Joining the dots: connecting behavioural insights to improvement, and to our humanity

Behavioural insights – often referred to as ‘nudging’ – are lessons from psychology, cognitive science, social science and behavioural economics that shine a light on how we make choices. At their core is the recognition that we are not always consistent nor rational in our choices and behaviour. Rather, our behaviour is determined by a fallible brain that is greatly influenced by the context in which our choices are made.

In the last few years the application of behavioural insights to NHS policy and practice has continued to gain momentum. In its discussion on accelerating innovation in new ways of delivering care, the Five Year Forward View explicitly stated that ‘work will also be undertaken on behavioural “nudge” type policies in health care’. Since then the new National Institute for Health Research (NIHR) Policy Research Unit in Behavioural Science has been set up to provide high-quality and timely behavioural science evidence to inform effective policymaking. This is all hugely encouraging to those of us working in this space.

How do behavioural insights make a difference?

Making things easy, attractive, social and timely for people can lead to significant behaviour change. There are many great examples of how behavioural insights have been applied or are being tested in the NHS. Here are just a few examples:

• A letter signed by the Chief Medical Officer to the highest prescribing GPs showing how their antibiotic prescribing compared to other GPs in their area (‘social norming’) resulted in a 3.3 % reduction in prescribing.
• A simple reminder of the cost of a discretionary lab test at the point at which a doctor considered whether or not to order one (a ‘timely reminder’) led to a 30% reduction in the use of the test.
• Changing a few words on a website in a way that appealed to our human nature to return a favour (‘reciprocity’) led to almost 100,000 more people signing up to be an organ donor. 

Using behavioural insights for improvement in the NHS

The more I think about it, the more convinced I am that a great many of the behavioural insight examples out there use approaches we have all been using in our day-to-day improvement work to change behaviour. Prompts, reminders, cues, feedback, commitment planning, defaults, messaging, information provision and transparency are all delivery mechanisms that we use day-in, day-out to test and make improvements. Without knowing it, we are almost certainly all applying behavioural insights in our improvement work, and this also presents the NHS with a fantastic opportunity.        

In my role at Imperial we are trying to explore how to build the confidence, capability and capacity of staff to use behavioural insights in ways that can be applied to day-to-day improvement efforts. A key part of this will be to think about how to embed behavioural approaches into the 90-day improvement cycle – the cornerstone for learning about improvement prior to scale, spread, diffusion and transformation.  

And this week, the Health Foundation has announced support for three exciting research projects as part of our Behavioural Insights Research Programme. We have worked closely with the three teams to ensure that their ideas draw on key improvement principles. As a result, our three new projects now all have a substantive ‘explore’ phase, mirroring the ‘plan’ phase of a ‘plan, do, study, act’ cycle in improvement. We believe that this is critical to ensure that the behavioural interventions the teams develop are feasible to implement and evaluate in the real-world NHS. 

Knowing the limits

Of course, we shouldn’t view behavioural insights as a silver bullet. A great many challenges the NHS faces are not behavioural – for example, IT systems that do not speak to each other. And there are other excellent behaviour change frameworks that take a much broader approach than behavioural insights. But where behavioural insights offer promise we should explore their potential to bring about the kinds of improvement that we all wish to see for patients and our health care services.      

Behavioural insights may also offer us more than accelerating the testing, scale and spread of innovation and improvement in the NHS. It can also help us to reconnect with our humanity. By recognising and being more aware of our own biases and fallibility in making consistent and rational decisions, we can also become more understanding and accepting of others. Perhaps it is this lesson that behavioural insights can most immediately offer.

Darshan Patel (@DarshPatelHF) is a Senior Research Manager at the Health Foundation and an Improvement Partner at Imperial College Healthcare NHS Trust