What behavioural economics has to offer to the NHS

This article was first published in Open Access Government

Behavioural economics says that we don’t always make healthy food choices, we forget to strictly abide by medication and rehabilitation protocols, and we procrastinate about doing exercise even though we know it’s good for us.

Traditional economic theory in contrast assumes that we have the capacity to understand large amounts of information and make rational choices which are always in our best interest.

The NHS has been using this traditional economic theory as an organising principle in recent decades through the establishment of a quasi-market, and an underlying assumption that patients are able to make sound, fully informed decisions about their care.

However, behavioural economics more closely resembles reality and therefore offers us the opportunity for more accurate and effective health and care interventions.

Despite the potential benefits, there has been limited application of behavioural economics within healthcare policy design and implementation. There have been individual examples for solving specific demand challenges such as sending letters to GPs who were prescribing more than their peers, and cutting unnecessary prescriptions by 3%, but it has not been applied to a set of policy design principles that would allow the benefits to become part of the system.

Instead, there has been a philosophy of streamlined efficiency over investment in personalisation.

What do we mean by behavioural economics in healthcare?

Some of the key theories of behavioural economics include:

• Bounded rationality: people don’t have endless time and cognitive ability to sort through all available information to make evidence-based decisions that are in their best interest.
• Loss aversion: people are more motivated by fear and loss than they are by potential gains.
• Nudge: people should be given choices, but within fixed parameters or guided by experts.

These principles have a direct application to population health management within the NHS. For example, a patient’s doctor may recommend that they lose weight because it can lead to ill health in the future. The gain is good health, the loss is the food the patient enjoys. The loss is immediate, but the future gain is less tangible and uncertain. The loss trumps the gain, and the behaviour does not change.

What can the NHS do differently to tap into the potential of behavioural economics?

Much of the current research on this isn’t enormously helpful. The most researched applications of behavioural economics are in overseas healthcare markets and involve mechanisms such as financial incentives which aren’t appropriate to the NHS context, or basic nudges that have already been adopted such as appointment and screening reminders.

The most useful way to leverage tools like behavioural economics for the benefit of population health management is by using the key theories as design principles in the development of new care models and clinical interventions.

We’ve created a checklist to help make this easier:

Give people insight

Bounded rationality suggests people don’t have infinite time and ability to research their own health. We need filtered insight to help us make decisions that are in our best interest. The NHS needs to use data and information to create health insights that are specific, personalised, and easy to access and act upon. For example, the NHS app – which many of us have become accustomed to using because it provides our proof of vaccination – could have a landing page with links for booking screening appointments relevant to our personal risk profile (based on age and other demographic information).

Get creative with gamification

Gamification uses game features, like points and levels, in nongame contexts to motivate people to exhibit desired behaviours. Gamification interventions that leverage social incentives by providing peer support, accountability, and even competition support mental health and promote healthy behaviours. Using technology like apps, phone notifications and Fitbits is one of the easiest ways to use gamification to promote healthy behaviours.

Make losses and gains feel more immediate

The nature of personal health is such that actions and reactions are rarely immediate, or even known and fully understood by an individual. The NHS could benefit from making losses and gains feel more obvious and immediate. Sending people a screening letter with a pamphlet about cancer doesn’t necessarily engage people’s sense of loss and gain in the immediate term. If that letter had personalised insight like cancer prevalence and/or survival rate statistics related to screening in that person’s age group, the potential ‘loss’ or ‘gain’ feels a lot closer to home.

Give people less choice, not more

This may sound counterintuitive but having to make too many decisions can lead to decision fatigue. Patient choice is of course important and should remain, but we can do some of the hard work for them. However, that mostly relates to choices once people are within the healthcare system. One of the biggest challenges in population health management is patient engagement and activation (people accessing the right services in the first place).

Taking the decision for people to engage out of their hands could be very beneficial. For example, rather than relying on people to book an appointment/ vaccination/ screening etc, you take away the active choice they would otherwise need to make by coming to them through pop-up clinics, vaccination buses, workplace visits etc. This removes the need for someone to make a proactive decision. This was used to great success in the UK COVID-19 vaccination programme where people were sent an SMS when it was their turn to get vaccinated and all they had to do was click on a link and pick a time that suited them.

Connect health messages more explicitly with experts

We also saw expert ‘nudges’ employed effectively as a tool during the pandemic. For example, Professor Sir Jonathan Van Tam was often used to disseminate key messages in a straightforward manner to directly appeal to people and the decisions they were making.

Local NHS leaders need to think about how to translate this into place-based population health management. In designing new care models, they should think about how every step of the patient journey, including all communications, can be made to feel like personalised messages from experts or trusted community leaders to guide decision-making.

This was used during the pandemic when religious leaders and BAME community leaders were integral to local vaccination campaigns. The NHS has a strong track record in community consultation, but there is more that could be done to use local community leaders and trusted experts to disseminate health promotion material and prevention initiatives. For example, if there was an app where patients were accessing personalised healthcare advice, this advice should be clearly coming from a personalised, trusted source.

Behavioural economics has the potential to transform the health of the population and the subsequent demands placed on the NHS. Designing policy that allows the benefits to become systemic will help the NHS manage population health and improve outcomes. It’s a simple switch to design around ‘real life’ human behaviours.