Behaviour Change: Science and Technology Committee Report

Baroness O'Neill of Bengarve Excerpts

Wednesday 11th July 2012 Grand Committee

[Baroness O'Neill of Bengarve]

My Lords, I, too, thank the noble Baroness, Lady Neuberger, our special adviser and, of course, the secretariat. This was a complex report to get together. The evidence was unusually disbursed, and I cannot say that we got together all the sorts of disbursed evidence that would be relevant. Here and there, I caught a note of disappointment that certain sorts of evidence had not been covered. I think that that is right. We took, if I may put it this way, a dipstick approach. We were looking for evidence and where it has not been collected there is no systematic picture of evidence. We did not look at what is delightfully called “renorming”, where you tell people what is the proper thing to do about something—what is the norm. For example, noble Lords have no doubt stayed in hotels where they are informed that their guests use their towels on average X number of times, as opposed to throwing them on the floor for the laundry. That is said greatly to reduce the demand for laundry and reduce laundry bills and energy expenditure because people think that the respectable thing to do is use their towel for three or four days and not throw it on the floor immediately.

In one way the Government’s response to the report is rather gratifying as they agree to a fair number of the central recommendations, but in another way it is not at all gratifying because, although they agree, they do not then explain clearly what they will do or suggest a timetable. The disappointment is that the Government have not specified what action they will take on the very measures that they agree are relevant within a specified timeframe. I have every sympathy with the Government on one point. Behavioural changes might—I say “might”, not “will”—provide an excellent solution to many problems from smoking to obesity or the excessive use of cars to the excessive drinking of alcohol. The question addressed by the Committee was the rather sobering one of whether and how well they actually work. We should remember that behavioural solutions are nevertheless appealing because if they work individuals will change their behaviour to some degree without the need for enforcement or penalties and the problem goes away. Choice is preserved, harms and ill health are avoided and costs are minimal—if it works. It is said that all that is needed may be a nudge, a minimal intervention that leads people to view a different, less harmful or healthier way of behaving as the default option—indeed, ideally as their preferred option—and they will change their behaviour accordingly. However appealing it may be it is not very useful if it does not work.

The patchy evidence that the committee heard, and the two detailed case studies of obesity and car use that it undertook, repeatedly showed two things. First, there was a dearth of evidence about the effectiveness of many behavioural interventions and, with that dearth of evidence a lack of robust evaluation. Secondly, there was insufficient evidence of the staying power of behavioural interventions, either taken individually or in interaction with other interventions. That was particularly marked in some of the evidence about the efficacy of exercise in addressing obesity.

The Government have pointed out in their response that they are funding the Policy Research Unit on Behaviour and Health, based at the University of Cambridge and directed by Professor Theresa Marteau to undertake rigorous evaluations. This work is admirable, but it is on a small scale. Often an intervention shows promising results but unless its cost and its efficacy are carefully compared with other approaches across various contexts in combination with other interventions, and its staying power after the intervention is monitored, promising initial results may turn out to have limited staying power. I hope that we will find policies that use behavioural interventions but provide robust and generalisable evidence of the efficacy of those interventions across situations. We need a broad and systematic approach, as other noble Lords have said.

Moreover, as others have also said, the report did not find much evidence of the efficacy of behavioural interventions taken in isolation. I make no apology for quoting that it noted that,

“the evidence supports the conclusion that non-regulatory or regulatory measures used in isolation are often not likely to be effective and that usually the most effective means of changing behaviour at a population level is to use a range of policy tools, both regulatory and non-regulatory”.

I suppose that that is hardly surprising. We have huge experience of the sheer difficulty of changing entrenched behaviour when we consider the more than half a century of strenuous efforts to reduce smoking. So far they have had a marked yet still incomplete effect, despite deploying a complex combination of behavioural, fiscal and regulatory interventions. This difficulty of achieving change, even using a mix of measures across a long time, is despite the reality that, as an editorial in the Journal of Public Health of February 2011 nicely put the matter:

“Tobacco is clearly an exceptional product; no other consumer product kills one in two users when used exactly as intended”.

Many of the changes in behaviour that the report discusses are of comparable complexity to giving up smoking. Although the harms they address appear less straightforwardly lethal, they are very significant harms. The same editorial in the Journal of Public Health suggests that while smoking and alcohol in combination account for fewer than 20% of deaths in high-income countries, the six most serious diet-related risk factors account for 17.5% of deaths in high-income countries. The figures are not as different as you might expect. This is not an area in which there is reason to hesitate about using fiscal or regulatory interventions if behavioural interventions are known not to be sufficient. The matter is urgent, and rising obesity and diabetes are heralds of a public health tsunami.

The Government’s response argues:

“It is not a question, therefore, of the use of regulation being ruled out altogether, rather that regulation is only used when satisfactory outcomes cannot be achieved by alternative approaches, or where alternative approaches would involve much higher costs”.

Evidently the Government are pinning quite a lot of hope on the efficacy of behavioural interventions or on finding effective ones, but they have also pinned quite a lot of hope, as others have mentioned, on the so-called responsibility deal with the food industry, by which it agrees to reformulate products to make them healthier. Yet the committee was told by Mr Justin King of Sainsbury’s that voluntary agreements were sometimes unsatisfactory. He said:

“There was an attempt by the industry to coalesce around a voluntary agreement together with the FSA … and we felt very strongly that it was coalescing around a lowest common denominator, when our customers had clearly told us they expected something more and better. And when we made the change”—

because Sainsbury’s did make a change—

“we were not the most popular people in the industry”.

How long are we to wait to establish whether behavioural approaches work? How much faith can be put in responsibility deals that have to be sold to the least as well as the most responsible companies in the food industry? The public health problems created by overeating an affluent diet are grave, and delay in taking effective steps to prevent these problems would be serious.

I shall finish with two questions for the Government. First, what steps are Her Majesty’s Government taking to ensure that food served in public institutions, where the available menu in any case limits consumer choice, does not contribute to the obesity and related epidemics? In particular, what steps are they taking to ensure that meals in schools, in prisons, in the armed services and in canteens catering to public services do not contribute to these epidemics? Will they rely on behavioural interventions in these contexts where more direct interventions are readily available and are, in effect, being made every day when menus are chosen? If not, what reasons can they give for offering unhealthy meals when healthy meals can provide equivalent choice, and need be no more expensive? A lot of meals are eaten in public canteens in this country every day.

Secondly, what steps are Her Majesty’s Government taking to evaluate the efficacy of the public health responsibility deal with the food and retail industries, and what benchmarks and timeframe have they set for the industry to demonstrate that the deal is effective? It would be unfortunate if the responsibility deal turned out to have created one more last chance saloon, in this case for the food industry rather than for the media, allowing the less scrupulous performers to spend a decade pretending to produce healthier food while continuing to peddle excess fat, sugar and salt.