Associations (IFPMA). In this article

he stresses the need for pharmaceutical and other health companies to alter their

business models to ensure the long-term sustainability of healthcare provision.

‘Developing vaccines is pointless if they sit on a shelf, out of the reach of those who need them’

Rapid medical advances have transformed millions

of lives over recent decades. Antibiotics have made

complex surgery possible. Antiretroviral therapies

mean HIV is now a long-term condition with the life

expectancy of many people living with the virus now

approaching that seen in HIV negative people.

One of the most extraordinary changes has been the

way vaccines have transformed public health, turning

the tide against infectious diseases such as polio and

tetanus. With the exception of clean drinking water,

no intervention has rivalled vaccination in its ability

to save lives.

Despite all the achievements of recent

years, the World Health Organization estimates that

nearly 19 million infants worldwide are still not

being reached by routine immunisation. Even very

close to home here in Europe, the last 12 months

have seen outbreaks of infectious, vaccine-preventable

diseases like measles and diphtheria with devastating

consequences. While we have made great progress,

clearly we need to do more to make sure the tools we

have in hand today help prevent these diseases are

available to all those that need them.

At the same time as overcoming the

obstacles preventing wider uptake of vaccination,

equally pressing is the need to find new vaccines

for diseases such as RSV – a respiratory virus which

largely affects children and is not currently vaccine-

preventable – as well as emerging threats like MERS

and the still elusive HIV vaccine.

In such constantly evolving circumstances,

it’s clear we all need to step up and evaluate our ways

of working in order to continue to make advances in

public health. In this process, we’ve had to challenge

ourselves as a business. How can we change our

behaviour to ensure we continue to play our role

in developing and providing quality

medicines and vaccines that meet public

health needs and, at the same time,

perform financially?

For a healthcare business

like GSK, this demands invention both

inside and outside our laboratories. This

can be hard in the risk-averse corporate

world where you may have thousands of

employees to convince as well as the board.

But over a number of years at GSK, we

have been radically changing our business

model in three key ways – through

innovation, collaboration and access.

Getting a new medicine or

vaccine from bench to patient can take

many years, not to mention millions of

pounds of investment that may never

be realised – it is a fine line between

success and failure. Cracking these

challenges requires a different approach

to research and development. So now

our scientists work in smaller groups

dedicated to particular disease areas or

therapies. These units are more focused,

nimble and entrepreneurial.

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31

developing countries which include least developed,

low and middle income countries.

Underpinning innovation, access and

collaboration are other important behaviour changes.

Transparency with clinical trial data is one example.

We know this resource is incredibly valuable to the

scientific community to learn about what research

has and hasn’t worked. So we post summaries of all

our clinical trial results, whether positive or negative,

on our website for anyone to see and we have

committed to seek publication of all of our clinical

studies in peer-reviewed journals.

More recently, we have embarked on a

journey to reform and modernise how we sell and

market our products to health care professionals,

phasing out payments to doctors to speak on our

behalf about our products. Instead of individual sales

targets, our sales people are increasingly evaluated

and rewarded for their technical knowledge and

quality of service. These new approaches will improve

how we provide information to doctors and will make

us more transparent.

None of this is easy. Big bold changes

take time and demand each and every individual

plays their part. Businesses are made up of the

people who work for them; one of the hardest yet

most important actions a company can take is to

embed change by instilling the right culture and

processes to help employees understand that “how”

you do things can be as important as “what” you do.

As individuals and as an organisation, we are still

working to achieve this.

It is a challenge worth taking on. In a

setting where it may seem like change is the only

constant, we need to keep open the dialogue on new

ways of working. Innovation, collaboration and access

are the bedrock on which we can respond in the right

way to a shifting environment – and ultimately do

better in a sustainable way for patients, shareholders

and society.

Nobody has a monopoly on science or

great ideas. So we are also innovating through

collaboration – thinking hard about how we can

best combine the considerable skills, expertise and

resources of GSK with the complementary qualities

of different organisations to help tackle some of the

biggest global health issues. By creating networks

across academia, industry, government and civil

society, we can bring together the best minds and

share expertise, which stimulates innovation.

Malaria is a case in point – it is a

particularly tough challenge because the parasite

is clever enough to evade human immune system

responses. This year, we achieved a significant

milestone for our malaria vaccine candidate, designed

for young children in Africa. It is the first in the

world to receive a positive scientific opinion from

European regulators. Getting to this point has taken

30 years and scientists from Washington to Malawi.

Only by working with partners from other countries

and sectors, could we together shoulder the scientific

and economic risk of developing such a vaccine.

The experience gained from malaria is

now lending itself to other vaccines, for example

opening the way for vaccines against other

infections that affect older people or those with

weakened immune responses.

Developing vaccines like this is pointless if

they sit on a shelf, out of reach for those who need

them. So we have tried to be more innovative in our

approach to access – flexing our business model and

working with others to help keep vaccines affordable.

In GSK’s vaccines division, we use tiered

pricing which asks countries, at each step of their

development journey, to pay a fair price which

reflects their particular circumstances and the return

on investment that they receive from vaccination.

This is designed to support those countries which

commit to vaccination for the long-term. We also

work with Gavi, the Vaccines Alliance, and Unicef,

who can purchase large volumes of vaccines at our

lowest prices for children in the poorest countries.

Our approach has been successful in

broadening access. Of the 800 million doses of

GSK vaccines distributed in 2014, over 80% went to

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‘Our approach has been successful in broadening access. Of the 800 million doses of GSK vaccines distributed in 2014, over 80% went to developing countries’

Fear of Nanny Could Make the NHS Unsustainable

By Sir Liam Donaldson | former Chief Medical Officer for England

In A State

Sir Liam Donaldson is recognised as a global leader in patient safety and public

health. He is currently Associate Fellow in the Centre on Global Health Security at

Chatham House and Chancellor of Newcastle University. From 1998 to 2010 he was

the Chief Medical Officer for England. In this role, Sir Liam was the chief advisor

to the UK Government on health matters and was one of the most senior figures

in the National Health Service. In the following article, Sir Liam discusses the

importance of political leadership in improving public health.

the North of Ireland. As my colleague was parking

the car, he heard the six-year old on the back seat

whisper to his brother: “If Daddy gives you a burger,

don’t eat it; they’ve got the Mad Cow up here.”

The BSE crisis quickly became a scandal

as the public lost confidence in the health advice

coming from government. Trust between the citizen

and their elected representatives lay in tatters.

Deference was not quite dead but there would

certainly be no going back to the uncritical public

acceptance of bland reassurances. BSE cast a long

shadow over modern public health and certainly

fuelled mistrust in Government when the next crisis

- loss of confidence in the Measles, Mumps and

Rubella (MMR) vaccine - came along. I found this to

my cost in managing the fall-out as the Government’s

Chief Medical Officer.

What did the public think was the role

of government? It was pretty obvious that people

expected it to protect them against risks to their

The biggest public health crisis of the last 30 years

involved Bovine Spongiform Encephalopathy (BSE),

a fatal disease of cattle whose soubriquet “Mad Cow

Disease” gave it a lurid escape from dry scientific

terminology into everyday parlance. With the

dramatic discovery in 1996, that it could transmit

to people as new variant Creutzfeldt-Jakob disease

(nvCJD), the term “Human form of Mad Cow

Disease” was born.

