STEVE J MARTIN
Influence at Work
Steve is a New York Times bestselling author and Director of Influence At Work. He co-authored Yes! 50 Secrets from the Science of Persuasion, which was nominated for the Royal Society prize for science writing. Steve speaks about social influence and behaviour change to a variety of business and government organisations around the world. He works with the Behavioural Insight Team in the UK Cabinet Office and with the Behaviour Change Responsibility Network in the Department of Health. He is advising on patient engagement, adherence and communication programmes for newly forming clinical commissioning groups. His business columns are read by more than 1.8 million readers every month
Dear old Mary Poppins. Her advice may have been quaint, entertaining even, but, as the wise practice manager knows only too well, it often takes more than “a spoonful of sugar” to help the medicine go down. Sometimes the medicine won’t even find its way out of the bottle or blister pack in which it is dispensed.
Imagine how marvellous it would be if patients did pay more attention to the advice and information they are given about their health. Consider how much more efficient and effective our wonderful, yet financially stretched, health service would be if patients took greater responsibility for their wellbeing, behaving in ways that were in their best interests and the interests of others.
Even though most patients will claim to recognise the need to incorporate a little more exercise into their daily lives, smoke a few less cigarettes or eat a little more healthily, the knowing practice manager will be more familiar with the realities when it comes to influencing patient behaviour.
Few would be so bold as to claim that understanding and changing behaviour is straightforward. Far from simple, it can be a hugely complex task encompassing all manner of social, psychological, environmental, cultural, contextual and economic factors.
But however difficult it can be to persuade patients to behave in desirable and beneficial ways, we shouldn’t shelve our attempts. Given the current financial pressures one could convincingly argue that there has never been a more important time to influence patients to play their part in taking greater responsibility for their own health.
Fortunately a significant body of evidence exists within the behavioural sciences that can provide insights when creating policies and programmes that strive to influence patient behaviours in desirable ways. And even though no behavioural scientist will ever issue a 100% cast-iron guarantee, these ‘social influence’ approaches can be an incredibly effective set of tools for practice managers and clinicians to learn about and apply.
In fact these approaches are being tested and applied now in GP practices and hospitals up and down the country, with remarkable success and often at little cost. Take, for example, the frustrating and frequent issue of DNAs (‘did not attends’).
Six million appointments are wasted each year because patients do not attend their appointment and fail to contact the practice in time for it to be offered to another patient.(1) Direct costs alone are estimated to be some £700m, and 84% of GP practices consider DNAs a major problem resulting in lengthened waiting times, difficulty in reaching performance targets and greater costs.(2-3) Reduced patient satisfaction, public health issues and increased inappropriate Accident & Emergency attendance are also likely consequences.(4)
Patients ‘DNA’ for many undoubted reasons. Some simply feel better; others experience anxiety or encounter problems with appointment systems. The simple reality though, backed up by surveys of patients themselves, is that most simply forget.(5)
Some support the introduction of a modest charge for appointments or fines for non-attendance. But half of all appointments made are accounted for by patients with long-term conditions such as diabetes and arthritis, leading to claims that such a system penalises people for falling ill.(6) Fines present difficulties too in terms of administration and enforcement.(7)
They can also backfire. Studies in children’s daycare centres found that penalising late or non-attendees actually increased lateness and non-attendance.(8) As appealing as economic and legislative approaches can be to dealing with issues of undesirable behaviour, sometimes other methods are required.
Debbie Wilkins and Nadia Smith, practice managers at two busy health centres in NHS Bedfordshire, joined forces with behaviour change experts Influence at Work and the Health Advisory team at accountancy organisation BDO to test several of these ‘social influence’ interventions with the aim of reducing DNAs (see box).
At first glance the interventions tested appear small and unlikely to generate any meaningful impact. But small changes can sometimes lead to big differences. In the studies, DNAs reduced by 31.4% – a result subsequently described by senior government officials and media commentators as “extraordinary”. Just three small changes led to these extraordinary results.
The renowned social psychologist Robert Cialdini has written of the example of Chicago restaurateur Gorden Sinclair, who changed two words that his receptionists used when making customer bookings over the telephone.(9)
Instead of the usual “Please call us if you need to change or cancel your booking” before hanging up the phone, Sinclair asked his staff to instead say, “Would you be willing to call us if you need to change or cancel your booking?” and then pause, waiting for the customer to answer, “Yes”.
