Changing Behaviours In Public Health - Local Government Association

To nudge or to shove?Health, adult social care and ageingChanging behavioursin public health

IntroductionThis briefing for councillors and officers explains how behavioural changeinterventions – or nudge theory as it is dubbed – can help local authorities fulfiltheir public health responsibilities.Prevention, it is often said, is better thancure. If people didn’t smoke, drank less, hadbetter diets and exercised more, the burdenof disease would be reduced. But what is therole of the state in persuading people to altertheir lifestyles?The traditional approach dictates that incases where something causes seriousharm, such as drug use, restricting choiceor even an outright ban is appropriate.However, where it is less clear cut, theargument goes, the state should leave it toindividual choice.But this ignores the fact that there is avariety of ways in between that behaviourcan be influenced from encouraging andincentivising people through to subtly guidingchoice in a certain direction.This can include enticing people to takeup activities or using subliminal marketing.For example, stressing social norms canencourage people to change behaviourbecause they want to be alike. Alternativelyit can involve making an environment lessconducive to someone making an unhealthychoice. An example of this would be makingsalad a default option as a side instead ofchips or placing clear signs to steps ratherthan escalators.This is known as behavioural change andthere has been growing interest in the issueamong policy-makers across the world - andnot just solely in terms of health. The choices2people make can have a profound impact ina host of other areas from education to crimeas well.Much of the debate stems from the 2008book ‘Nudge: Improving Decision aboutHealth, Wealth and Happiness,’ which waswritten by US academics Richard Thaler andCass Sunstein.Their theory is that libertarianism andpaternalism do not have to conflict and thatthe state can – and should – act as a guidinghand, “nudging” citizens in the right direction.But the term nudge probably does not dojustice to the full range of interventions thatcan influence behaviour.The spectrum has been set by the NuffieldCouncil on Bioethics in its “ladder ofintervention”. See page 3The fact there is such a wide range ofapproaches is reflected by the other termsthat have started being used to describeinterventions other than nudges.Techniques like direct incentives, such asvouchers in return for healthy behaviour,are being labelled hugs, while the toughermeasures that restrict choice, like restrictingtakeaways from schools, are shoves. Bans,such as the restriction on smoking in publicplaces, are simply known as smacks.Changing behaviours in public health – to nudge or to shove?

Nuffield Council on Bioethics ladder of interventionExamples of intervention techniquesSmacksEliminating choice – Banning goods or services such as the restriction on smoking inpublic placesShovesFinancial disincentives – Taxation on cigarettesRestricting choice – Banning takeaways setting up close to schoolsNudgesProvision of information – Calorie counts on menusChanges to environment – Designing buildings with fewer liftsChanges to default – Making salad the default side option instead of chipsUse of norms – Providing information about what others are doingHugsFinancial incentives – Vouchers in exchange for healthy behaviourChanging behaviours in public health – to nudge or to shove?3

Local governmentand public healthResponsibility for public health transferredfrom the NHS to local authorities in April2013 under the wider shake-up of thehealth service.It means upper tier and unitary authoritieshave become responsible for improving thehealth of their population.This is backed by a ring-fenced public heathgrant and a specialist public health team, ledby the director of public health.Each top tier and unitary authority has ahealth and wellbeing board (HWB) whichhas strategic influence over commissioningdecisions across health, social care andpublic health.Statutory board members include alocally elected councillor, a Healthwatchrepresentative, a representative of a clinicalcommissioning group, a director of adultsocial care, a director of children’s servicesand a director of public health.Needs Assessment (JSNA) and a JointHealth and Wellbeing Strategy (JHWS).Local authorities will also have a statutoryfunction to provide public health advice toclinical commissioning groups, while HWBswill have to monitor performance.In terms of behavioural change, it could besaid local authorities have two roles: taking astrategic lead for their area, such as settingpolicy and evaluating schemes, as well asplaying a part in organising the interventionsalong with other partners from the private,public and voluntary sectors.To help support them and other organisationinterested in behavioural change, PublicHealth England has a behavioural insightsteam, which can lend advice and expertise.Other organisations can offer help too, suchas Sustrans which has a strong track recordin using behavioural change to get peoplewalking and cycling.HWB members from across localgovernment and the health and caresystem work together to identify localneeds, improve the health and wellbeingof their local population and reduce healthinequalities.The HWB is a key forum for encouragingcommissioners from the NHS, councils andwider partners to work in a more joined upway. Central to achieving this is the HWB’sresponsibility for producing a Joint Strategic4Changing behaviours in public health – to nudge or to shove?

