nhs wales: applying behavioural insights wa… · our responses to incentives are shaped by...

NHS Wales: Applying behavioural insights

Luke Ravenscroft and Veerle Snijders

Aims for the workshop

Answer 3 questions:

1. What are the main principles from behavioural science?

2. How can you apply these principles in practice?

3. How do we test whether the changes had an impact?

Plan for the day

09.30 Aim and background10.00 Introduction to behavioural insights

- MINDSPACE- Group discussions

Lunch - 12.30 (will also have a coffee break)

13.30 Applying behavioural insights: - Organ donation and reducing missed appointments- Letter exercise: worked examples- Obesity

15.00 Break

15.15 Running a trial- TEST framework- Evaluation

16.30 Question and close

About the team

“David Cameron’s Vanity Project”

There was a lot of skepticism

Press coverage

Academic Advisory Panel

Richard Thaler Chicago Booth

Business School

Nick Chater Warwick Business

School

Theresa MarteauUniversity of Cambridge

Gus O’DonnellFormer Cabinet

Secretary

Dan GoldsteinLondon Business

School

Maurice BiriottiSHM

Peter JohnUCL

What are behavioural insights?

Most policy concerns behaviour

Addressing behavioural drivers is extremely important for improving health

Institute for Health Metrics and Evaluation (2013) The State of UK Health

Traditional policy levers

Regulation

Incentives

Information

Behavioural Insights

Criminal sanctions

Financial penalties

Communication

We ran a trial on the ‘Tax Return Initiative’ with HM Revenue & Customs

Direct to form

Webpage

Dr R Arnott2 Marsham StLondon SW1P 4DF

Robert,You really need to open this

Reanalysis of HMRC Trials:Self Assessment Tax

29% 33% 35%

19% 22%28%

Link to the campaign webpage in brown envelope

Direct to form in brownenvelope

Direct to form in whiteenvelope with hand written

message

Response Rate File rate

Lessons drawn from a variety of disciplines

Psychology

Ethnography

Economics

Public Policy

Understanding how people behave in practice so that we can design policy better

Behavioural insights in everyday life

We are not hyper-rational supercomputers with infinite time:• we rely on ‘automatic thinking’

• we have limited attention so use shortcuts

• we change our behaviour depending on the context

Automatic thinking: Two systems

SLOW•Effortful•Needs attention•Controllable •Analytic

FAST•Automatic•Little or no effort •No sense of control•Intuitive

System 1 System 2

SLOW• 17 x 13• Planning a trip abroad

FAST• 2 x 2• Taking your daily commute

System 1 System 2

A bat and ball cost a £1.10. The bat costs £1 more than the ball. How much does the ball cost?

A. 1pB. 10pC. 5p

A bat and ball cost a £1.10. The bat costs $1 more than the ball. How much does the ball cost?

We see £1.10 We see £0.10

System 1 is in control

BUT…..If ball costs £0.10, therefore bat must cost £1.10 – and £1.10 + £0.10 = $1.20

Mental short cuts; limited attention

We use shortcuts to make sense of the world

Upside: saves time and energy Downside: sometimes creates problems

We use shortcuts to make sense of the world

Shortcuts used by system 1

Upside: saves time and energy Downside: sometimes creates problems

Danziger et al. 2010????

Context matters

You go out to buy a belt. You find one for £12.

Someone tells you that can save £5 if you walk five minutes down the road to another shop. Do you walk five minutes to save the money?

A. YesB. No

Context matters

You go out to buy a TV. You find one for £220.

Someone tells you that can save £5 if you walk five minutes down the road to another shop. Do you walk five minutes to save the money?

A. YesB. No

Context matters

Hawton, et al. (2013) Long term effect of reduced pack sizes of paracetamol. British Medical Journal.

Changing packaging led to fewer deaths

But do people just compensate elsewhere?

Kreitman (1976). The coal gas story. UK suicide rates, 1960-71. Journal of Preventative medicine.

Context matters

60%47%

Glass cage Open dock Bar table

% found guilty• Gender of lawyer?• Race of the

defendant?• Time of day?

MINDSPACE: a framework for applying behavioural insights

What does MINDSPACE try to do?

