System transformation: A nudge in the right direction

Inaugural members of Sciana: The Health Leaders Network are spending part of their third meeting investigating the potential impact of behavioural economics and behavioural psychology on health care.

The 2017 cohort, which arrived on Tuesday, was introduced to the subject during a plenary discussion on their first full day of the programme.

Beforehand, members had worked alongside the 2018 cohort to consider how major change can take place in health systems and what approaches to such change work best and why.

Engaging with a presentation after lunch, members learned behavioural insights could translate into “understanding how people behave in practice” so that policy and services can be designed better.

Behavioural science can provide an opportunity to explore new solutions in the public health domain where previous studies haven’t worked. As one of the speakers remarked, it can provide “a lens through which to see policy, not a set of tools in a toolkit.”

In 2008, Richard Thaler and Cass Sunstein published Nudge, a book which made it more widely known there were decades of research which suggested many judgments made by humans weren’t rational. Members were asked to consider, “What next?” How can we change the world or choice architecture to allow people to make better decisions?

A challenge exists to scale successful behavioural science projects within health care and other sectors. People have to take into account what behaviours they want to change and whose behaviour it is. In health and health care, this could be the general public, people as patients, or general practitioners.

One of the case studies members explored concerned a UK hospital and an initiative to reduce the number of missed appointments. Patients were sent four messages, each one carrying a different detail such as cost, a contact number, and information on how many other patients attended appointments.

The best performing message reduced missed appointments by 25 per cent. The authors of the study, which used findings from two randomised controlled trials, indicated there would be 5,800 fewer missed appointments if applied over one year in the same location.

Members were shown an overarching framework as to how to introduce ideas from behavioural science. Any potential changes should be EAST: easy, attractive, social, and timely.

In our day-to-day lives, we have so many people, gadgets, and signs competing for our interest. Something which is attractive could be personalised to help attract someone’s attention. It could optimise incentives and cater to the ego and emotion.

One of the speakers suggested that a default option in health care is to assume there is a knowledge problem among patients. Merely providing additional information, however, is not the solution. Technology can help deliver interventions in the moment and when it is appropriate.

Members were asked to contemplate if patients weren’t engaging with doctors or medical professionals, who were they engaging with, and how could they be targeted to help spread necessary information?
Towards the end of the afternoon, members considered further where “nudge” could support system transformation and what limits existed.

Members took part in table discussions and put forward several ideas. As the session came to a close, these thoughts were narrowed down further in preparation for Thursday’s programme.

The 2017 cohort will look at priming and framing health games to detect early-stage cancer; nudging to adhere to protocols and guidelines; nudging specialists to act in teams and not in their specific disciplines, and nudging patients to choose a second medical opinion.

Groups will work on pre-prepared briefings looking at behaviour change in diverse contexts.

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