Public concern and awareness of the

disease spread more rapidly than the disease itself.

This was fuelled by the knowledge that it was

incurable, by the idea that seemingly any meat eater

could catch it, and by the distressing, grainy image

of an afflicted cow staggering to keep its foothold.

This image accompanied virtually every news report,

and there were many. I remember a colleague who

lived in Dublin at the time telling me about taking

his two young sons, aged six and four years, for a day

out. They drove to a beauty spot across the border in

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Fear of Nanny Could Make the NHS Unsustainable

health. They became particularly angry if there

was any hint of a cover-up and they didn’t like it if

the government seemed to be placing the interests

of industry ahead of the public’s health. This was

long before social media were developed. Surely,

there would have been complete meltdown in public

confidence if BSE had happened today.

Moving into the 21st century, after

the BSE experience, the (largely unwritten)

rules for handling a putative health risk seemed

straightforward. Be completely open about what is

known. Never, ever cover up. Be prepared to say

the words that were taboo in the 20th century: “We

don’t know.” Rather than waiting to see whether

people were harmed, adopt the “precautionary

principle”, and take action to mitigate a hypothetical

risk. Don’t get cosy with industry.

Governments now seem to accept their

responsibility to protect the public against threats like

pandemic flu and SARS. They certainly gave me full

support, as Chief Medical Officer, in the planning

and action necessary in mitigating their risks. They

wavered when I insisted that they should keep the

beef-on-the-bone ban in place for a bit longer. I

pointed out that the public enquiry had said that the

infective dose for people was an amount of tissue “the

size of a peppercorn.” It surprised me, after all that

had happened with BSE, how quickly pragmatism

flooded in to replace the precautionary approach to

this residual risk, but then politicians do not like

media ridicule, and that was what was beginning

to happen. Their idea was now to give people an

informed choice, as to whether to eat a T-bone steak.

Helping the public to avoid the risks of

modern living is contentious and is not usually

seen through the lens of “protection.” It is an area

governed by a different frame of reference and

polarises opinion between those who see solutions

through strong state and regulatory action and

those who believe only in providing information

and inviting people to make their own choices

and decisions. This does not always split down

right-left political lines. The problem with the

second approach is that whilst it is ideologically

comfortable it brings about change very slowly

and usually only benefits the health

conscious and risk-averse middle classes;

people in disadvantaged communities are

constrained by their circumstances from

making healthy choices.

During my time as Chief

Medical Officer I made a range of

recommendations to government but two

were dismissed out of hand. One was

eventually introduced. The other is still

in the long grass. When I proposed that

England should have smoke-free enclosed

public spaces and workplaces, the media

were briefed that it would never happen.

When I proposed, in my final annual

report, that there should be a minimum

price for a unit of alcohol, not only was

my report leaked (the first time ever that

this happened), the government got its

rejection in first. The same government

was wedded to “evidence-based

policy-making.” Both proposals were

underpinned by evidence.

So what was the problem about

taking a Chief Medical Officer’s carefully

considered advice? And what happened

to the government’s role in protecting

the public, especially children? The

answer turns on two primal political

forces: firstly, the politician’s mortal

dread of being labelled a member of

the Nanny State; secondly, a fear of

removing people’s perceived pleasures,

especially those of the poor, ironically,

in this case, the group that suffers most

harm from the risk factors at the centre

of the controversy.

Such polling of public attitudes

as has been undertaken suggests that

the population quite approves of strong

action to protect the public health.

Certainly, in building to the position

where Parliament passed smoke-free

legislation, large-scale engagement of the

public by my regional directors of public

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health, together with strong advocacy by

Action on Smoking and Health (ASH)

and major professional bodies, meant

that public opinion eventually led the

politicians, not vice versa. Not so with

minimum pricing on alcohol, a sensible

policy that would hit heavy drinkers and

children who drink dirt-cheap cider and

lager just to get drunk, and not moderate

drinkers. Three governments have rejected

it. Good scientific modeling work by

researchers at the University of Sheffield

has consistently pointed to the benefits.

It will not on its own solve the medical,

social and economic damage caused by

excessive alcohol intake but it will make

an impact on what is an intractable and

worsening problem. Most public health

problems need a range of interventions

but action on price and access are usually

the most powerful. This is an evidence-

based policy that is seen as politically

toxic. Progress on one of the biggest

health and social problems of modern

times is denied. The need for more livers

for transplantation is only one costly

consequence of such a situation.

Historically, Britain has been a

pioneer in public health policy-making.

The great sanitary reformers of the

Victorian era waged war against filth and

disease and their victory left a legacy to

all of us: the 20th century’s low child

mortality and greater longevity. Almost a

century earlier, Edward Jenner, a country

physician practising in Gloucestershire,

made a discovery that effectively invented

vaccination. There can be few individuals

who have a stronger claim to have made

the greatest contribution to the health

of Humankind. His statue was removed

from Trafalgar Square because he did not

fit in with the military heroes. Richard

Doll and Austin Bradford Hill uncovered

the link between smoking and lung

task. Yet, the fundamental challenge for every

government is how to create a sustainable health

care system: one that provides safe, high quality care

to everyone without running out of money. The

National Health Service in Britain is in the same

boat. There is no simple answer to preserving what

is still a national treasure, celebrated in the Olympic

opening ceremony. One inescapable need, though, is

to change the pattern of disease. Delaying the onset

of chronic disease, extending years of healthy life,

and promoting behaviours that preserve health rather

than initiating disease would be a giant step forward

to achieving a sustainable NHS.

The management guru Jim Collins spoke

of the galvanising effect of BHAGs - Big Hairy

Audacious Goals. In my role as Chairman of the

independent board that monitors the global polio

eradication programme, I have seen how pursuing a

clear, common cause unites people and inspires them.

The commitment is deeply impressive and people

have lost their lives going into the most dangerous

parts of the world to give the precious drops of

vaccine to prevent children becoming paralysed and

dying. Health matters to people in the poorest parts

of the world. In India, 300 million children are

vaccinated three times a year. Yet, in Britain, services

cannot organize themselves to eliminate measles.

Today, the public in Britain needs to see

inspirational leadership and the big health challenges

being addressed. It also needs a government willing

to act with boldness and imagination that unites

everyone to achieve an audacious goal. Why couldn’t

we become the healthiest country in the world?

Politicians’ fear of being branded as the Nanny State

currently makes this impossible. It makes Britain

a limping also-ran in the race to be the best. Given

the failure to reduce the rising tide of chronic

disease that is placing great pressure on our health

care system, fear of Nanny may mean that the NHS

becomes unsustainable.

cancer, and began the long march towards a tobacco-

free world. Today, Britain is no longer a public

health leader.

The government of the day faced with

epidemics of obesity, diabetes, heart disease and

cancer recently rejected a sensible measure to

promote health: the so-called sugar tax. Our

forefathers encountered controversy in making public

health policy but they were bold and showed courage.

Today’s health policy-making too often starts with the

question: “Who will we upset?” followed by adoption

of the first of the possible actions that appear in every

civil service briefing - “The do-nothing option.” Fear

of Nanny runs deep.

