Missing: healthy choice

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The UK House of Lords Select Committee Behavioural Change Report was released on 19th July 2011. It’s an interesting read. However, more interesting is the transcript of evidence taken before The Select Committee that led to the report. In particular, a response to a question from Lord May of Oxford to Dr David Halpern about the analysis of evidence of efficacy of behavioural factors in the NHS. It revealed the size of backing given to behavioural research – or rather, the lack of it.

Professor Dame Sally Davies is the Director General of Research and Development and Chief Scientific Adviser for the Department of Health and NHS. David Halpern says

“[she] . . . sits on £500 million of research moneys, of which . . . we believe less than 0.5% of health research goes on behavioural factors . . . “

If behavioural factors make little or no difference – or perhaps 0.5% of a difference – to our health, than this is a fair distribution. Is this the case? Halpern continues:

” . . . and yet we know that more than half of all years of healthy life lost are to known behavioural factors . . . “

It’s a pretty big discrepancy, he goes on to say. Too right; 0.5% of the budget on factors that are likely to kill us in one-way-or-another is a pretty unfair distribution.

The question you should throw at me is ‘prove it’.

Proving it

I’m going to heartlessly skip over patient support stuff, such as the New Jersey suicide prevention” . . . deaths from individual’s choices increasing from 5% of deaths in 1900 to 55% in 2000 . . . “ programme where participants became more likely to see suicide as an answer to their own problems, and an eating disorder help-group for young women requiring participants to describe their harmful eating resulting in greater eating disorder symptoms (both due to the mere exposure effect), and leap straight to patient attendance rates.

Why?

Because it can transform a hospital’s efficiency which is a benefit to both:
1. Those that use it because it is more efficient at the point of use
2. Those who don’t use it (but still pay for it though their taxes) because it is a more efficient use of every unit spent.
(For non-UK readers who are unsure of the NHS’s structure it is a nationalized health service, free at the point of use, funded by tax-payers)

Attendance rates: How many?@?!!

The question is not how many who appear for out-patient appointments, but how many who don’t. It’s often presented incorrectly. There are, and I have seen with my own eyes (quite what else I would have seen with I don’t know), notices in waiting rooms about failing to turn up for appointments. They are true, and “We’re all missing appointments, I’m not so bad for missing mine, am I? The hospital are used to it . . . ” well meaning, but unhelpful. I saw one that added up all the appointments missed in the previous year and presented this in comparison to the size of the waiting list. It was quite dramatic; missed appointments totaled four weeks, the waiting list to be seen totaled four weeks. If all had arrived as planned – it said – there would be no waiting list. Broadly true, rather dramatic, but unhelpful.

Or, unhelpful if one wants to increase desire to stick to appointments.

The truth, the whole truth, and nothing but the truth. (The first way.)

My brain was fuddled by the ‘four weeks of appointments missed’ comment. There was even a chart. It looked something like the image below.

Three appointments an hour, every day, for ONE MONTH; that’s a lot, right? A hell of a lot: four hundred and twenty ‘no-shows’ using a conservative
DaysDiary
calculation. Therefore, no-shows must be prevalent, and – one can only infer from a large number such as this – are ‘approved’ by the group as a way of behaving. Must be: “We’re all missing appointments, I’m not so bad for missing mine, am I? The hospital are used to it . . . ” you’d think. Well, you would, wouldn’t you?

However, this is a strange truth.

The truth, the whole truth, and nothing but the truth. (The second version.)

‘Liberating’ (I’m being generous) the number of appointment no-shows “Few people miss them, I’m an outsider for missing my previous one, they’re not used to it . . . ” from the number of appointment shows presents a lop-sided view. While it is true that there were four hundred and twenty ‘nos’ totaling one month, there were four thousand six hundred and twenty ‘shows’ totaling the remaining eleven months.

Already, that changes thing’s a bit. But we can do better.

One month out of twelve is 8% of the total. Only 8% of appointments were missed, or, 92% of appointments were kept.

That’s even more powerful; all true, all real, all the same data. Let’s visualize that.
8_100
Eight out of every one hundred people fails to show for an appointment. Now, no-shows are not prevalent, and – one can only infer from a small number such as this – are ‘not approved’ by the group as a way of behaving. Can’t be: “Few people miss them, I’m an outsider for missing my previous one, they’re not used to it . . . ” you’d think. Well, you would, wouldn’t you?

(For comparison, In 2009/10 the total number of outpatient appointments missed totaled 6.7 million, or 7.9 per cent.)

_______

Delivering one’s message in favour of the intended outcome sits in the epicenter of behavioural communications. Using prevalence to drive that behaviour is not a new thing (as I have written about here and here). But with 84.2 million planned hospital visits per year in the UK (2008/9 numbers), you can see how well-meaning messages can be garbled by ignorance, and how much of a difference they can make (either way).

Indeed, beyond appointments, behaviour sits at the heart of our health issues: Ralph Keeney’s paper in Operations Research cites deaths from individual’s choices increasing from 5% of deaths in 1900 to 55% in 2000; Dr David Halpern talks about the same. We’re not dying of disease and pestilence anymore – and the top killer isn’t cancer, heart disease, smoking, or overeating – we’re dying from the choices we make about our lifestyles (that have readily available alternatives).

The least we could do is make the communication interface in hospitals fall in favour of cost effective positive health outcomes.

(And we can start by marginalising missed appointments.)

• Oliver (LinkedIn) is author of the behavioural communication book Inspiring Sustainable Behaviour: 19 Ways To Ask For Change published by Routledge, available in most countries.
• Member of the Influence Advisory Panel
• Join the London Behavioural Economics Network Meetup group
• Join the London Behavioural Economics Network on Facebook


One Comment

United India says:

August 11, 2017 at 10:50 am

we should take care of our health.

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