Peter Lapsley: Effecting behavioural change

Peter LapsleyIt seems unlikely that many of the BMJ’s readers are able to listen to Radio 4 between 8.30 and 9.00 am on a weekday, and even less likely that they could find time to read a 96 page paper by the Institute for Government, signposted on the Today programme a week or so ago, although its accompanying “Practical Guide” is at least as useful and rather more digestible, as is its paper “Using social influence to reduce DNA rates in healthcare settings.” Being semi-retired, I am fortunate in being able to listen to the radio over breakfast, and the signposting in question was sufficiently intriguing to encourage me to read all three papers.

Prepared under the Mindspace banner by the Institute for Government, an independent charity working to increase government effectiveness, the paper, “Influencing behaviour through public policy,” is about effecting behavioural change. It is co-authored by Paul Dolan, a professor of economics in the department of social policy at the LSE; David Halpern and Michael Hallsworth, the director of research and a senior researcher respectively at the Institute for Government; and, from Imperial College London, Dominic King, an SpR in general surgery and a clinical research fellow in the department of surgery and cancer, and Ivo Vlaev, a senior lecturer in psychology. And it is signed off by Sir Gus O’Donnell and Sir Michael Bichard.

It is a bit rambling and would benefit from a more detailed contents page or, better, an index, but the main paper makes fascinating reading. While it covers a multitude of subjects, from tackling gang culture and violence (particularly timely at the moment), to preventing littering, bad behaviour in schools, truancy, excessive energy use, and encouraging recycling and voter turn out, much of it has to do with health and health service provision.

Both papers are based on the premises that we are heavily influenced by who communicates information; the ways in which our responses to incentives are shaped by predictable mental shortcuts, such as strongly avoiding loss; how strongly influenced we are by what others do; how we tend to “go with the flow” of pre-set options; how our attention is drawn to what is novel and seems relevant to us; how our acts are often influenced by sub-conscious cues; how powerfully emotional associations can shape our actions; how we seek to be consistent with our public promises, and to reciprocate acts; and how we act in ways that make us feel better about ourselves.

It was initially the reference on Radio 4 to reducing “did not attends” (DNAs) that caught my attention.

DNAs in clinics are but one example of several similar challenges. They are not unique to the NHS. Witnesses fail to show up in court; offenders fail to attend for community service; and restaurateurs complain that diners often fail to take up table reservations.

Where medicine is concerned, DNAs are a major drain on NHS resources. Around six million appointments are wasted each year at an estimated direct cost of £700-£800million. 84% of GPs cite DNAs as a problem – leading to lengthened waiting times, difficulty in reaching performance targets, reduced patient satisfaction, greater costs, and potential public health issues.

As GPs prepare to commission services and to balance budgets, the need to persuade patients to take greater responsibility for their health and to use services responsibly will become even more important. The practical guide shows how simple changes informed by behavioural science research can improve patient engagement and commitment and result in a significant reduction in DNA rates. It offers three practical actions that healthcare professionals can take immediately to reduce DNA rates, at no cost.

Healthcare professionals should actively involve patients in the appointment making process. People generally prefer to live up to their commitments, especially those that are owned and require their active rather than passive involvement. In the Mindspace study, asking patients to repeat back the time and date of their appointment whilst on the phone led to 6.7 percent reduction in DNAs.

Get commitments in writing. Most people know that if they write down a task they need to carry out, they are more likely to remember it and do it. DNAs can be reduced by asking patients to write down the date, time, and purpose of their appointment. Adding a unique number identifying a specific appointment can also help. In Mindspace studies, asking patients to write down the details of their appointments, rather than have a nurse or receptionist do it for them, reduced DNAs by 18 percent.

Publicise the right norm. Messages on waiting room walls decrying high rates of DNAs present two problems. They can lead to an increase in DNAs because they send the message, “look at all the people who aren’t turning up!” And, the people who don’t turn up never see them, so they are targeting the wrong patients. Far better is to highlight the much larger number of patients who do turn up on time for their appointments. When Mindspace tested this in addition to the other changes, DNAs were reduced by 30 percent.

No clinician needs to be told that the rising incidence of obesity is high on the list of conditions posing the greatest threat both to health and to NHS budgets, or that diet and exercise offer the most obvious solutions.

I have long been wary of fad diets, not least since a friend of mine put himself on one that involved eating nothing but citrus fruit and then wondered why he developed gastro-intestinal bleeding. As a colleague pointed out recently, they are usually published in women’s magazines and Sunday supplements opposite recipes for the juiciest burgers in town. I am neither a doctor nor a dietitian but suspect strongly that the real solution is to eat healthily and to eat less – just get a smaller plate and a smaller glass. The Mindspace research confirms this.

It might be supposed that, while smaller plates may make us eat less initially, we will pile them higher, to compensate. The evidence does not support that. Instead, it suggests that the sizes of food containers have a strong influence on subsequent eating. In one study, cinema-goers ate 45 percent more popcorn when it was given to them in a 240g container instead of a 120g container. And even when the popcorn was stale, the larger container made them eat 33.6 percent more.

Where alcohol is concerned, people’s portion sizes vary according to the container size, so people who use larger glasses tend to pour themselves larger measures – and vice versa. Where spirits are concerned, many people merely slop “some” gin or whiskey into a tumbler; obtaining and using a spirit measure can significantly reduce the size of that “some.”

With diet goes exercise. The Mindspace study found that payments for gym membership leave many people’s bank accounts without those people ever crossing the gym’s threshold. A Danish chain of gyms is offering a new way of encouraging its members to visit their gyms regularly. They offer free membership, the only condition being that if you fail to show up once a week you will be billed for a monthly membership fee. The scheme seems likely to increase gym usage, if not profit, because it will generate continuing feelings of loss aversion for failure to go to the gym.

Commitment to a goal (such as 10,000 steps a day using a pedometer) appears to increase success, too. Mindspace found an experimental study compared two groups; one signing a contract specifying the exercise goals to be achieved. Those in the control group were simply given a walking programme without entering any agreement or signing a contract. All participants recorded daily walking activity for six weeks: a remarkable 81 percent of the contract group achieved their exercise goals, while only 31 percent of those without contracts did so.

“Influencing behaviour through public policy” and its accompanying papers contain several other comparable ideas on a number of subjects, including smoking cessation and increasing organ donation. Complex and wordy they may be, but they are well worth reading by anyone concerned with improving people’s health and reducing NHS costs and waste.

Peter Lapsley is patient editor of the BMJ.