Tag Archives: nhs

The median and the message

How does the man on the Clapham omnibus stay in shape? NHS Choices has an idea.

It’s fairly reasonable for NHS England to worry about lazy weekends. The British population is very inactive, worrying given the extraordinary physical benefits of regular exercise. The limited effect of the UK’s public health campaigns urging us to take more exercise despite years of messaging is also undeniable.

The above tweet does helpfully illustrate a pervasive style that characterises most British public health messaging. You could fruitfully compare it to the five-a-day campaign, guidelines setting out the number of alcohol units men and women should respectively drink, even the laughable ‘Go for Gold‘ effort to reduce the potential carcinogenic effect of overdone toast. The easiest way to describe it is as rational: clearly linking a defined behaviour with a defined problem, and offering a solution with a different activity.

What I mean by this is best illustrated with a simple thought experiment. Consider the sort of person whose weekend is largely sedentary: football on the TV, alcohol in the pub or at home, fried food, transport largely by car. Then, ask: is this person likely to be willing to undertake a ‘sofa workout’ at all? To ask the question is to answer it.

To expand: NHS Choices appears ignorant of selection problems. The traits which lead to couch potato syndrome are precisely opposite to the traits which would induce someone to undertake exercise on the sofa towards a defined health benefit. The problem is not the activity being recommended, the problem is that the people most in need of exercise are also the least likely to be responsive to the prescription they get. The same is true of five-a-day campaigns. If you like, the sort of person who is likely to carefully mediate what they eat, count portions, plan meals and so on is probably quite conscientious and has a little above average intelligence; she probably has a university degree, or would have if she came of age after the expansion of higher education in the 1990s. In other words, the only people on whom the messaging works are the people who will be fine anyway. The marginal benefit is almost nil.

This strikes me as a particularly serious problem in nations like the UK, where virtually all policy of import in both the private and public sectors is designed by university graduates – who, by definition, are selected for above-average conscientiousness and above-average IQ. The trouble is that, by definition, half of the population have below-average IQ and below-average conscientiousness.  It might be natural to assume that this messaging will work if everyone around you talks casually about getting their five-a-day or their half-hour of exercise; when it comes into contact with the average person, it will likely be less effective. As a result, we see the same problems again and again: public advice made for homo economicus, who calmly, rationally and dispassionately analyses his habits to eliminate the bad and promote the good. It should not need to be explained that most people simply do not (and cannot) think in this way. Public health, without coercion, at scale, remains an unsolved problem.

To even begin to address this, it is not enough to “speak broadsheet to graduates“, but we have fewer and fewer interpreters as the intellectual selection processes for powerful institutions become stronger and more rigid. Our politics is increasingly designed for a particular grade of intelligence and for a particular set of habits of mind, so it becomes hard to see where the imagination necessary to cross the rationality gap might come from – and how the gap can even be pointed out to those too bright to see it.


Leave a comment

Filed under Culture