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  • Writer's pictureHannah Kapff

Nudge, nudge. The subtle art of using Behavioural Insights to improve our Health

Last week, I attended a talk for people involved in healthcare communications to hear how ‘nudge theory’ is being used at the Department Of Health to change health behaviours and improve outcomes. Definitions vary, but essentially, nudge theory is the use of suggestion or reinforcement to achieve non-forced compliance. Think toilet blocks in urinals to encourage better aim, or charging for plastic bags to shift shoppers to ‘save the planet and bring your own’. It’s not exactly rocket science, yet the subtleties involved in how groups of people can be nudged in a healthy direction for the long-term are intriguing, and can be explored in Nobel prize-winning Daniel Kahneman’s bestseller, Thinking, Fast and Slow.

It must be said that to the uninitiated, there’s a rather intimidating level of jargon in the behavioural insights lexicon: Terms such as ambiguity effect, inter-temporal choice and cognitive dissonance, but the key concept is that we are all affected by a range of ‘mental shortcuts’ which often help us, but can also lead us astray. Behavioural insights involve how people behave in real life – even when it may appear ‘irrational’.

But back to the jam-packed audience gathered at 34 Smith Square on a cold January night. With wine glasses clutched all round, Department of Health nudge guru, Dan Berry, asked wryly if a ‘dry January’ was being had by all, and by the time he’d taken up his laser pointer, the room’s cold Georgian windows were streaming with our seasoned breath.


Unless you’re remarkably healthy, you cannot fail to have noticed that NHS hospitals are sending patients appointment reminders via text message. This is not for the sake of our convenience; they are an attempt to cut down the 1 in 10 appointments missed – at a cost of around £225 million per year. Through trial and error, involving randomised controlled trials, no less, the nudgers got their message framing right, and at the end of these SMS messages reads the statement, ‘Not attending costs NHS £160 approx.’ The results are not to be sniffed at. This carefully designed wording meant missed appointments fell by 23% – at a marginal cost of just 1.8p per time.

NHS Text Message Appointment Reminder


Aside from message framing, reciprocity is a key tool to achieve specific nudge goals. An interesting pledge scheme has started to be rolled out in an attempt to tackle the NHS’s £500 million cost of drug non adherence by patients. When collecting their medicines at the pharmacy, patients are asked to sign a pledge to take their medicines as prescribed, or else seek GP or pharmacy advice if concerned. There are a myriad causes behind patients not taking their drugs as prescribed, and often reasons that can be logically justified by the patient to themself – but less so to those holding the purse strings.

One member of

the audience told how her elderly father suffering from COPD had frequent appointments to keep his symptoms under control. Yet, when given antibiotics to avoid developing pneumonia, he refused, believing that ‘taking them now means they won’t work if I’m really ill’. Human thinking is complex and there is no one-size-fits-all solution, though there are well known socio-economic and gender biases that influence if and how nudges are interpreted. The good news is that early indications of this scheme show a 10% improvement in compliance in those who’d signed the pledge. (And who knew that in a digital age, good old fashioned pen and ink could be so powerful…


As far as healthy eating is concerned, nudge can be a powerful tool. One delegate asked whether the NHS should go head-to-head with commercial organisations that sell junk food, which to me was a prescient question. Without the marketing and advertising budgets of said parties, we need all the help we can get to discourage ‘eat now, diet later’ behaviour which is steeped in evolutionary pressures, as outlined in our obesity blog. Indeed, I’d take his question one step further. Only yesterday, Curious PR’s digital experts were discussing the power of remarketing, whereby web users are targeted according to their web search history, and nudged with relevant advertisements, accordingly.

Perhaps we’ll see a time when healthy living messages are served up to people buying unhealthy foods or drinks online. Unless, it turned out, the strategy backfired with accusations of ‘big brother’ tactics, as mooted by another member of the audience. For sure, the ethics committee will remain fully on board the ‘nudge bus’, partly because ‘manipulation’ isn’t a million miles from ‘helpful influencing’. (Naturally, Berry preferred the term ‘influence’, and pointed out that people don’t wish to develop diabetes but ‘everyday life got in the way’: It’s hard to turn down cake when it’s on offer.)

The Western world faces some tough choices here if we’re to succeed in tackling the major causes of disease and ill health today, most of which are preventable. (Unless antibiotic resistance makes infection disease come back with a bang). It could be said that we are all like snooker balls, being nudged from all sides by cushions, cues and other balls. But will we reach the right pocket? Having worked in financial news through the stock market boom and bust of the ‘90s and ‘00s, I have a profound belief that people are very like sheep. Get the right sheep to move in the right direction, at the right speed, and you’ll eventually get them in the pen. But even the best shepherds need experience, a well-trained dog, and the right kind of whistle.


Berry’s presentation was refreshingly honest: we still don’t know the full potential of the power of nudge when it comes to improving healthcare outcomes – be that by getting people to turn up for NHS appointments, or asking GPs to consider prescribing a cheaper formulation of antibiotic (a suspension rather than an infusion, for example). In conclusion, I think we should be proud that along with the USA and Australasia, the UK is having a having a good stab at nudge.


There are four ways behavioural insights should be applied: Easy, Attractive, Social, Timely – and that’s according to the Behavioural Insights Team (formerly part of the Cabinet Office, now a listed company). Again, it isn’t that difficult to get in the ‘Easy’ or the ‘Simple’. When NHS Health Checks were first launched, long and detailed letters went out to patients explaining what’d be involved, and asking them to book a check. Uptake was poor, so letters are now no longer than one paragraph, and have proven far more successful. There’s an element of ‘game framing’ in there too, with the words, ‘‘Please call XXX as soon as possible to make sure you get your appointment.” The less is more approach can be a powerful thing, and I have no doubt that many of us communications professionals could learn from it!

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