Such a small change seems unlikely to yield big results, but this verbal commitment led to a notable drop in no-shows for one very important reason: people generally prefer to live up to their commitments, especially those that are owned and require their active involvement.
In Debbie and Nadia’s practices, we tested a slightly different version of this verbal commitment strategy. When calling for an appointment, patients were asked by receptionists to repeat back the time and day of the appointment they had been given before hanging up. The impact of this intervention was immediate and impressive – we measured a reduction in DNAs of 6.7%. Patients never questioned the change, and reception staff reported that it was generally easy to incorporate becoming a natural part of the appointment-making routine.
The ‘social influence’ literature provides a number
of additional insights into what persuades people to be consistent with, and live up to, their commitments. For example, one way we can strengthen a patient’s commitment is to get them to write that commitment down.
Patients who make appointments when they are in the practice might be given a small card with their appointment details on. Typically, those details are written by receptionist, practice nurse or even the GP. In the NHS Bedford studies, patients were asked to write down the time and date on the appointment cards themselves. This active written participation led to a fall in DNAs of 18%.
One way that GP practices routinely attempt to reduce DNAs is to highlight the number of patients that failed to attend the previous month. This is usually accomplished by displaying a poster on waiting room walls, pointing out the large number of patients who fail to attend. While understandable, such a strategy is not only unlikely to work but might actually lead to an increase in DNA rates.
Research from social influence theory has shown that drawing attention to the frequency of a given behaviour will often ‘normalise’ that behaviour regardless of whether it is desirable or not. This is one reason why many practices report that even though they display non-attendance rates, rarely does this information have an effect in reducing DNAs.
A second, more obvious and yet widely undetected reason why such a strategy is likely to fail is that only those patients who turn up for their appointments will see the information. In effect it becomes a rather effective advertisement to the merits of not attending in the future.
By replacing the more common poster with a new one that simply communicated that the majority of patients do turn up for their appointments on time, combined with the appointment card intervention, we recorded a 31.4% reduction in DNAs.
Specifically the new poster message read: “95% of [name of surgery] patients turn up on time for their appointment or call [insert appointment line telephone number] if they have to cancel.”
Social influence tools for practice managers
In the light of substantial changes taking effect in the NHS, it would be remiss not to view Debbie and Nadia’s DNA results in a wider context beyond the obvious frustration that DNAs cause.
Many of the issues around the current reforms are contingent on engaging patients, persuading them to take greater responsibility for their health and to make better health-related decisions. Other challenges will be internal: establishing trust among colleagues, communicating, commissioning and negotiating more effectively. Such challenges will require sound process and well thought-through policies. They will also require the ability to influence and persuade effectively.
The fact that, within social influence, there is a well established and evidence-based set of tools and approaches that can help to deliver against these important challenges might be comforting, perhaps even inspiring, for those involved in effecting such changes in practice management.
- The NHS Information Centre. Hospital Outpatient Activity 2009-10. Available from: www.ic.nhs.uk/pubs/hosout0910
- Dr Foster Health. Outpatient appointment no-shows cost hospitals £600m a year [online article]. Available from: http://www.drfosterhealth.co.uk/features/outpatient-appointment-no-shows…
- Developing Patient Partnerships. The forgotten millions: missed GP appointments figures released. London: DPP; 2004.
- Karter K, Parker M, Moffat H, et al. Missed appointments and poor glycemic control Med Care 2004;42(2):110-5.
- Neal RD, Hussain-Gambles M, Allgar VL, et al. Reasons for and consequences of missed appointments in general practice in the UK. BMC Family Practice 2005;6:47.
- Vaughan-Jones H, Barham L. Healthy Work: Challenges and Opportunities to 2030. London: BUPA; 2009.
- Fysh T. Missed outpatient appointments. JR Soc Med 2002;95(7):376-7.
- Gneezy U, Rustichini A. A fine is a price. Journal of Legal Studies 1999;29(1):1-18.
- Goldstein N, Martin S, Cialdini R. Yes! 50 Secrets from the Science of Persuasion. London: Profile; 2007.
Influence at Work
A free guide to reducing DNAs in general practice based on these studies is available to download at: www.influenceatwork.co.uk