There are moments when strong state

action can be more acceptable. For example, when

someone’s choice affects someone else. The harm of

passive smoking was the powerful argument for the

smoke-free legislation. Similarly, when someone is

not able to make a choice for themself – particularly

children – all political viewpoints tend to be happier

with regulation.

To tackle obesity, where the third party

effects are harder to see and the individual is easy

to blame, the risk of the Nanny label is high. The

argument of strong measures to protect children may

be the easiest place to start. Here, public attitudes are

starting to change. Public awareness of the societal

burden of obesity related illness is growing. It is

becoming less publicly acceptable to offer a can of a

sugar sweetened fizzy drink to a child. Jamie Oliver’s

restaurant chain is starting to tax sugary drinks.

Public health leaders and politicians need to use

these changing societal views to their advantage. We

may not be able to immediately replicate the brave

action of countries like Mexico – with their national

soda tax – but we need to be getting closer.

The last couple of years have seen

the world’s political leaders, in the throes of an

unprecedented and very serious outbreak of Ebola

virus, majoring on so-called global health security.

A great deal of resource has been allocated to the

task of learning from Ebola and on understanding

how to strengthen health care systems against the

potential threats of the future. This is an essential

‘Our forefathers encountered

controversy in making public health policy but they were bold

and showed courage. Today’s health

policy-making too often starts with the

question: ‘Who will we upset?’’

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By Sheila Mitchell |Director of Marketing, Public Health England

We’ve Cut Down

By Sheila Mitchell |Director of Marketing, Public Health England

What PHE has Learnt to Help Kick the HabitSince Public Health England formed in 2013, Sheila Mitchell has led a series of

mass public health awareness campaigns. She discusses PHE’s learnings from

the past two years and how communications can prove most effective in altering

behaviour. We’ve Cut Down

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“We need to do more. We need more investment

so that we can do X as well as Y”. The general

assumption is always that progress comes

from doing more things. People diversify their

activities; scope always creeps. There was even a

company called “New Zealand Towel Services”

which, after a period of diversification, adopted

the advertising slogan “We offer so much more

than just towels.”

But in fact progress more often comes

when you stop doing things. When you get rid

of lazy assumptions; when you break bad habits;

when you focus on the things which nobody else

can do as well as you can.

If you want to become a better runner,

it is more important to lose bad habits than

it is to acquire new skills. Deciding what not

to do is often the most important decision you

make in life. AOL began by offering dial-up

Internet access, a portal and proprietary content

and a search function; Yahoo came along and

didn’t bother with offering Internet access - it

just offered content and search. Then Google

supplanted it - with just search.

In the same way, progress in public

health can proceed not just by attempting

to do more, but by deliberately doing less:

focussing on the interventions, leverage

points and behaviours where you can really

make a difference, and stopping the kind of

activities which can be ineffective or give rise

to unintended consequences. What follows is a

list of things which we have stopped doing and

assumptions we have stopped making: these

changes have been made in the light of rigorous

testing and evaluation and have been informed

by the significant advances in the understanding

of psychology and behaviour which have been

made in the last 20 years.

Less nanny, more waiter.

Telling people what to do is often

counterproductive. It may even reinforce some

people’s determination to continue with the

condemned behaviour. By contrast, oblique

approaches, or presenting people with a scalable

menu of manageable and sustainable choices

make it far harder for people to do nothing.

“Still or Sparkling?” often sells more water than

“You should drink more water.” If the choices

are Easy, Attractive, Social and Timely, even

better.

Less assumption, more evidence.

Many people who work in public health (and

medicine, and academia) lead pretty healthy

lives and can be perplexed as to why others

don’t do the same. Well-educated people tend to

consider long term rewards and consequences

(after all, they spent seven years in medical

school); so to them, the idea that smoking or

drinking or poor diet could give you cancer, or

heart disease or diabetes thirty years from now

is a no-brainer: it’s not worth the risk. We are

often subject to very strident pleas to lecture

A step-by-step approach (chunking) is important.

It acknowledges the path dependence in changing

human behaviour. And, as a result, it also forces us

to stop focussing on “perfect” to the exclusion of the

“pretty good”. If people shift from cola to diet cola,

that may not be perfect, but it is better. Similarly

if people switch from cigarettes to e-cigarettes, they

reduce the harm. One problem with approaches

which emphasised the “perfect” was that they seemed

completely unrealistic and unattainable (and hence

irrelevant) to the highest-risk groups. If you weigh 19

stone, images of jogging are not an encouragement -

they may be an active disincentive. Similarly asking

people with a litre-a-day carbonated drinks habit to

change from cola to water: well, nice idea, but it isn’t

going to happen. The biggest gains come not from

getting someone who jogs to take up circuit training,

but from getting someone who takes no exercise to

take some - even if just five 30 minute bursts per

week. Most of all, we have abandoned the assumption

that people are possessed with limitless willpower,

and are incapable of self-deception.

We’ve abandoned vague prescriptions - such as “eat more healthily”, “lose weight” or “take more exercise”.

We have instead replaced these vague perscriptions

with specific actions that really matter. More

importantly, we have tried to make these targets

“binary” rather than “quantitative”. If a rule is

specific it is more likely for us to follow it than if it

is a question of degree - people feel more conscious

of rule breaking when there is a specific prohibition

(running a red traffic light) than when there is a

numerical limit (breaking the speed limit). Hence we

are willing to entertain the idea that a short period of

total abstinence from alcohol, as in Dry January, may

be an easier regimen to follow than counting daily

units. Almost every society in the world has periods

the public about health harms – ‘just get them to

see the world like we do and they will change their

behaviour’ runs the assumption. The trouble is,

behaviour doesn’t work like that. Many of the people

we serve have very short horizons. If you’re worried

about how you’re going to pay your rent at the end of

the month, that’s where your focus is: not on thirty

years hence. We recently completed an evidence

review on the role of ‘health harms’ communication

in behaviour change and what emerges is a mixed

picture. Sometimes, as in smoking, fear of future

illness can act as a spur to change your lifestyle;

sometimes, as in obesity it doesn’t. So despite calls to

shame the obese into changing their behaviour, we

won’t be doing that.

We’ve stopped assuming that behavioural change must always be preceded by attitudinal change.

Recent advances in psychology suggest that the

process often, perhaps more commonly, operates

in reverse. People form opinions to be congruent

with their behaviours, rather than the other way

round. Hence an emphasis on “awareness” or

“consciousness raising” has given way to more focus

on choice architecture, interface design or multi-stage

behavioural change, where people are encouraged to

make small, incremental changes to their behaviour

rather than focussing exclusively on attempts to

change attitudes. In many cases, even a small change

in behaviour can be a decisive first step from which

further beneficial changes follow. Change4Life’s

ten-minute shake up is a perfect example of a specific

behavioural aim. This campaign from Change4Life

and Disney breaks down the recommended 60

minutes of moderate-vigorous physical activity needed

by children into manageable 10-minute bursts.

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behaviours like smoking, drinking, diet

and activity. But we also don’t forget that

one in ten of the UK population has still

never accessed the Internet, four in ten

has not downloaded an app. So there is

still a role for local, face-to-face, services

and intensive interventions to support

these people. I’m proud of what we’ve

achieved in the past year. But, as we go

into 2016, I’m hopeful that, by doing

less, we will be able to achieve even

more.

of feasting and periods of abstinence: this insight

acknowledges that human psychology seems to be

better suited to variety than to regularity - and second-

order variety may even be better for human health.

