Intended for healthcare professionals


Finding the techniques to nudge the population to better health

BMJ 2011; 342 doi: (Published 20 January 2011) Cite this as: BMJ 2011;342:d389
  1. Nigel Hawkes
  1. 1London

Could shoppers be encouraged to buy more fruit and vegetables by providing a designated space for them in supermarket trolleys? Or students to drink less alcohol by telling them the truth: that most students are actually quite abstemious, in spite of their hard drinking reputation?

Both are examples of the fashionable nudge techniques being adopted as public health motivation tools by the coalition government. The first relies on the human tendency to go with the flow of pre-set options. If there’s a fixed space intended for fruit and veg, we fill it. The second aims to reset the “norms” that guide much behaviour. If students are supposed to drink, they drink—but if they discover this isn’t the norm, they throttle back.

Both examples were given at a meeting at the King’s Fund by David Halpern, director of the Cabinet Office’s Behavioural Insight Team. “Nudge is a complementary tool,” he said. “It doesn’t mean you’ll never regulate.” But strong-arm tactics hadn’t worked in many areas of behaviour that impinge on health, where the insights of social psychology might prove more effective.

“Half of all healthy life years lost are down to behavioural failures” said Dr Halpern. “But that hasn’t been our focus. The Darzi Report found that research spending in this area is only half of one per cent of the total spend, and most of that went on studying failures of medical compliance. If we can change this, the health effects could be very great.”

A compelling example outside health of the effects on behaviour of social norms was littering. “Where there is litter, people are much more likely to drop more, because it seems to them that that’s the norm. If litter is cleared, eight to ten times less is dropped,” he said.

Dr Halpern also gave some examples of the Big Society, David Cameron’s vision of a more cooperative, volunteering spirit, and how difficult it is to implement. “My son had a tracheostomy for the first four years of his life” he said. “He’s fine now. But when he was younger he would pull it out, and we had to develop the skills to get it back within two minutes, or risk a bad outcome. We developed great skill in dealing with it.

“When he no longer needed it, we volunteered to help another family in the same position, to pass on the skills we’d learnt. We were never asked to do it.”

Baroness Buscombe, a Conservative Peer and former chief executive of the Advertising Association, said Whitehall inertia was a huge obstacle to new ideas. She said she had “nearly lost the will to live” when trying to persuade the Department of Health to join up with the food and soft drinks industries and with the Department of Children, Schools and Families in launching what eventually became Change4Life.

Gordon Brown, then prime minister, had been supportive, but the Department of Health refused to get involved with the Department of Culture Media and Sport because the original concept involved promoting fitness in the run up to the 2012 London Olympics, and sport was considered “elitist.” “It took months of negotiation to get it going” she said. “The DH [Department of Health] was terrified of involving food and soft drinks companies. I wish we had ignored the DH and worked with DCMS [Department of Culture Media and Sport]—all DH did was call in expensive consultants, then launch the whole programme badly. It was a massive mistake to make it a DH programme.”

Change4Life uses the concepts developed by advertisers to promote healthy eating and a healthier lifestyle. It has been praised by Andrew Lansley, the Health Secretary.

Andrew Jones, Group Medical Director at Nuffield Health, said that changing social norms by replacing opting-in by opting-out had changed behaviour at a chain of gyms the company owned. By making health assessments the norm for new members joining the gyms, so that they did not have to opt-in but still had the choice of opting-out, they had been able to run assessments on 50 000 people.

The same change has been proposed by the government in a trial of “prompted choice” for those asked if they are willing to donate organs when they get a driving licence.


Cite this as: BMJ 2011;342:d389