Patients who fail to turn up for NHS appointments are a major drain on resources costing the health service between seven and eight hundred million pounds a year. In recent research, Influence at Work / BDO deployed three behavioural techniques aimed at reducing DNAs (Did Not Attends). The results were dramatic, with a 30% reduction in DNAs in the sample area.
No-shows aren't just a problem to the NHS. Witnesses fail to show up in court. Offenders fail to attend community service obligations.
No-shows are just one example of a wide array of public sector challenges. We want citizens to lead healthier lives, pay their taxes on time, support their community, reduce energy consumption, recycle more, be law-abiding. To be effective policies need to take account of how people behave.
Professor Robert Cialdini, Regents' Professor Emeritus of Psychology and Marketing at Arizona State University & author of the international bestseller Yes! 50 Secrets from the Science of Persuasion, along with a panel of experts spoke at the Institute about the potential for delivering better results through MINDSPACE.
- Professor Robert Cialdini, Emeritus Professor, Arizona State University, Influence at Work
- Ravi Gurumurthy, Director of Strategy, Department of Energy and Climate Change
- Professor Paul Dolan, LSE
- Clive Bates, Director General, Sustainable Futures, Welsh Government
- Danny Finkelstein, The Times
How can the techniques set out in the Institute for Government and Cabinet Office’s MINDSPACE report improve public policy outcomes? That was the starter for ten for the panellists at our question forum.
Professor Robert Cialdini opened with the example of using Commitment devices to reduce the number of patients who do not show up for GP appointments. Simple techniques like making people repeat back the appointment and commit to cancelling, or getting them rather than the receptionist to write down the time and date of their next appointment, cut no-shows. A further experiment used Norms by changing posters in surgeries from emphasising how many people failed to show up to emphasising the very high rate of attendance. These interventions had shown reductions of up to 30% in no-shows at no cost.
Ravi Gurumurthy outlined some of the measures DECC were taking to increase energy efficiency by looking at new Incentives. Under the Green Deal individuals were spared the upfront costs of making energy efficiency investments and able to set the cost off against future energy bills. Other moves were experimenting with different forms of rewards – council tax holidays and community rewards to increase Salience and to use Affect by making people feel part of a group activity rather than simply making decisions as individuals.
Professor Paul Dolan talked about Incentives. He noted that the only effective cash for weight loss programmes were ones that had penalties as well as bonuses – noting the powerful effect of loss aversion meaning that losing £10 was more powerful than gaining £10. It was also important to understand the way in which positive first round impacts could be undermined by compensatory behaviour. In another experiment, people had been incentivised on a stepping machine. Those incentivised did 100/steps vs 60 for the control group with no incentives. But then, over a calorie labelled lunch, the virtuous steppers averaged 100 calories more than the controls – vastly outweighing the benefit for their superior stepping performance. It was important to trial interventions – and to capture any unintended consequences.
Clive Bates said the Welsh Government was changing the Defaults on organ donation – from opt-in to opt-out. But because of people’s concerns about the state effectively claiming ownership of their organs this would be backed up with a veto role for relatives at point of donation. The smoking ban was an example where the formal policy rationale – protecting workers from second hand smoke – was less important than the establishment of a social Norm around the unacceptability of smoking.
Danny Finkelstein said he found Professor Cialdini’s insights on loss aversion crucial to understanding public scepticism on Opposition policy – why Oppositions had to offer twice the benefit from their proposed changes to policy. One insight was that people who went through the most humiliating initiation rituals stayed longest in fraternities in the US – the Coalition could learn from that – and from Mrs Thatcher – that pain could increase public Commitment to reducing the deficit.
Key points from the question forum:
- There were multiple potential change agents using these techniques – not just central government – examples given were European recycling activities, private sector initiatives etc.
- Behavioural techniques were a complement to other policies – to improve their effectiveness – not a substitute; in some cases behaviour change might make only small contribution to realising the policy goal. There was a real need for experimentation and willingness to learn from- and publicise- failures; psychologists had in the past been too unwilling to allow extrapolation from their results; economics had the virtue of offering predictability;
- It was important to think about behavioural effects for providers as well as customers - initiatives such as league tables played powerfully to the Ego of professionals; Incentives were important eg for people working in Jobcentres;
- Business was not always a pure rational economic actor either – the Carbon Reduction commitment was designed to increase the Salience of energy bills in corporate discussion;
- This was not a new area – but there was increasing interest as governments faced pressure on spending and regulation and needed to find more cost effective ways of achieving outcomes.