We’ve also abandoned the idea that social factors don’t matter.

If many of your friends smoke, it is simply much

harder to quit if you try to go it alone. Therefore far

more focus is on creating collective, synchronous

actions (such as ‘Stoptober’, where smokers are

encouraged to quit for the duration of October) than

relying on individual willpower. Group actions are

more likely to stick. New year’s resolutions work

better if people declare them to one another as a

mark of commitment.

We’ve stopped trying to do everything alone.

If a partnership under a different brand such

as Change4Life is a better vehicle for changing

behaviour, then why not work in concert with other

organisations, like Disney, rather than acting alone.

Finally, we’ve stopped pretending that social marketing will work for every problem or every person.

Health inequality is a gradient, and you do more

to reduce it by improving the lives of the 46%

of the population classified as C2DE than by

focusing relentlessly on the most disadvantaged

decile. We have evidence that our programmes

disproportionately engage people with lower

incomes, less education and unhealthier lifestyles,

but we also know that for some people in extreme

circumstances, a marketing-led intervention isn’t

going to do it. We’re currently putting the final

touches to a digital support product, designed for

and tested with C2DE adults, to help them change

freuds Case Study;

Public Health England

Public Health England (PHE) was formed

in April 2013 to protect and improve

the nation’s health and wellbeing and

reduce health inequalities. freuds has

been working with PHE, and previously

the Department of Health since 2008,

delivering high profile behaviour change

programmes that make it easier for

mums, dads, daughters and sons to make

positive changes to their health. From

the creation of national movements such

as Change4Life, Stoptober and Dementia

Friends, to the ongoing public education

for a variety of cancers and diseases under

the Be Clear on Cancer umbrella, all

campaigns are evidence-based. They use

behavioural science, commercial best

practice, digital tools and popular culture to

engage hundreds of thousands of people on

a journey to better health.

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VITAL STATISTICS

Obesity is an acknowledged problem

62% of England’s

adults are overweight

or obese¹

1. Health survey for England: 2013

2. freuds focus: freuds conducted a nationally representative poll of 2,000 people. The survey was hosted by Bilendi in August 2014

62% of England’s

adults are overweight

or obese¹

79% acknowledge that there is an obesity crisis²

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But who should tackle the obesity crisis?

54% blame advertisers for influencing the unhealthy food

choices we make 42% blame

the influence of food

companies

33% blame

ineffective education in schools

freuds focus

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Blame for UK obesity levels is placed at many doors:

23% think government

comms and health policy are to blame

23% say it’s a matter for parents or individuals

20% blame GPs for

not being proactive enough

It’s an emotional, not rational issue and changing habits isn’t always easy:

74% say bad habits are hard to break

freuds focus

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7% say there are no barriers to reducing obesity levels in the UK

So what is preventing individuals

taking action?

Many parents don’t want to acknowledge, or recognise the problem:

While medical assessments placed the number of

overweight children in the group at 369, only 4

parents thought their child was very overweight¹

1. Black, Park, Gregson et al. Child obesity cut-offs as derived from parental perceptions: cross-sectional questionnaire, British Journal of General Practice

2. freuds focus

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S34% of mums agree that they don’t look too closely at the food they buy and eat because it’s often better not to think about it²

In a recent study of 2,976 families in the UK, nearly a third, 31%, of parents underestimated the weight of their child¹

Half (46%) are dissatisfied with food manufacturers’ efforts to help consumers with the UK’s obesity issues¹

1. freuds focus

2. Opinium conducted a nationally representative poll of 2006 UK adults, 30 October to 3 November 2015

81% say their main concern about sugar is

the levels of sugar hidden in prepared foods¹

87% think there is often too much sugar

in foods that seem like they are healthy¹

There is a lack of confidence in the industry:

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73% claim that common sense based on ingredients and level of processing is helpful when it comes to choosing which foods to eat¹

89% of us say that eating healthily is common sense¹

There’s a desire for education to enable informed personal choice:

78% said that education would work better and

allow people to make their own choices²

By Ali Parsa | CEO, babylon

Tech Tonic

A Revolution: How Tech is Transforming the Future of HealthcareJust about everything we do to look after ourselves will be revolutionised in

the next ten years, British health entrepreneur Ali Parsa says. He believes the

answers for the UK’s embattled health care system lie just around the corner.

After creating a major healthcare firm, the Tehran-born physicist now believes

the world’s future health literally lies in our own hands. His mobile app, babylon,

promises it can help patients answer medical queries, check symptoms, consult

a doctor, monitor their health and seek referrals from anywhere in the world.

Ali’s pioneering app won the Innovation Prize at the World Extreme Medical

Conference, organised by freuds earlier this year.

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‘Just about everything we do to look after ourselves

will be revolutionised in the next ten years’

I am a health entrepreneur. Entrepreneurs do things

because they have a vision for fixing a problem.

It’s the stuff of dreams, passion, stubbornness and

essentially being a maverick – that’s what makes

them mortgage their houses. For me, it’s the belief

that we can absolutely solve the problem of access to

healthcare. In fact, healthcare will be unrecognisable

in 10 years, the same way 10 years ago no one

imagined we’d be able to socialise, find information,

restaurants and even date with our smartphones.

Today, when we are sick we must ring up to

book an appointment, wait days in some cases until a

slot is available, take half a day off work and then

queue up in a waiting room which is probably one

of the most infectious places on the planet. More

importantly, what we call healthcare is actually

‘sick care’. We wait until we’re ill then spend a lot

of time and effort trying to get better, meanwhile

50% of the world’s population have almost no

access to healthcare.

One look at your car will tell you why it

needn’t be like this. It has so many sensors now, that

we can intervene before anything goes wrong.

Within just a few years it will be the

same with your own body. Right now, I know my

cholesterol, my temperature, my heart rate, what’s

happening in my liver. I have my medical records

on my phone and I can speak to my doctor from

wherever I am in the world. But in a few years’

time, we will no longer need to prick your finger

to take a test to know what is happening in your

blood stream. We will be able to collect all of your

health information automatically and intervene

when the first warning signs occur. This can have

profound effects. For instance, we lose more people

to suicide in Britain than any act of terrorism or

war. It’s proven that if you are clinically depressed

you’re more likely to suffer a depressive episode if

you’re using your phone more and not leaving the

house. Analysis of phone use and location can flag

these warning signs enabling us to intervene before

anything happens.

You will also be able to analyse your health

in far more detail than we ever thought possible.

We already do something similar today with our

weather forecasts. The Met Office doesn’t have a

scientist studying a map, all the analysis is done with

computer modeling. In the same way, we can analyse

trends and information to predict what’s wrong with

you before you are even ill and then intervene to

keep you healthy.

Only a few years ago, access to information,

music or books was dependent on where you lived

or how rich you were, and today it doesn’t matter

who you are or where you are, everyone has near

equal access to everything that is digital. In the same

way, a very different model and means of delivery

of healthcare is unfolding, and it should make the

future of healthcare significantly better and accessible

to all.

Here are the four major trends that are

melting all that is solid in medicine into air, and

transforming the industry:

Diagnostics

The cost of diagnostics has already fallen by an

incredible 99% in the past decade and is projected to

be near free in the next five years.