Policy contextThe current government has made exploringthe potential of behavioural change a priority.In fact, the coalition agreement itself madedirect reference to the issue, stating thatthe government would be “harnessing theinsights from behavioural economics andsocial psychology”.In July 2010 a Behavioural Insights Team– or “nudge unit” as it has become known –was set up within the Cabinet Office.It was initially funded for two years, but thegovernment was so impressed with theresults it has since been given funding foranother two years and its work has beenexported to Australia. And now, to secureits future, it is in the process of becominga mutual.differentiated between the two extremes of“intrusive intervention” and being “completelyhands-off”. It then went on to highlight theNuffield ladder of intervention.But it is also clear that the governmentis not afraid to consider more draconianapproaches as shown by the fact thatconsultations were carried out on plainpackaging for cigarettes (a shove) andminimum pricing for alcohol (a smack).However, neither policy has subsequentlybeen introduced.The unit has overseen a number ofdedicated projects across the public sector.These have included a trial with HMRCwhich encourages people to pay tax bytelling late payers most people in their townhave already paid up. Another has involvedgetting the DVLA to ask people whether theywanted to be an organ donor when theyapply for a new or replacement licence.But the influence of the team stretchesfurther than that – as there are signs it hasseeped into individual departmental thinking.The Department of Health’s public healthwhite paper, Healthy Lives, Healthy People,published in November 2010, made it clearthere needed to be a new approach thatChanging behaviours in public health – to nudge or to shove?5

Does it work?It is clear nudging works. After all, visualprompts are regularly used by supermarketsand the food industry to encourage shoppersto buy their products.But the question of how effective it canbe in encouraging good behaviour is stillemerging. The Institute of Government’s2010 report, Mindspace, which wascommissioned by the government, said itcould be a “powerful tool”. However, it isfair to say research into the effectiveness ofbehavioural change in terms of public policyis still in its early days.An internal review by the BehaviouralInsights Team concluded it had identifiedspecific interventions which would saveat least 300m over the next five years.This included the pilot targeting late taxpayers which increased payment rates by15 per cent as well as a trial with the courtsservices which showed personalised textmessages were six times more effectivethan final warning letters at prompting thepayment of fines.Success has been seen elsewhere in theworld too. For example, donor registrationjumped from 38 per cent to 60 per cent inthe US state of Ilinois when drivers applyingfor new or replacement licences were askedif they wanted to go on the register.Meanwhile, in Denmark policy makershave been so impressed with the results ofschemes they have tried that a dedicated6Nudging Network to coordinate efforts toinfluence behavioural change has beenset up.But with much of the evidence basecompiled from small scale studies, someexperts have questioned whether nudgecan be used on a larger scale and if theimprovements are sustained in thelong-term.Others have even suggested the approachcould be ethically wrong as it could beargued behavioural change is a form ofcovert coercion.Evidence presented to the House of LordsScience and Technology Committeealso raised this issue. But its final report,published in 2011 after a year-longinquiry, concluded behavioural changetechniques had a role to play. In particular,of local authorities, it said they were the“most qualified to assess the need forand implement interventions”. It was alsosuggested that councils could play a keyrole in developing an evidence base forbehavioural change by evaluating their localschemes. However, the committee also hada warning. It said nudging was only part ofthe solution as on its own it was “unlikely”to be successful. The solution, accordingto MPs, lay in combining it with othermeasures, some of them regulatory.Changing behaviours in public health – to nudge or to shove?

How can councils make useof nudging and shoving?Ensure the strategy and interventions meet local needs, identified through theJSNAs and other local data.Consider naming a strategic local authority lead – member or officer to addressbehavioural change.Ensure the content, scale and intensity of each intervention is proportionate.Ensure behaviour-change interventions aim to both initiate and maintain anychange. They should also include strategies to address relapse and recognise thatthis is common.Base interventions on a proper assessment of the target group, where they arelocated and the behaviour which is to be changed.Ensure time and funds are allocated for independent evaluation of the short-,medium- and long-term outcomes of any behaviour-change service.Take account of – and resolve – problems that prevent people from changing theirbehaviour. For example, the costs involved in taking part in exercise programmes.Train staff to help people change their behaviour.Consider how interventions should be complemented by other measures, includingregulation.Harness the power of the community - some areas have appointed championsamong their local population.Changing behaviours in public health – to nudge or to shove?7