• Using BI in policy

• Practical applications

• Memorable checklist (mnemonic)

Messenger We are heavily influenced by who communicates information

IncentivesOur responses to incentives are shaped by predictable mental shortcuts such as strongly avoiding losses

Norms We are strongly influenced by what others do

Defaults We ‘go with the flow’ of pre-set options

Salience Our attention is drawn to what is novel and seems relevant to us

Priming Our acts are often influenced by sub-conscious cues

Affect Our emotional associations can powerfully shape our actions

Commitment We seek to be consistent with our promises, and reciprocate acts

Ego We act in ways that make us feel better about ourselves

MINDSPACE

CabinetOfficeBehavioural Insights Team

Perceived authority(formal or informal)

Expertise, trust and liking

Peer effects, someone like me

Can we get bank employees to give away one days pay?

Proportion giving away a day’s salary to charity

5% 7%11% 12%

Control Group Celebrity Sweets Personal email Sweets +Personal

Our trial raised £500,000 in one day.

Increasing payroll giving inside government

The image of a colleague more than doubled the number of people who signed up

Control Group Image

Loss aversion

We discount the future

We overweight small probabilities e.g. lotteries

Possibility of losing an 8% payment motivated teachers more than gaining 8%

Fryer et al. (2012) Enhancing the effectiveness of teacher incentives through loss aversion: A field experiment. NBER Working Paper no. 18237.

We ran a lottery for voter registration

YOU AND YOUR HOUSEHOLD COULD WIN £5,000 IF THIS FORM IS RETURNED BEFORE 28 SEPTEMBER 2012

The lottery was highly cost-effective (and the size of the prize didn’t matter much)

© Behavioural Insights ltdFogarty A.W., Sturrock N., Premji K., Prinsloo P. (2013). Hospital clinicians’ responsiveness to assay cost feedback: a prospective blinded controlled intervention study. JAMA Internal Medicine,173(17).

Total number of tests ordered reduced by 32% post implementation

If scaled this could lead to £3m cash savings to the NHS per year

Randomized Trial of Four Financial-Incentive Programs for Smoking Cessation, Halpern et al. (2015)

Discussion

● Discussion on your tables for 5-10 minutes

● One example of where you have seen these used in practice or could see these used in the future

○ Messenger effects

○ Incentives (non-financial or non-standard)

CabinetOfficeBehavioural Insights TeamIf most people do the

right thing, let people know

Personalise the norm

Beware of boomerangs

Nine out of ten people pay their tax on time.

• With HMRC, our tax trials brought forward £200million in 12 months.

Nine out of ten people pay their tax on time.

Social norms to increase tax payment rates within 23 days

33.6% 35.1% 35.9% 37.2% 39.0%

Control (8,558) UK Norm(8,300)

Local Norm(8,403)

Debt Norm(8,779)

Local + DebtNorm (8,643)

“Por favor presente su declaración del impuesto sobre la renta”

“Si usted no declara, puede ser auditado y ser sujeto al procedimiento establecido por ley.”

Standard letter – interestingly, it did not tell you how to file your taxes!

“Please file your declaration of income tax.”“If you do not declare, you may be audited and could face the procedure established by law.”

“According to our records, 64.5% of Guatemalans declared their income tax for the year 2013 on time. You are part of the minority of Guatemalans who are yet to declare for this tax”

“Previously we have considered your failure to declare an oversight. However, if you don’t declare now we will consider it an active choice and you may therefore be audited and could face the procedure established by law.”

“You are a Guatemalan citizen and Guatemala needs you. Be a good citizen and submit the 2013 annual return of Income Tax. […] Are you going to support your country?”

Control

Incentives

Affect / Ego

“According to our records, 64.5% of Guatemalans declared their income tax for the year 2013 on time. You are part of the minority of Guatemalans who are yet to declare for this tax”

“Previously we have considered your failure to declare an oversight. However, if you don’t declare now we will consider it an active choice and you may therefore be audited and could face the procedure established by law.”

“You are a Guatemalan citizen and Guatemala needs you. Be a good citizen and submit the 2013 annual return of Income Tax. […] Are you going to support your country?”

BIT and the World Bank: Tax Compliance in Latin America

18.4%20.3% 20.0%

22.7%21.1%

17.3% 18.3% 18.3% 18.9%16.5%

Control(no letter)

GuatemalanTax

AuthorityLetter

BehaviouralLetter

BehaviouralLetter +National

BehaviouralLetter +

DeliberateChoice

BehaviouralLetter +SocialNorms

People take the easiest option

Even important decisions are

procrastinated

Prompted choice

Changing the pensions default has meant 400,000 more people now have a pension

Opt-in Opt-out

Changing the default application form helped disadvantaged children go to university

Source: Bettinger et al, 2011

Discussion

● Discussion on your table for 5-10 minutes

● Again, any examples of where you have seen these used in practice or could see these used in the future

○ Norming

○ Defaults

We learn to block out the irrelevant

Keep things simple

Personalisation

Robert,You really need to open this

Eyewitness testimony

Can you see a suspect?