Ten years ago, it would have cost over a

million dollars for full physiological and genetic

diagnostics. Today, the same can be done for less

than ten thousand dollars, including full genome

sequencing.

But something even more transformational

is about to take hold: an avalanche of new

applications, mobile devices, bio-sensors, biological

and imaging technologies, wearable and soon

embeddable devices, which are making it possible to

virtually track any of the body’s bio-signals in real

time, and if we wish, transmit them for continuous

analysis.

For the first time in medical history, we

will have the “check engine” capability that we are

accustomed to in our cars but never had for our

bodies, leading to real prevention possibility.

Information

While healthcare has been slow to adopt information

technology, patients have not. Healthcare is now

the third largest web activity across all generations.

Patients are already able to read and watch the

entire world heritage of medical libraries. Ever more

sophisticated symptom checkers are distilling these to

offer diagnosis on every condition.

But this is just the start: Machines

like IBM’s Watson are beginning to use artificial

intelligence to cope with the new scale of knowledge

and data being generated by the said biosensors in a

way that was never possible for a human brain. Soon,

IBM is hoping that Watson will be able to examine

a patient’s data, search the medical literature, and

make a recommendation for treatment in specific

specialties. As the technology matures, significant

companies are being formed with the aim of putting

a personal avatar doctor in everyone’s pocket.

Smartphones and “The Internet of Everything”

What a smartphone can do today is only 3% of what

it will be capable of in just five years time, and a mere

thousandth of its ability in ten years.

Today, the vast majority of people on the

planet are connected by mobile phones. These are

increasingly becoming smart with a remarkable

number of devices from video recorders to sensors,

rolled into one, creating a personal gateway to the

world’s collective knowledge.

More importantly “The Internet of Everything”, will

soon make cheap smart sensors that will connect every

aspect of our lives from our environment to our bodies.

Armed with intelligent apps and

loaded for medicine, these will collect and

send much of one’s vital signs in real time

for continuous analysis by bio-algorithms.

In the short term, they will alert and

allow a face-to-face virtual consultation

with a doctor anywhere, anytime. In the

medium term, much of it will be done by

artificial intelligence.

Intervention

From nanotechnology, to laser and

ultrasound manipulation, embedded smart

devices, organ replication, bio-molecular

engineering, robotic surgery and electro-

biology, we are re-inventing almost every

aspect of intervention in health care.

The breadth of what is

happening in clinical intervention is so

expansive that it requires a lot more space

than what is available here, but with the

help of synthetic biology, for the first time

in history, it is not evolution (or creation)

but humans who are capable of creating

new forms of molecules, and even life.

So where will all these changes

come from? From government or even big

corporations – not at all. Just ask yourself

- why did M&S not do what fashion

brand ASOS did so successfully? Why

did Sainsbury’s not do what Ocado did?

Because there is a disincentive for big

companies to divest from what they have

already. They have tremendously bright

people, but the mind share and the brain

power is all engaged in what they do each

day. Instead it will be new firms and start

ups who will create this change.

Whether it is our company

or another, I seriously believe it must

happen, as it always has historically with

disruptive innovation.

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How Innovation and Digitalisation Can Better Manage Chronic Disease

By Dr. Suzanne Clough | Chief Medical Officer, WellDoc

Help In Hands

Dr. Suzanne Clough is the Chief Medical Officer of WellDoc, an American

healthcare company she founded in 2005 that develops digital and mobile

health technology solutions to support chronic disease management. As an

innovative physician, Suzanne sought a better way to help patients manage type

2 diabetes between doctor visits. The company launched BlueStar, the first mobile

prescription technology that delivers automated personalised and adaptive

feedback and guidance to patients and health care providers, enabling them to

better manage their disease within the demands of everyday life.

decision is made as to whether or not an action should,

or will, be taken. While this way of moving through

the world holds true for some, it is not the lens

through which the rest of the population views the

world, or their healthcare choices. That’s because life,

rather than being linear, is often complex, dynamic,

and chock-full of apparently random events. Many of

our decisions come from quantum, rather than linear,

events driven by a surge of motivation or inspiration

that “is greater than the sum of its cognitive parts.

It is not so much a planned decision, but something

that arrives beyond cognition.” Motivation arrives

versus being planned. So, it is not surprising that the

complexity of human behaviour cannot be adequately

addressed or supported via the traditionally autocratic

healthcare paradigm that was built to serve patients,

not people all within a 12 minute clinic visit.

As it currently stands, a 12 minute clinical

meeting must covers all aspects of the patient’s care.

It’s clear that pills and injections and overall

treatment plans are critical for the management of

chronic disease and acute illness. It is also clear that

any treatment plan is only as good as how well it

is understood, tolerated, and adopted by the person

for whom it was designed. This has led to incessant

debate about how and why poor patient compliance

to treatment plans is one of the largest drivers of

healthcare costs. And herein lies the problem: we talk

about patients instead of people. The result is that we

have built behavioural frameworks that don’t consider

the complexity of the human. This complexity of an

individual cannot be accounted for by interventions

and guidelines built for populations.

Historically, as evidenced by behavioural

models based on the cognitive-rational paradigm,

health professionals have assumed rational, linear

behaviour by patients: the pros and cons of a situation

are assessed by the patient, and at some point, a

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In those 12 minutes the physician must establish the

scope of the symptoms, be it a cold or cancer; offer a

full medical investigation, mitigating any bias from a

patient’s symptom story; and should ultimately offer

a series of clear and manageable directives to assist

the patient in moving forward in their day-to-day life.

Simple in theory. Crude in practice. This top-down

healthcare structure has indeed come to create a

gulf in patient care, falling short of contemporary

healthcare demands, and failing to contend with

the huge paradigmatic shifts occurring in the way

people choose to live their lives. Now, more than

ever before, we need insight into the moments that

really matter: that is, those occurring within the

8700 hours a year that people living with chronic

disease are experiencing their dynamic and chaotic

lives outside of the healthcare system. We need a big

picture view of the patient’s life that helps a doctor

create a treatment plan for that one individual,

rather than offering one that is simply a copy and

paste from the population guidelines. A contemporary

healthcare framework must work within an

ecologically grounded framework, acting reflexively

to the everyday nature of healthcare concerns and

responding with the delivery of adaptive, dynamic

and individualised behavioural support.

We can get there, to this state of delivering

adaptive, dynamic and individualised behavioural

and clinical interventions, by leveraging the multi-

faceted, multi-media capabilities of digital and mobile

technologies. The ubiquity of these products are

never in doubt: on average we look at our phone 150

times a day. Smartly designed digital health products

have combined behavioural and clinical algorithms

with features already built into phones, like GPS,

to deliver anytime, anywhere behavioural feedback

to people on their mobile devices.

Additionally, digital health products can

glean what information from the patient’s

digital data is relevant for the health care

team to optimize the treatment plan at the

next visit. On this basis, we can develop

personalised digital health solutions

that offer a level of ongoing support to

people living with chronic disease that

has not existed before. Additionally, done

right, digital health products, can and

should, improve healthcare outcomes and

decrease health costs.

