Researchers who observed a child day care centre found that on average eight parents per week were late picking up their children. One day a sign was placed outside stating that a late parent would incur a fine.

How much did the fine affect the rate of lateness?

It obviously goes down, right? No. Late collections doubled.

So, what is this telling us? Well, before the fine, parents felt bad about keeping the child minders waiting, but after they paid the fine, they didn’t feel bad because they were now paying for their time. There are two motivating factors at play here: the threat of a fine, and social norms. Prior to the fine being introduced, parents acted based on socially acceptable norms, but after it was introduced parents acted based on market norms. In this case social norms affected behaviour more positively than a financial disincentive.

What has this got to do with health and health care? Well bear with me a moment…

Health care costs in the UK continue to rise, as does demand for health care. These combined pressures mean that health and social care is staring at an estimated funding shortfall of £8 billion in 2020/21 and £22 billion in 2030/31. Improving efficiency and reducing waste, whether in terms of supplies, equipment, space, capital, ideas, time or opportunities, is, therefore, of national importance.

The Health Foundation has argued that efforts to effect change and to accelerate improvements in the NHS follow three broad types of approach: directing providers from the outside; enabling organisations more directly; and prodding and supporting staff within NHS organisations. In my mind, at the heart of the last of these is effective behaviour change. Providers’ behaviours – stemming from the collective behaviours of individuals – are the major determinant of whether the most appropriate care is delivered. More so, it is people’s behaviours that are a major determinant of their health. However, often the behaviours of both can lead to outcomes that seem inconsistent, and that is where behavioural insights may have a role to play.

Predicting ‘unpredictable’ human behaviour

Insights from behavioural science – ‘behavioural insights’ – give us a rounded and realistic understanding of all of the factors that influence human behaviour.  

At the core of behavioural insights is that human behaviour is determined by a fallible brain that it is greatly influenced by the context in which choices are made. Small targeted changes to the context or presentation of choices can lead to important and impactful changes in behaviour.

The day care example illustrates that people’s behaviour may at times seem counterintuitive, a bit unpredictable or even irrational. However there is a growing body of work, including from winners of the Nobel Prize, that suggest there are predictable patterns of ‘unpredictable’ human behaviour.

Nudging to reduce missed hospital appointments

What does the day care example have in common with today’s NHS?

Well in my eyes, it is that a deep understanding of human behaviour is important in any public policy formulation which is attempting to change behaviour; and that it can be drawn upon in ways that can save money and reduce waste in the NHS.

Sticking with the day care example, missed appointments are a challenge in the NHS too. They lead to poorer care for patients and cost the NHS around £225m in lost productivity each year.

Many hospitals already send patients a text message reminder before their appointment. These messages include the location, date and time of the appointment. Behavioural science suggests that this is important.

A recently published study found that the best reminder message told patients the specific costs to the NHS of not attending. This small change had a big impact and reduced missed appointments by a quarter, compared to the standard reminder message.

Because the text messages were already being sent, this improvement was at zero additional cost. It was easy to apply; it took the outpatients manager just a few seconds and it doesn’t penalise patients in any way.

Untapped potential for the NHS

Nudges have been applied across a wide range of areas in the UK and globally. There are a number of notable sources that document and collate some of this application in development policy, for policy design and the policymaking community, and the design of health projects.

We know there is also a great deal of encouraging work taking place in the UK that is highlighting the potential for behavioural insight to generate solutions for existing health care problems. That’s why we’ve published Behavioural insights in health care. The report collates and summarises the evidence on the application of behavioural insight interventions in health care, and then goes on to consider some opportunities where application of behavioural insights may lead to reduced inefficiency and waste in the NHS. The report includes great examples of nudges – such as the text messaging one above – that have been, or are ripe for, application in our health care setting.

Behavioural insights are not a magic bullet. But if we can reduce missed hospital appointments by a quarter simply by telling patients the cost, then many argue, including Lord Ara Darzi, that there is great potential for the NHS.

Oh, and watch this space as we’ll soon be announcing a number of innovative behavioural insights research projects that we think have the potential to improve efficiency and reduce waste in the NHS.  

Darshan is a Research Manager at the Health Foundation

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