False Identifications without suspect in line-up

Simultaneous + Warning + Suspect Sequential + Warning + Suspect

(Steblay et al., 2001)

Imperial College worked to simplify hospital prescription charts

King et al. (2014) Redesigning the ‘choice architecture’ of hospital prescription charts.BMJ Open.

The revised chart reduced prescribing errors

Priming can take all sorted of forms

Words, sights & smells influence our behaviour

Size of plates and portion size effects how much we eat

Priming honesty

$97 difference in insurance premiums

Miles declared

Anchoring effects

Low anchor: “Do you think that the sentence will be

higher or lower than 1 year?”

High anchor: “Do you think that the sentence will be

higher or lower than 3 years?”

Source: Playing Dice With Criminal Sentences: The Influence of Irrelevant Anchors on Experts’ Judicial Decision Making

High anchor: 8 months extra prison time

‘Bad’ behaviours can prime others

No Graffiti Graffiti

Littering Encouraged by Graffiti

Discussion

○ Salience

○ Priming

Emotional responses are fast and automatic

Moods can be more important than

deliberation

“Hot” and “cold” states

Letters to persistent non-payers of road tax

UNTAXED VEHICLE WARNING

Our latest information shows you have not taxed your vehicle.

PAY YOUR TAX OR LOSE YOUR [MAKE OF CAR]

You have been caught driving your [make of car] untaxed.

Image captured on traffic camera of untaxed car stapled on the front of the letter

Original New New + image

% Relicensing rates of persistent offenders to DVLA letters

40.4% 42.4%48.8%

Original New New + image

Increasing legacy giving

Control Just Ask Passion Ask

Commitment devices –make public and write down

People can actively choose to constrain their

future self

Importance of reciprocity

(Scott Barbour/Getty Images)

All primary schools in Dumfries and Galloway have implemented a pre-ordering system.

Pre-ordering in schools

Pre-ordering No pre-ordering

Percentage of students who choose healthy lunch

Hanks, Andrew S., David R. Just, and Brian Wansink. "Preordering school lunch encourages better food choices by children." JAMA pediatrics 167, no. 7 (2013): 673-674.http://archpedi.jamanetwork.com/article.aspx?articleid=1682338

Commitments can help us achieve goals

Williams, Bezner, Chesbro, Leavitt (2005)

Contract No Contract

Attribution error – also applies to groups/teams

We overestimate our own abilities

We think of ourselves as consistent

Our HM Revenue & Customs trial on Doctors and Dentists

1: The filing deadline for online tax returns is 31 January

If your tax return is not filed by this deadline you will have to pay a £100 late filing penalty

2: The purpose of this letter is to remind you about the Tax Health Plan campaign

Last year HMRC offered a voluntary disclosure opportunity to all GMC registered doctors.....

3: This is your final opportunity to contact us to ensure your tax affairs are up to date.

Your failure to contact us in the past may have been an oversight. However, if you do not respond to this letter, we will treat it as an active choice.

4: Same as 3, but includes this phrase at the top:

9 out of 10 people surveyed by Ipsos MORI in 2011 said that they trust their doctor to tell the truth.

Doctors & Dentists’ response rate to different trial arms

35% 35%

Generic Letter Traditional StyleMedics

Simplified (WeKnow + Oversight)

Simplified + IpsosMori data

Appealing to professional identity to increase hand washing

Grant and Hofmann (2011) It’s Not All About Me: Motivating Hand Hygiene Among Health Care Professionals by Focusing on Patients.Psychological Science, 22 (12), 1494-1499.

"Handwashing prevents you fromcatching diseases"

"Handwashing prevents patients fromcatching diseases"

Discussion

○ Affect

○ Commitment

○ Ego

Messenger We are heavily influenced by who communicates information

IncentivesOur responses to incentives are shaped by predictable mental shortcuts such as strongly avoiding losses

Norms We are strongly influenced by what others do

Defaults We ‘go with the flow’ of pre-set options

Salience Our attention is drawn to what is novel and seems relevant to us

Priming Our acts are often influenced by sub-conscious cues

Affect Our emotional associations can powerfully shape our actions

CommitmentWe seek to be consistent with our public promises, and reciprocate acts

Ego We act in ways that make us feel better about ourselves

MINDSPACE

Plan for the day

09.30 Aim and background10.00 Introduction to behavioural insights

- MINDSPACE- Group discussions

Lunch - 12.30 (will also have a coffee break)