Ultimately the marriage of big

data, data science, and the digital and

mobile health industries will make it

possible, for the first time in the history

of medicine, to deliver highly scalable but

highly personalised healthcare that have

a demonstrable ROI to the healthcare

system. Technology, in this form, bends

time and seamlessly and smartly connects

the 8700 hours people are away from

their health care team to the 12 minutes

they are with them. The time to act is

now to ensure we empower individuals

to make accurate healthcare choices for

themselves, in their personal lives, and in

their own time.

‘We have built behavioural frameworks that don’t consider

the complexity of the human’

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Road ToRecovery

By Charlie Howard | Founder, MAC-UK

Out Of The Clinic, Onto The Streets

Charlie Howard founded MAC-UK in 2008. The aim was radically to transform

mental health services for excluded youth, specifically those involved in gangs.

MAC-UK has developed the INTEGRATE model, which takes mental health

provision out of the clinic and onto the streets. It puts health professionals at the

heart of activities led by the young people themselves and is designed not only to

adjust health behaviour but the ‘wider system’.

were expected to talk to “people like me” but it wasn’t

safe. They were seen as “snitches” by their peers and

it was quite literally a matter of life and death. The

young man I was with had lost his cousin because he

talked to an outsider. They also told me they would

need “cash” to get to the service and it would need

to be one that got them a job; because they wanted a

“proper job”.

It became clear that to help young people

such as Tom or those I encountered in New York, it

had to be more than helping them change directly.

It needed to be about changing their worlds as well

as their heads. The services that were there to help

weren’t reaching them. And if they did, they weren’t

offering what they needed.

Preventing gang-related violence is a major

government priority. Despite media portrayal, only

a small number of young people are involved but

they commit disproportionate levels of crime. It’s an

expensive problem costing the economy £4 billion

a year and it’s a moral one, with many of the young

people coming from childhoods where it’s a wonder

they have survived at all. An area that is often

overlooked in discussions around gang prevention

is mental health. Gang-affiliated young people

are disproportionately affected by mental health

difficulties. Poor mental health can both attract

young people to gangs and be a barrier to persuading

them to leave. Gangs are not just an issue for justice.

They are a public mental health issue.

Together with a group of gang involved

young people, we founded MAC-UK in 2008. The

My first memorable encounter with behaviour change

was during my university finals when faced with the

question “What can social psychology contribute to

smoking cessation? Discuss”. I did as all students do

and recited everything I had memorised, passed the

exam and then promptly forgot most of it. My second

encounter, however, was far more useful and has

fundamentally shaped the rest of my career.

I was working as a trainee Clinical

Psychologist in London and received a referral for a

young person suffering with anxiety. He also had a

learning disability. Let’s call him Tom. I went to see

Tom and he told me he was scared to leave his house

because a gang of young men had starting hiding

around the corner and spitting at him. Last time they

stole his hat and wallet too. Tom had stopped going

out and was feeling increasingly low and anxious.

I was supposed to do 10 therapy sessions with him

to help him to manage his anxiety. I found this

insulting to Tom’s experience which struck me as

entirely normal. It was the gang of young people that

needed the referral.

Inspired by Tom and an approach called

‘Community Psychology’, which seeks social

environmental changes to improve mental health, my

next destination was New York. Here I worked with

young people from the Bloods and the Crips, two of

the biggest street gangs in North America. When I

asked them what they might need in a service to help

them to move away from gangs and violence, they

said that i) it had to be built on their ideas and ii)

it couldn’t involve “people like me”. They said they

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65

aim was to radically transform mental health services

for excluded youth, specifically those involved in

gangs. And we wanted to achieve it in 10 years. We

figured that if we were still the only ones doing

it after that, then we wouldn’t have transformed

anything; yes we might have helped young people but

we wouldn’t have helped the wider system that wasn’t

meeting their needs.

We developed a series of approaches which

we now collectively call INTEGRATE. It takes help

to young people where they want it, where they need

it and it brings together the best aspects of youth

work and clinical practice. We’ve been externally

evaluated by the Centre for Mental Health at four

sites across London and the findings suggest that

INTEGRATE works in moving young people away

from offending lifestyles.

INTEGRATE isn’t just about working with

young people. Donald Berwick, leader in American

medicine, said that if we keep using healthcare to

get to health than we are missing the point: 40% of

health variance is due to things relating to where we

live. It’s hard to get out and exercise, for example, if

your neighbourhood is scattered with people who are

after you. It’s impossible to open a bank account if

you don’t have ID. And so it goes on. The ID thing is

actually a really significant problem for the majority

of young people with whom we work.

When we told people that we wanted to

change the “wider system” they laughed at us and

said “Ah! Good luck with that”. So we stopped telling

them. One of my funniest experiences was sitting

down to a meeting with people thinking they were

all in the wrong place. The police thought they were

there to discuss offenders, the health staff to discuss

‘DNA’ rates and so it went on. Of course, they were

all there to discuss the same thing: I just had to be

creative in how I got them there!

One thing that seems certain is that if

we’re going to change health behaviours, it can’t

be done alone or in silos. We need to

work together across organisations,

communities and sectors. INTEGRATE’s

successes come from working in

partnership with many others and then in

getting them to work in partnership with

each other. Governance is a permanent

headache. You can imagine the chaos of

working across four agencies with their

own ways of managing risk and recording

information, not to mention their own

service specific insurance policies. But

actually it’s this chaos which helps people

like Tom because it’s the key to getting us

all working together: health, justice, social

care and others. It forces us to rewrite the

way things are done.

INTEGRATE’s next challenge

is scale. So many innovative approaches

that have gone before us have failed when

they’ve ventured to new areas and/or

staff have changed and founders moved

on. We’ve set up a new sibling social

enterprise, The Integrate Movement, or

TIM for short. Its aim is to make mental

health everyone’s business by sharing all

of INTEGRATE’s ingredients with others

to build on and ‘steal with glee’. They

will do the scaling for us and MAC-UK

will cease to exist in its current form in 3

years. At least, that’s the plan.

If it works, we will have made

a difference to people’s lives and also

proved an important point; intelligent

organisational reform designed to deliver

widespread behaviour changes can have as

much impact on mental health outcomes

as clinical interventions.

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65

‘It needed to be about changing their worlds as well as their heads’

providers need to know more and work harder at

making their services accessible to men.

Over the last five years we have been working

on an innovative project with Network Rail to see if

making safer environments can help steer those most in

danger away from taking their lives.

Around five per cent of all UK suicides occur

on the UK’s railways, so we have been working to cut

what is known as ‘the access to means’.

That means creating more physical barriers,

including mid platform fencing at 67 stations, platform

end barriers at 135 stations, platform hatching, trespass

guards and smart cameras to report unusual movements

at the track side.

Crucially though, it’s the power of human

connection. We are social animals and we thrive on

connection with others. Human connection is central

to our wellbeing.

So, perhaps most importantly, Samaritans has

run more than 800 courses since the scheme began in

2010, training a total of over 10,000 railway staff, and

British Transport police to recognise the signs of someone

who may be vulnerable or distressed. These skills in

‘emotional first aid’, giving staff the confidence to ask

“are you ok” and take someone to a place of safety for a

cup of coffee and a chat can make all the difference.

It is a little known fact that there are significantly

more suicides than road traffic accident deaths in

Great Britain.

