Only a tiny amount of medical research spending focuses on changing behaviour, despite evidence theses approaches can be practical and cost effective, says David Halpern
More than half of years of healthy life lost are as a result of behavioural or lifestyle factors, such as smoking, poor diet or lack of exercise. This is before we factor in social relationships and frame of mind − having someone to talk to and a positive outlook on life have been found to have a major impact on longevity, with an effect comparable to not smoking.
‘Behaviourally based approaches can achieve highly practical and cost-effective effects across many policy areas’
The curious issue is why these familiar statistics have so little impact on clinical practice or how we spend money. Historically, the billions we spend on health research are strangely disconnected from the weight of evidence on causes.
The Darzi review estimated that less than 0.5 per cent of medical research spending was directed at behavioural factors − and the majority of this tiny portion is actually spent on medical compliance (ie: why people don’t finish taking their medication or complete courses of treatment).
One argument is that in contrast to the pharmaceutical industry, behavioural scientists haven’t offered the same specificity of products or advice (with the possible exception of areas such as smoking cessation). But over the past two years, the work of the Behavioural Insights Team an the Cabinet Office has shown that behaviourally based approaches can achieve highly practical and cost-effective effects across many policy areas.
Where possible, the team uses randomised controlled trials to test the effect of these approaches. For example, highlighting the fact that that most people pay their taxes on time in reminder letters has led to marked reductions in late payments and saved millions of pounds. When people were offered loft clearance schemes at cost price, there was a fivefold increase in loft insulation. Taking any “friction” out of the equation is often more important than cost per se.
‘Supermarkets and loyalty card schemes are perfectly positioned to offer insights and could prompt consumers to make healthier choices’
We can, and should, use similar approaches in health, starting with some of the easy wins in healthcare itself. Research from the US shows substantial increases in the uptake of cancer screening and vaccinations, by between 5 and 20 per cent, by including simple prompts to plan when and how these treatments will happen. Missed appointments can be reduced by almost a third by getting people to write down their own appointment times and reminding patients that “most people let us know if they can’t make it”.
We’re also fairly confident that clinical errors can be dramatically reduced with the use of simple checklists and changing the format of patient charts in hospitals to decrease misunderstandings.
Even bigger wins are likely from applying behavioural insights to the more fundamental drivers of ill health. When it comes to diet, consumers rarely add up calories, salt intake or systematically check food labels. Supermarkets and loyalty card schemes are perfectly positioned to offer these insights and could prompt consumers to make healthier choices (indeed, one Finnish grocery chain, Kesko, already does this).
New types of data flows, habit reprogramming, and online-based commitment contracts − “if I don’t lose weight or exercise more, I’ll make a donation to my arch-rival football team” − are creating a suite of lifestyle change programmes that are offering better results than the current best treatments for conditions such as diabetes and pre-diabetes.
Perhaps most intriguingly of all is the emergence of approaches to harness and foster the “hidden wealth” of our communities − the social networks around and between patients. Patient hotels, where relatives can share a room with the patient, achieve better clinical outcomes, higher satisfaction and lower costs.
Similarly, by encouraging and supporting expert patient groups to have appointments with groups of patients and their relatives rather than individually (if they wish), outcomes are improved, costs are reduced and mutual support is harnessed.
The Behavioural Insights Team is currently working with the Department of Health and the new Public Health England to develop policy ideas that are firmly rooted in the science of how people behave. It’s an area of great promise and real excitement − I wonder how many other examples there are out there?
Time to Think Differently is a new programme of work from the King’s Fund aimed at stimulating debate about the changes needed for the NHS and social care to meet the challenges of the future. By engaging others and promoting discussion, it hopes to generate new thinking about innovative ways of delivering high quality care and support health and social care leaders in their decision making. Join the debate.
David Halpern is director of the Behavioural Insights Team, Number 10 and the Cabinet Office