13.30 Applying behavioural insights: - Organ donation and reducing missed appointments- Letter exercise: worked examples- Obesity

15.00 Break

15.15 Running a trial- TEST framework- Evaluation

16.30 Question and close

Applying behavioural insights in practice

Behavioural insights adds another dimension

1. Regulation

1. Incentives

1. Information

Not just ‘nudges’....two different ways of applying behavioural insights

High-level policy(goals, rules, structures, funding, “terms of the debate”)

Opportunistic delivery(timing, wording, design, friction costs, trial and error)

ge“S

Organ donation

Increasing organ donation registrations

Source: NHSBT

What levers can you use to encourage organ donation?

1. Three die every day… 2. You can save nine lives…

3. If you needed transplant… 4. If you support donation…

Proportion joining the organ donor register after a simple online prompt

2.3%3.1% 2.9% 3.2%

Control 1. Three die 2. You cansave

3. If youneeded

4. If yousupport

Our organ donation trial added 100,000 organ donor registrations in a year.

Smoking in pregnancy: we don’t always know what will work

Reducing missed hospital outpatient appointments

Trial partners

Michael Hallsworth, Dan Berry, Michael Sanders, Anna Sallis, Dominic King, Ivo Vlaev, AraDarzi (2014) Stating appointment costs in SMS reminders reduces missed hospitalappointments: Findings from two randomised controlled trials. Under review at PLOS One

Trial 1 Messages

Name Message

ControlAppt at [hospital] on [Sep 16] at [10:00am]. To cancel or rearrange call the number on your appointment letter.

Number Appt at [hospital] on [Sep 16] at [10:00am]. To cancel or rearrange call 02077673200.

Norm We are expecting you at [hospital] on [Sep 16] at [10:00am]. 9 out of 10 people attend. Please call 02077673200 if you need to cancel or rearrange.

Costs We are expecting you at [hospital] on [Sep 16] at [10:00am]. Not attending costs NHS £160 approx. Call 02077673200 if you need to cancel or rearrange.

The best performing message reduced missed appointments by 25%

11.1%9.8% 10.0%

Control Number Norms Costs

Total n = 10,111 * p < 0.05, ** p < 0.01

% of appointments recorded as missed

•This result would lead to 5,800 fewer missed appointments if applied over one year in same location

406,740 fewer if applied in England

Benefits x5 with full mobile coverage

Trial 2 Messages: Best-performing message now the default

Name Message

Costs specific

We are expecting you at [hospital] on [Sep 16] at [10:00am]. Not attending costs NHS £160 approx. Call 02077673200 if you need to cancel or rearrange.

Costs general

We are expecting you at [hospital] on [Sep 16] at [10:00am]. Not attending wastes NHS money. Call 02077673200 if you need to cancel or rearrange.

FairnessWe are expecting you at [hospital] on [Sep 16] at [10:00am]. Please be fair to others waiting and call 02077673200 if you need to cancel or rearrange.

Recording We are expecting you at [hospital] on [date] at [time]. Please attend or call 02077673200 to cancel/rearrange, or we will record as a missed appt.

Specific costs work better than general costs

11.7% 10.6% 9.6% 9.8% 8.2%

Control (fromprevious trial)

Fairness Recording General costs Specific costs

% of appointments recorded as missed

Specific costs (“£160”) are more effective

Total n = 9,862 * p < 0.05, ** p < 0.01

Finally… reciprocity matters: if hospital cancels on you, you are more likely to not attend later

65.7% 72.5%

Last Session Cancelled Last Session Not Cancelled

Letter exercise

Applying behavioural insights in practice

Behavioural insights adds another dimension

• Regulation

• Incentives

• Information

High-level policy(goals, rules, structures, funding, “terms of the debate”)

Opportunistic delivery(timing, wording, design, friction costs, trial and error)

ge“S

High-level policy: Obesity

We need a new policy narrative for obesity.

• Consuming food is often a “mindless” response to our environment.

• The past thirty years have seen a massive increase in the supply of calories and our exposure to these calories.

• Physical activity brings a variety of health benefits. However, it is mainly an increase in calorie intake, not a decline in physical activity levels, that has caused the obesity problem. Increasing activity alone is unlikely to be the solution.

Mindless eating: Visibility and proximity of food

4.65.6

Close and Visible Close and not-visible

Far and visible Far and not visible

Actual Number of Sweets Consumed

Estimated Number of Sweets Consumed

Wansink, B., Painter, J. E., & Lee, Y. K. (2006). The office candy dish: proximity's influence on estimated and actual consumption. International Journal of Obesity, 30(5), 871-875.