There are around 18 suicides per day - yet we

don’t know nearly enough about why they happen. Every

suicide is a tragedy with immense social and economic

costs, the more so because they are not inevitable and can

be prevented.

The UK’s latest figures show just how

serious our problem is. There has been a 4 per cent

increase in the last recorded year in 2013 - over 6000

people.Amongst middle-aged men the statistics are

more shocking still - the highest for 30 years.

While the factors are complex, these

statistics may have something to say about the place

of men in our society, given that they are three and a

half times more likely to die by suicide than women.

If you are a man and on a low income

in the UK that rises to 10 times more likely. The

reasons behind suicides can often be difficult to

unpick, but it may be that in some ways men are

more emotionally brittle.

The ideal of trying to live up to the ‘gold

standard’ of masculinity - of being strong and

protective, can present a barrier to asking for help

because they fear shame and failure. However, service

Network Rail & Samaritans: Engineering an Approach to Suicide

By Ruth Sutherland | Chief Executive, Samaritans

End of the Line

The UK’s suicide rate is rising rapidly with the most at risk group – the deaths

of middle-aged men - at a 30 year high. Here Samaritans’ CEO Ruth Sutherland

reveals how an innovative new approach with Network Rail may be making

inroads, saving up to 1,000 lives to date.

278 two years ago and 293 in 2015, but we believe

these fail to take account of 400,000 extra passenger

trains and 13 per cent more trains running on the

network in the past five years. In other words,

without this intervention, the numbers would have

been far higher.

The actions were certainly a departure

from our core work but it is our experience of

answering 5.3 million calls for help each year

which impels us to work in prevention. Addressing

alcohol issues could be another really good way of

reducing suicides.

Research shows men are also more likely

to turn to alcohol and drugs and risky behaviour in a

time of crisis. The problem with alcohol and drugs is

that they are a dis-inhibitor and alcohol features a lot

in suicide deaths.

Overnight is also our busiest time for calls,

between 10pm and 3am, that’s when people are often

alone and worrying and unable to sleep.

Other courses have been run for train staff

who may have been affected by serious incidents.

The impact cannot be underestimated – the

suicide prevention programme, which now spans

the entire rail industry, has so far prevented around

1,000 suicide attempts in the last three years.

The statistics for rail suicides initially

remained static during the first two years rising to

can last for years and be much longer

and deeper.

At Samaritans, our

fundamental belief is in people. There

is a recent critique of the welfare state,

which is that despite all the good that it

does, it can disempower people and create

dependence. Our relationship with the

NHS and the welfare state needs to be

about us inviting them into our life to

help us at difficult times, not about giving

up control, power and responsibility.

Only when the public sphere

and those who work in it learn to

understand this fundamental lesson,

will they begin to shape public policy

interventions that successfully act to

reduce the terrible scourge of suicide in

our society.

We know that suicides

increase during an economic recession,

but we need to be aware of the social

consequences of recession too and these

can last much longer than economic

pressures. For example if you face

family breakdown driven by economic

pressures then the social consequences

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‘It is a little known fact that there are significantly

more suicides than road traffic accident deaths in

Great Britain’

By Dr. Angel Chater | Lecturer in Health Psychology and Behavioural Medicine, UCL Centre for Behaviour Change

Behavioural Problems

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The Power of Language: Why Patient Consultations Often Fail to Change BehaviourDr. Angel Chater is a health psychologist and lecturer in health psychology

and behavioural medicine at University College London. She is a member

of the UCL Centre for Behaviour Change, which is a cross-disciplinary

research centre aiming to connect researchers, practitioners and policy-

makers. In the following article, she explores the power of language

during doctor-patient consultations and the profound importance of

phraseology in influencing patient behaviour.

The key to behaviour change is effective

communication. Think of your best

friend, loved one, or the person you turn

to when you don’t know which way to

turn. What is it about them that makes

it easy for you to talk to them? Are

they a good listener? Do you feel like

they really ‘get’ you? Do they help you

to come to a decision you have been

pondering for some time? Or do they

encourage you when you feel you can’t

do something? These are the attributes

you want to strive for and see in an

effective health care practitioner. Easier

said than done. All too often, poorly

delivered interventions hinder rather

than help behaviour change efforts.

A common question is how can health

promotion and treatment efforts be improved? The

major epidemics of chronic disease now facing us,

such as obesity, diabetes, coronary heart disease and

cancer are clearly crying out for effective health

professional-client consultations as part of the

shift from treatment to prevention. However, poor

health professional to client relationships can lead

to client dissatisfaction and anxiety, often fuelled by

poor communication skills, a lack of information,

explanation and feedback.

Nobody likes to be told what to do, yet this

is a common trait that runs through many health

consultations via practitioners who just want to help

their patients/clients by trying to come up with

helpful solutions to their given situation. Let’s go

back to our loved ones, imagine that someone you

care for needs to change their behaviour in order to

stay healthy and avoid dying early, be it smoking,

alcohol use, drug use or the food that they eat.

Would you be tempted to a) tell them they should

change; b) tell them how to change; and c) emphasise

the risks if they don’t change their given behaviour?

This is a natural instinct; we want to help people we

care about. But, if the said loved one, friend or client

was morbidly obese, an alcoholic or addicted to drugs,

it is more than likely that they already a) know they

need to change; b) know the options in front of them

and c) know the risks if they continue with their

given behaviour. They have also most likely tried to

change before. Therefore, in highlighting the obvious

to them, this may in turn, lead to them feeling

annoyed or demotivated, and research suggests that

people are less likely to welcome advice that comes

across as being ‘told what to do’ or ‘nagged’.

Therefore, this ‘righting reflex’ can lead to resistance

to change, leaving both parties frustrated. In a

consultation setting, the client will feel that the

health professional is not listening to them, telling

them things they already know and are not really

‘on their side’, and the practitioner will feel like the

client is wasting their time.

If the communication style is

confrontational or too persuasive, with sentences

starting; “Why don’t you…?” or “Have you

considered…?” and the practitioner sides strongly

with the health-protective behaviour (i.e. reducing

alcohol intake, stopping smoking/drug use, changing

diet, taking medicine), the client is often forced to

take the opposite side of their ambivalence (i.e. to

defend their current behaviour) to avoid annoyance at

being challenged on a behaviour that they are already

feeling two ways about. Therefore, in their head,

they argue the reasons to continue as they are to

justify their actions and can become more committed

to it, answering you with the likes of “Yeah, but...”; or

“I do it because...”. These ‘yeah, buts’ and ‘becauses’

are important to listen out for in a consultation

setting, as they suggest that the communication style

needs to change.

Therefore, the language which is used in

health care consultations could be a fatal flaw in

any behaviour change attempt if it comes across as

prescriptive or persuasive rather than empowering.

Perhaps we focus too much on changing the

behaviour of others, when we should first focus on

changing our own behaviour.

Using a motivational interviewing style

when delivering behaviour change techniques may

be the way forward. Motivational interviewing is a

client-centred style of communication, which aims

to evoke behaviour change by facilitating the client’s

intrinsic motivation to change, drawing out their

deep rooted desires and fears, and increasing the

client’s belief that they can indeed make a change.

