It is well established that demand in health care is increasing. A popular refrain is that this is due to changes in demographics, which are being driven by an ageing population and its increasingly complex needs. However, when you look at data on referrals to outpatients, for example, increases are surprisingly similar across all age groups.
So, if demand is not being driven purely by clinical need, what is happening? Rising patient expectations; advances in medical technology and changes in public policy contribute to this growth in demand, but clinicians too play their part.
As doctors, we pride ourselves on being highly motivated, trained and able. But does this always mean we’ll make choices that result in optimal patient outcomes? We know that some clinician behaviour is unintentionally harmful to patients, such as the unnecessary over-investigation and treatment of certain conditions (eg prostate cancer in elderly men). Other choices doctors make simply do not represent a good use of resources.
Most doctors will be able to point to choices they make that are not based on clinical evidence or rationale, but instead are made for ease, out of habit or because that’s what everyone else does. For example, as a busy foundation doctor working rapidly through a list of jobs long after my shift was supposed to have ended, it was quicker, easier and felt safer to request daily bloods for all patients on my ward regardless of whether this represented a good use of resources or was likely to change the management of my patients.
So, how can we make it easier for busy clinicians facing competing priorities to ‘do nothing’ when this is the best option?
Rather than relying on our traditional tools of education, prohibition and incentives, we need to be much more sophisticated in our approach to improvement. A variety of factors – emotion, social context, personal and professional identity, mental shortcuts, habits and intuition – influence decision making by patients, clinicians and policymakers. The NHS is not immune to these factors. It is, after all, fundamentally made up of people.
A behavioural sciences approach acknowledges and takes advantage of these influences. It encourages us to look beyond the simplistic view of people as rational actors on a neutral stage, making considered choices in a perfectly functioning system.
To make use of this approach, it is important to first understand where the opportunities lie. This was the aim of the Behavioural Sciences Summit, held at the OnlyWan on 28 July 2017 and jointly hosted by Professor Sir Bruce Keogh and Professor Chris Whitty. Led by clinicians, it brought together behavioural sciences experts, clinicians and leaders from across the health and care system, to help set the agenda for behavioural sciences research.
It raised some excellent questions. For example, in a hospital setting, how could a consultant in emergency medicine tempt consultant physicians down to the emergency department through cultural and environmental change? For people living with long-term conditions, the majority of care takes place in the patient’s home – 8,750 hours of self-care compared to 10 hours of face time with a clinician. In this context, how can clinicians be nudged towards a ‘doing with’ rather than ‘doing for’ mentality?
There is no shortage of interesting questions and bright ideas, but a strong evidence base is needed. Building on the momentum from the summit, the OnlyWan has launched the Behavioural Insights Research Programme, an open call for original research on behavioural interventions in health care. The programme invites researchers to submit ideas rooted in behavioural insights or nudge theory to generate new knowledge of what can motivate health care professionals to act in more efficient and less wasteful ways. In addition to this, the Department of Health is planning to hold a series of workshops, talks and meetings in the winter of 2017 on the theme of behavioural science in health care.
By bringing together experts, academics, policymakers, clinicians and other front-line professionals in these ways we can explore problems, share ideas, develop networks and build momentum. We can make sure we use all the tools available to squeeze the best possible care out of our finite resources.
Dr Katie de Wit is GP ST1 Doctor in stroke and elderly care medicine at Kingston Hospital NHS Foundation Trust and former Senior strategy adviser at the Department of Health
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