Food that is closer and more visible to us is more likely to be eaten.

Mindless eating: We underestimate the calories in a “healthy” meal

8701085 1170

Actual calories Perceived calories Actual calories Perceived calories

Adapted from Chandon, P. (2013). How package design and packaged-based marketing claims lead to overeating. Applied Economic Perspectives and Policy, 35(1), 7-31.

“Unhealthy” meal “Healthy” meal

+ 25% -33%

Portion sizes have increased greatly in the last 30 years.

Levitsky, D. A., & Pacanowski, C. R. (2011). Free will and the obesity epidemic. Public Health Nutrition, 15(1), 126

Calorie supply: Portion sizes

Physical activity: Levels are not correlated with obesity for children

Source: PHE KIT Team – Public Health Outcomes Framework, ONS

Health Survey for England 2012

Physical activity: Levels have remained relatively static over time

Talbot, L. A., Fleg, J. L., & Metter, E. J. (2003). Secular trends in leisure-time physical activity in men and women across four decades. Preventive medicine,37(1), 52-60.

Physical activity: In contrast, energy intake appears to be correlated with obesity levels

Levitsky, D. A., & Pacanowski, C. R. (2011). Free will and the obesity epidemic. Public Health Nutrition, 15(1), 126

The need for a new policy narrative

• People tend to think they have more control over their eating than they do.

• This leads to unsuccessful attempts to control eating based on willpower.

• People can take responsibility, but only if they understand the habitual, contextual, automatic nature of eating.

Ideas to reduce obesity

1. Pre-ordering in schools

2. Labelling

3. Fast-food Exclusion Zones

4. SSB tax, Sugar tax

1. Pre-ordering in schools: Theoretical basis

• People are more willing to commit to virtuous behaviour if it occurs in the future.1

• 74% of people who chose a healthy snack one week in advance swapped to an unhealthy one when given the choice.2

• People want to pre-commit: a recent study found that self-aware consumers will choose to commit to healthy choices.5

1. Pre-ordering in schools: Existing studies

Pre-ordering No pre-ordering

Percentage of students who choose healthy lunch1

Hanks, Andrew S., David R. Just, and Brian Wansink. "Preordering school lunch encourages better food choices by children." JAMA pediatrics 167, no. 7 (2013): 673-674.http://archpedi.jamanetwork.com/article.aspx?articleid=1682338

1. Pre-ordering in schools: Existing examples

OS9 love it. one obvious question is why give kids the choice to have an unhealthy meal? why not just make all the food healthier? (presumably to encoruage people to actually go to the canteen?)Owain Service, 02/07/2014

1. Pre-ordering in schools: Existing examples

All primary schools in Dumfries and Galloway have implemented a pre-ordering system.

• There are theoretical reasons to be cautious about calorie labelling.

• There is some real-world evidence that it can reduce calorie consumption modestly.

• There are labelling alternatives that appear to be more effective than calorie labelling. The most attractive is traffic light labelling.

2. Labelling: Calorie labelling

2. Labelling: Simplicity is key

The Department of Health’s ‘Guide provides a simple table to determine the traffic light colours

The traffic light element will remain voluntary and exists in addition to the information mandated by the European Commission regulation.

2. Labelling: Single traffic lights: Implementation: Policy landscape

Menus: Control

Menus for “Drinks” and “Sides & Desserts” were in the same format

Menus: Numeric calorie labelling

Menus: 3 traffic lights (traditional system)

Menus: 3+ traffic lights (extended orange)

Menus: 4 traffic lights

The best traffic light system reduced total calories purchased by 12%

Reduced byabout 100 kcal

* Significantly different (p < 0.05) from control

• Will power is a limited resource in the short term.

• Effect may be particularly noticeable after school when cognitive resources are drained from day of school2.

• Social norms can increase the likelihood that people indulge in unhealthy snacks1.

3. Fast-food Exclusion Zones: Behavioural rationale

3. Fast-food Exclusion Zones: Secondary Schools and Hot Food Takeaways

Secondary Schhols and 400m buffers with A5 Food Outlet Catchment HotspotsTaken from Food Outlet Mapping in the London Borough of Newham (2010)

• If we believe this is so important, why not introduce a tax?

• Pros• Viable close substitute• Drive reformulation• No nutritional benefit• Don’t notice the calories

• Cons• Too interventionist?• Regressive?• Real-world evidence?

4. Taxes: SSB or sugar tax

Questions?

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