Instead of talking at them and telling them

what to do, this approach first aims to establish

the client’s point of view and what ways they

see forward. Typically, these involve the use of a

variety of ‘tools’, including the use of open-ended

questioning, reflective listening, using affirmations,

and summarising what the patient has said. The

practitioner uses these skills to accurately understand

the patient’s perceptions about a behaviour they wish

to change (“What do you want to change?”; How

does this behaviour impact on your life?”), heighten

the patient’s problem recognition (“How important

is it for you to change..?”; “What would happen if

you didn’t change?”), and resolve ambivalence about

changing it (“What would life be like if you were to

‘Perhaps we focus too much on changing the

behaviour of others, when we should first

focus on changing our own behaviour’ 71

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Professionals working on

the frontline of health care, such as

pharmacists, GPs, nurses and dieticians

are not routinely trained in such

communication skills, yet they are often

expected to engage in interactions with

the aim to change behaviour (such as

smoking cessation/ weight management).

Pills are no substitute for skills,

and although the traditional bio-medical

model can support health and the

treatment of illness; without behavioural

medicine and effective communication,

we are doing a disservice to the health

needs of all in society.

make a change?”). They will incorporate these skills

using the four pillars of motivational interviewing,

which are; Resist the righting reflex, Understand,

Listen and Empower and the four key strategies of

Expressing empathy, Developing discrepancy, Rolling

with resistance and Supporting self-efficacy. These

are used alongside behaviour change techniques

such as problem identification (“What makes your

behaviour a problem for you?; Who else agrees that

this is a problem?”), exploring decisional balance

(cost-benefit analysis; “What are the good things

and the not so good things about your current

behaviour?”), and developing cognitive dissonance (a

discrepancy between how the client wants to behave

and what they are currently doing; “Describe to me

where you are now, and where you want to be?”).

Flavour perception is one of the most complex

activities undertaken by the human body. Our

experience of being human begins with food. It’s

central to the journey that our species took to get here.

We were essentially chimpanzees that began

to use tools and which were associated with food;

either the killing of it, or cutting it up in order to eat

it more easily. Then we discovered fire, and started

cooking food on it, beginning a process that saw our

brains treble in size. Eating also brought us together

as a group around a fire, and our lower jaw shrank,

as we no longer had to tear through raw cartilage as

meat was cooked. The neck and larynx lengthened in

the process.

To eat cooked food then is to be human,

so it’s not surprising that changing what we eat

has proved such a tough problem for public health

experts. Shifting our relationship with food requires

us to re-engineer our most fundamental behaviour

patterns. Its possible, but its not easy and it goes way

beyond the normal parameters of public policy.

We think we understand eating as a

functional process that moves from flavor perception

to swallowing, from digestion to nutrition. But it’s

so much more than that. We truly are what we eat

because diet influences not only our physical health,

but also our mental state. Food is intimately associated

with intelligence, character and confidence.

In the following article, Heston

Blumenthal explores humans’

complicated relationship with food.

He argues that changing our eating

behaviour cannot be achieved

through law or labelling alone.

Policy makers must also appreciate

our deeply emotional connection to

food in order to more intelligently

bring about genuine transformation.

By Heston Blumenthal | OBE

Play The FoolWinning Over Hearts and Stomachs in the Battle Against Obesity

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We are only beginning to understand this

journey. Human babies are helpless for far longer

than any other species, but they seem to put this

extra time to work to learn about the world they are

about to join. A baby’s brain has been described as

‘the most powerful learning computer on the planet’.

This process starts well before birth.

Babies learn a huge amount in the womb;

the flavours of the foods a mother eats find their

way to the unborn child through the amniotic fluid,

and after birth they prefer those flavours. In

one experiment, one set of mothers regularly

drank carrot juice while pregnant, while

another set drank water. Six months later,

their babies were offered cereal flavoured

with carrots, and the children of the carrot

juice drinking mothers noticeably preferred it.

In another version of this

experiment, French babies whose mothers

consumed anis during pregnancy liked

So instead we need to be smarter. There

are ways of structuring dishes, for example, that can

fool the brain into thinking its getting more of a

particular taste than it really is. Think about making

a cup of coffee with one coffee bean, it would taste

pretty insipid. But then imagine drinking a cup of

hot water and then eating a whole coffee bean, it

would have much more impact. You can do the same

with food, packaging the release of particular flavours

to maximize their impact.

You can also think about the other sensory

inputs that go alongside simple taste. If you want to

accentuate the sweetness of a food item, imagine that

you pick up the packet and it’s all soft and smooth,

and then there’s a satisfying squidgy noise when you

open the lid. In fact everything about the experience

is kind of fluffy. If you make many small changes

of this kind, you’ll dramatically increase the overall

impact of a small amount of flavor.

Other examples of this might be the weight

of the glass you eat something in, the smell of the

food, the shape of the ceiling, the shape of the bowl

and the cutlery. All of these and many more will

have a fairly major impact. If you don’t believe me,

just think about a triangle as food, it really wouldn’t

be warm chocolate sauce, but it might be lemon juice.

This might sound strange to some but language can

cross senses. For example, sharp can be the sense of

touch (a knife), the sense of sound or taste (acid) so it

is possible to use one sense to influence another.

So instead of regulating and taxing and generally

trying to dictate to people, the way to change our

eating habits, to tackle our food cravings, is to set

about fooling our brains into thinking we are getting

more of what we want than is actually the case.

This isn’t a rational approach, it’s an

emotional one, and that’s because eating is an

instinctive and not a rational activity. Setting aside

the rational is a real challenge for policy makers,

but if they want us to become less obese as a nation,

they must learn that laws are often the worst way to

change human behaviour.

the taste immediately after birth, while other

babies actively disliked it. Foetuses then are being

introduced to food, and therefore to the culture and

environment into which they will have to survive,

long before they are born.

In addition, babies whose mothers face poor

nutrition during pregnancy have been discovered to

suffer more from obesity and other challenges later

in life. Scientists now believe that the foetus adjusts

its metabolism for the world which it believes it will

to have face. So if the body calculates that it will face

a world of scarcity but then there is plenty of food as

it grows up, obesity is the result.

This continues after birth. Children soon discover

that their most effective tool for controlling the

adults around them is by refusing or accepting

different foods. So its not surprising that the food

we are exposed to during the first two years of

our life determines what we want to eat through

into adulthood. It’s also the case that although it’s

important to serve good food in schools, if you go

home every night and eat chicken and chips and

ketchup, there simply aren’t enough hours in the

school day to change that.

So what can we do? Well as parents, both

before and after the birth of our children, we can

expose them to as many and varied foods as possible.

Don’t cut them off from sweet things, but remember

that as humans were not really designed to eat too

much sugar, and that includes all sugar, whether in

yoghurt, or coca cola, or even fruit, and regardless of

whether its sucrose, fructose, lactose or glucose. Some

fats are fine, as long as they aren’t excessive, but

above all we need protein.

But those of us who are for whatever

reason already hardwired to expect too much sugar

or salt in our diet, we need to adopt a far more

intelligent approach to changing behaviour. There

is a role for labelling, but when it comes to food,

few of us are truly rational beings, so giving us

perfect information won’t necessarily lead to making

perfect decisions. There might be a role for taxation,

but once again money only has so much impact

in changing our emotional relationship with, for

instance, hot chocolate.

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‘The way to change our

eating habits, to tackle our

food cravings, is to set

about fooling our brains’

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