Originally published on spiked.
Norway and the UK are among world leaders in spending on healthcare, but both countries are faced with a looming crisis. In Norway, the prospect of economic slowdown has led some to question whether the country’s famously generous welfare model is sustainable. In the UK, the prolonged recession has meant that all the leading parties are promising big cuts in public spending. While Labour and the Conservatives make high-minded promises to protect health spending, future governments are sure to be keen to find savings in one of the largest areas of state expenditure.
The answer emerging from the policy wonks is to instigate wide-ranging reviews of how services are run. Hence, UK healthcare managers, politicians and policy makers are looking outside healthcare for inspiration. In particular, they are asking designers to reassess how services are provided and how healthcare demand can be reduced, particularly through illness prevention. The goal of improving treatment is being superseded by a rush to design ways to discourage our apparently unhealthy lifestyles.
The Conservative Party wants to ‘prevent people getting ill in the first place’. The ruling Labour Party wants everyone to have routine check-ups and more diagnostic testing to identify illnesses early on. And the Liberal Democrats, not to be outmanoeuvred, put it more simply: let healthier people pay less tax!
These policies end up shifting the burden of ill-health on to the public. As one NHS manager put it, ‘encouraging people to make healthier lifestyle choices plays a crucial role in tackling the increased costs to the health system’. A UK government report published in March this year, Mindspace: Influencing Behaviour Through Public Policy, made clear the future direction of healthcare. The report’s authors argue that problems such as the increase of chronic conditions like obesity or diabetes can only be resolved ‘if we are successful in persuading people to change their behaviour, their lifestyles or their existing habits’.
Similar themes are central to the Norwegian government’s approach to healthcare. For example, a 2009 document from Helsedirektoratet(the Directorate of Health), Norway and Health: An Introduction is littered with references to the need to change people’s habits and to increase ‘lifestyle intervention’.
British think-tank the Young Foundation has placed manipulating our behaviour at the heart of improving health. Its report, Influencing Public Behaviour to Improve Health and Wellbeing, states that behavioural psychology must be used in an ‘economical [way], and often more can be achieved by positive messages, that emphasise personal wellbeing rather than just stoking fears’. The report suggests that ‘the most powerful tools involve reshaping environments to encourage people to make healthier choices’. Such is the political interest in these ideas that the Young Foundation, together with a number of leading designers, has outlined plans to establish an Institute of Healthcare Design.
But will all of this—especially in such a volatile context of rationalising services and reducing demand—actually improve people’s health? It doesn’t look like it. In the UK and the US, more designers are following the prevailing preventative approach established by the government, while medical expertise is being deprioritised in favour of treating patients as customers. The UK secretary of state for health, Andy Burnham, made this clear when he said that what matters most is how you are addressed by doctors, the warmth of the welcome given by receptionists and the quality of the food on offer. If customer service is all that matters, hospitals become reduced to hotels.
In the current climate design’s influence tends to be a conservative force rather than a progressive one. For example, it is now common for designers, together with architects and urban planners, to devise buildings, including hospitals, schools and offices, that make people walk or use the stairs (rather than the lifts) encouraging fitness. Preventative healthcare is becoming a feature of our everyday lives where even at football grounds like Liverpool’s Anfield stadium, fans are now lectured on the merits of healthy eating during half time.
Behavioural psychology is also used to change how people make choices. For example, lighting is now being actively employed to manipulate people’s mood. One design researcher has created a toolkitused to get people to reveal their underlying motivations (and the causes of their unconscious ‘bad’ behaviour) so that better services can be delivered without creating any more undesired effects.
Of course there are many examples where design has been used imaginatively so that we can get more out of healthcare. But even then, many new ideas often end up reinforcing the connection between health and our behaviour, encouraging us first to recognise unhealthy habits and then to change them. An example of this is the relatively new field of telemedicine that connects a person to their doctor using technology that sends data over the internet using wireless tools. If a person is recovering from a heart attack, it means they can recover at home rather than at the hospital, while still being monitored by doctors.
In the context of preventative healthcare, however, the liberating potential of this innovation is turned on its head. As one service designer pointed out, ‘monitoring how we are doing may actually change what we are doing’. If we have the potential continually to monitor our health (forgetting the anxiety that would cause), why does it automatically follow that we must become more responsible for it? Why can’t we design systems that let doctors look after our health on our behalf, letting us get on with our lives? The introduction of telemedicine may well be used to justify yet more medical lectures and cutbacks in provision in the name of personal responsibility.
At a time when we are healthier than ever, living longer lives and are less prone to serious disease, the discussion about health can only pose our lifestyles as a costly burden. In this context, design and technology – far from liberating us from illness – may bind us even closer to our health.
The problem for designers is that they must decide what design is for. Is it about opening up more choices in how we live our lives or should design promote social policy agendas that remove those choices? An honest and open debate about the role of design would be far healthier than blindly pursuing the manipulation of our behaviour by stealth.