Lifestyle-related problems - should we pay for the treatment of them?

The cost of so-called lifestyle related problems on both the NHS and society as a whole is increasingly being scrutinised; figures such as 10% of the NHS budget have been quoted previously and today, savings of £400m are claimed to be possible by making such individuals pay at least in part for the cost of their treatment:

Make people pay for lifestyle related problems

The article in question makes pointed reference to those with Type 2 diabetes, suggesting that they should pay for their prescriptions.  This is one example of a huge range of health problems that can at least in part be caused by a person's lifestyle choices.

There is no doubt that as the number of people in society grows and as the population of older people requiring some form of care increases, the NHS as it appears now will have to change; possibly out of all recognition to the service that we are privileged to have today.

Maintaining a health service that is for the most part 'free at the point of delivery' is an ideal that we should surely strive to maintain but in order to achieve this, it is likely that many harsh and difficult decisions will have to be made; the cost of problems associated with a person's lifestyle may well be one of them.  However we must be careful in pursuing this path no matter whether it seems entirely correct to make those with 'self-inflicted' problems pay for their care....after all they did this to themselves right?

However there are a number of significant problems to this idea.

Firstly who decides which problems are lifestyle related?  If I choose to go rock-climbing and in spite of my best efforts, honed skills and high quality equipment fall and fracture a bone in my leg, is that 'lifestyle related'?  Should I pay for the cost of repairing my leg, the cost of prescribed medications I may require or the cost of after care such as physiotherapy?  If I choose to drink alcohol in excess of lower risk guidelines and develop pancreatitis, should I pay for this care?  If I choose to work in a job that is potentially hazardous (driving a petrol tanker, working on an oil rig for example) and then become ill should I pay? ... ... ....the list is endless.

Secondly who decides to what proportion someone's health problems are lifestyle related?  If I am a serious road runner and develop a problem with my knee, how could anyone prove beyond doubt that this was related to my chosen lifestyle?  If I use ecstasy at weekends and develop a cardiac arrhythmia, again how can you prove it is related to my substance use, particularly if I have a family history of arrhythmias?

Furthermore should other factors such as a person's circumstances be taken into account as part of such decision-making; should people who are victims of traumatic events in their lives (for example, those with post-traumatic stress disorder having served in the armed forces or survivors of sexual abuse) be given more leeway so to speak should they drink alcohol excessively?  If they develop 'lifestyle problems' should they pay less than someone deemed to have fewer mitigating circumstances?

It may well be that ultimately there is a case for charging for certain parts of a person's care.  And it may well be that lifestyle factors should be taken into consideration as part of this.  But this must be done with extreme care and certainly without prejudice or discrimination.  It is all too easy to blame someone's lifestyle on their subsequent needs, yet it is often extremely difficult / impossible to know the extent to which someone's lifestyle contributed to their problems.

Indeed, if raising the public's awareness of the financial cost of care provision is deemed to be important, would it make more sense to provide all patients who receive NHS care, with a theoretical bill of how much it cost?  Doing this in itself may encourage people to consider their lifestyle and how they choose to use the care provided by the NHS.

To my mind awareness raising in regard to this issue and articles such as the one that this blog links to, should provoke us to consider how best to change the implications that the scenario of escalating 'lifestyle related problems' has.  We know that delivery of interventions aimed at positive behaviour change can be extremely effective, yet how much of our resources are genuinely aimed at ensuring that this occurs?  How many nurses and doctors receive training on how to deliver effective interventions?  How many healthcare professionals clearly see this as a part of their role or have the time afforded to them to provide such interventions?

We should grasp every opportunity to promote positive behaviour change - it isn't the magic answer and it won't make this problem go away, but if more of our energies were focussed on providing this part of care as thoroughly and properly as possible, it would make a significant difference.

Maybe it would reduce the need for us to make as many difficult decisions about who should and should not pay for their care.

The brilliance of opportunistic interventions

For almost the last 8 years of my life, I've worked as a specialist nurse in the field of substance misuse (alcohol and other drugs).  However I've done this work in a relatively unusual setting (though one which is thankfully becoming less unusual as its potential is increasingly realised); that of the general hospital as opposed to in the community.

My work is extremely rewarding, I am passionate about the role and its effectiveness; so contrary to what a number of people may believe, the job - whilst undoubtedly challenging at times - is certainly not "depressing" or filled with a continual procession of people who "don't want to change" or who are "hopeless cases."  Sadly there are a small number of people who I see on a number of occasions but even then to regard people in the negative terms you often hear is at best unfair and at worst hopelessly inadequate; the way I see it is that people take differing lengths of time to place sufficient value on aspects of their lifestyle and as such take varying lengths of time to decide to make changes / make sufficient changes.

The main differences between my work and that of workers in community settings are firstly that the people I see have an active physical health problem that may or may not be related to their substance use; this health problem is so severe that hospitalisation is required.  Secondly and crucially they are not actively seeking support or advice at the time of their admission to hospital.  Indeed the first time they often become aware that support is available to them is when I arrive at their bed-side.

The majority of my interventions are therefore highly opportunistic; I am required to have a range of specialist skills in initial engagement in order to take advantage of what has rightly been coined "the teachable moment."  Over the years of doing this job I have come to realise that using this moment to its fullest potential can often be a crucial component of an individual's recovery; it can be the "light-bulb" moment when the person begins to truly see the negative consequences of their substance use and more importantly acknowledge that something needs to change.

Taking advantage of moments when people are the most receptive to behaviour change messages is key to our success as substance misuse workers or indeed anyone engaged in the area of promoting behaviour / lifestyle change.  Using these moments to foster belief, optimism and hope in an individual is paramount.

Having someone who believes in you and the changes that you can make is a powerful thing.

Having said that these moments can be fleeting and therefore it is vital that they are recognised and valued as soon as they occur and regarded highly; they can represent a significant turning point in a person's life.

The evidence base for the effectiveness of such interventions is now so strong (around 30 years worth) that their value cannot be disputed.  In spite of this health professionals generally receive little or no training in delivering brief advice; as such they frequently fall back upon out-dated and inaccurate stereotypes; a version of the world where people don't change because they either don't want to or are incapable of it.  The greater esteem in which such interventions are held, the better for people who would benefit from them.

In almost 8 years I've seen on too many occasions to count (I estimate that I've now seen around 5000 individuals), the value of talking to people about their lifestyles at times when they've not necessarily requested such advice or support but who are receptive to such messages because of their situation.  This of course doesn't have to be due to physical ill health, this concept can readily be applied to any number of settings.

What is key is using the 'teachable moment' to its fullest potential and empowering people with the belief that they can make positive changes to their lives.