The softly-softly approach can't slow down a speeding train

Nudge theory is a useful tool in the public health armoury but the growth in chronic diseases will require more robust action.

I don’t often spend a weekday lunchtime at the cinema but I did recently. Before my clients and colleagues think I’ve been bunking off, I was actually listening to Richard Thaler – behavioural economist and godfather of ‘nudge’ theory.

Nudge argues that we can encourage people to change their behaviour, without restricting choice or offering significant financial incentives, but by presenting choices differently. This struck a chord with the Conservative small-state ethos and the Liberal Democrat libertarian agenda. In 2010, the coalition Government established the ‘Nudge Unit’ – or Behavioural Ins­ights Team to give it its proper name – tasking it with applying behavioural economics to improve public policy and save money.

The unit was spun out of the Cabinet Office in 2014 as a for-profit social-purpose company. Experiments proliferated with nudges everywhere: fruit replacing sweets at checkouts; signs saying take the stairs instead of the lift. In health, the evidence has perhaps not justified the hype: the unit’s biggest success has been increasing sign-up to the organ donor register via prompts to people renewing their car tax or driving licence online.

It’s inescapable that we have to do more to support people to take responsibility for their health. Headlines scream about the pressures on the NHS. The warning from NHS chief executive Simon Stevens in the Five Year Forward View could not be clearer: "The future health of millions of children, the sustainability of the NHS and the economic prosperity of Britain all now depend on a radical upgrade in prevention and public health."

The biggest recent public health wins have come off the back of changes to tobacco policy – bans on advertising, smoking in public places, point-of-sale restrictions and plain packaging. All of these took clever comms to persuade politicians and the public of the need for a shove, rather than a nudge.

Many will question if the Government really has appetite for the "hard-hitting national action" on chronic diseases called for in the Five Year Forward View. The signals are not good. While the Treasury pored over spreadsheets showing that, within 15 years, 40 per cent of the working age population will have at least one chronic health condition, the Chancellor cut £200m from councils’ "non-health" – read public health – budgets.

So expect more nudges. More carefully crafted messaging about the importance of healthy diet. More wearable tech to get us to take 10,000 steps a day. But – even as a healthcare communicator believing in the power of the message to influence – I can’t see that nudges will be enough.

The public health community should not be despondent. Every Government advocates voluntary action. In the tobacco examples above, the Government was strongly opposed to legislative action, right up to the point where it announced legislation. The job of public health communicators is to persuade them to change their minds.

Because a nudge will not always do. Our public health crisis is a speeding train. And you don’t nudge someone out of the path of a speeding train. You shove them.

Sarah Winstone is a founding partner at Incisive Health

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