The Big Society: nudging the public towards better health

The final event in our series on health and the Big Society covered some interesting ground, including the role of reciprocity in health and social care, volunteering, and how to shape the environments in which patients make their choices.

However, the clear focus, and the subject to which the discussion continued to return, was the effectiveness of nudges in changing health behaviours.

Dr David Halpern, Director of the Behavioural Insight Team at the Cabinet Office, stressed that despite the fact that health behaviours are responsible for more than half of avoidable healthy years lost, it is estimated that less than 0.5 per cent of health research funds are spent on behavioural research – this balance is not right. Philosophically the government has a clear preference for nudge over compulsion and voluntary agreements over regulation.

Business, and particularly the food and alcohol industries, clearly has a critical role to play. Baroness Buscombe, Chair of the Press Complaints Commission and a member of the Public Health Commission, shared her experience of working with industry in developing Change4Life and the ongoing work around the Responsibility Deal, while Dr Andrew Jones, Group Medical Director at Nuffield Health, discussed how Nuffield Health was using behavioural psychology to help nudge the behaviour of its patients and customers. There are commercial examples of positive public health initiatives: Mars has reduced the size of its famous bars – although the real test of corporate resolve will be where there are conflicts – rather than such star-crossed alignments between profit and public health motives

It therefore remains to be seen whether the Responsibility Deal will deliver more broadly, or whether tighter regulation by the government – which has already shown itself ready to regulate around below-cost alcohol sales – will eventually be required both in terms of incentives and of effectiveness. As one of the audience pointed out, the strict regulation of smoking in public places delivered results far more quickly and comprehensively than a myriad of micro-nudges would have done.

More broadly, changing social norms will be critical to the success of health behaviour change. Clearly, the long-term change in social norms in relation to smoking made the public response to tighter regulation more positive and effective. A critical question is whether wider application of nudging will widen or narrow inequalities in health? In many cases, the more educated and wealthy may have the greatest capability to respond; the government needs to evaluate the impact of nudge policies on the behaviour of different groups.

Changing social norms means changing what is happening among peer groups and local communities. But when, for instance, smoking rates are so specific to social groups and micro geographies (as in parts of Warrington for example, where rates are close to 40 per cent for some communities but as low as 3 per cent elsewhere), will any amount of nudging act powerfully or swiftly enough to overcome such deeply embedded and normalised behaviour? In such communities, empowering local people to find solutions by using the new powers of localism – including local regulation – may be a more effective answer.

Nudging individuals to change their behaviour clearly has an important role in improving health, but ultimately changes to communities and society are needed if we are to tackle deeply ingrained inequalities.