Nudging towards NHS innovation

Let’s start with a conundrum.

Nine out of ten people in England would be happy to donate their organs after they die.

And awareness of the way to do this – joining the organ donor register – is good. It’s also easy to join: a simple Google search will take you to the organ donation website where registration takes a few seconds.

So here’s the conundrum: if it’s something people believe in, it’s well understood and easy to do, why have less than a third of people in England expressed their wishes by joining the organ donor register?

This is where insights into how people actually behave become so important. And it is so good to see that there have been major advances in recent years in understanding the full range of influences on people’s behaviour. We now know that people often do not respond in what economists would call fully rational ways.

Instead, all of us have in-built responses to the world that are automatic: we respond without paying conscious attention. Hence, even though these responses are not ‘irrational’ per se, they often lead to unexpected behaviour or behaviour that deviates from what we would wish to do. 

The good news is that these responses are increasingly being understood, meaning there is untapped potential to use these insights to help us to tackle some of the NHS’s biggest challenges, such as improving the quality of patient care, encouraging self-care, and securing efficiencies. And, of course, to increase the number of organ donor registrations.

Behavioural insights or ‘nudge’

The understanding of these observed automatic responses is commonly referred to in the UK as ‘behavioural insights’ or more colloquially ‘nudge’. What is clear is that interventions informed by behavioural insights can have a very powerful impact, as they go with the grain of how people actually think.

These behavioural interventions can be very low cost. They can manifest themselves as small changes: from how messages are framed, to simplified processes. And they can be effective without restricting choice or requiring regulation.

Opportunities for the NHS

Behavioural insights have obvious benefits for NHS innovation. The NHS is under unprecedented strain: facing a funding gap of up to £30 billion by 2020. At the same time, the service needs to be more responsive to patients and ever-increase the quality of the care it provides. Behavioural insights aren’t a magic bullet, but they can inform simple, cheap and easy to implement innovation than can make a positive contribution.

Indeed, we’re already seeing this happen.

Recently the Department of Health collaborated with Medway Council to use behavioural insights to increase uptake of the NHS Health Checks programme. Run as a randomised controlled trial – the gold-standard of social research – a simple and entirely free intervention increased uptake by 13 per cent. Another example was at a hospital in Derby where they tested the impact of simple and timely information.  This intervention reminded hospital doctors of the cost of a common lab test at the time they order the test. This reduced use of the test by a third.

And now to return to the organ donor registration conundrum. The NHS is now increasing organ donor registrations by prompting people to make a decision when applying for a driving license or purchasing car tax on-line. It’s as easy to say ‘no’ as it is to say ‘yes’: this does not impact people’s freedom. But the very act of making this easy for people – giving them a ‘nudge’ – is showing positive results.

This hasn’t solved the problem of too few organ donor registrations. But it has taken a sizeable chunk out of the problem at negligible cost.

New ideas, ongoing problems

We are keen to explore the potential opportunities that behavioural insights can have on existing NHS challenges. To this end the Health Foundation has launched a £1 million Behavioural Insights Research Programme to support original research into behavioural interventions that have the potential to increase efficiency and reduce waste in UK health care services.   

I have to say I was a little nervous when developing this research programme,: I wondered if our thinking aligned with others out there? But then a few weeks ago I read a Perspective piece in the prestigious The New England Journal of Medicine. The piece discussed the promise and challenges of behavioural insights, and argued that behavioural insights can provide a theoretical and empirical foundation for aligning incentives with organisational goals – and that these should be tested in rigorous experiments. It made me smile, as our new research programme provides the precise vehicle by which to do just this.

Darshan is a Research Manager at the Health Foundation