Intended for healthcare professionals

Editor's Choice

Behavioural fatigue: a flawed idea central to a flawed pandemic response

BMJ 2020; 370 doi: (Published 06 August 2020) Cite this as: BMJ 2020;370:m3093
  1. Kamran Abbasi, executive editor
  1. The BMJ
  1. kabbasi{at}
    Follow Kamran on Twitter @KamranAbbasi 

What is behavioural fatigue? Nobody really knows, but it is something we should be acutely aware of because it is a major reason why the UK delayed implementing lockdown, even though the best research indicates that swift and strict social distancing measures will limit the incidence of covid-19 infections.12

That delay in lockdown helped contribute to England achieving the highest excess deaths in Europe, as calculated by the Office of National Statistics.3 The full burden of long term complications in people who survive is yet to be calculated.4 It is not as if behavioural fatigue is a concept recognised by behavioural experts. Susan Michie and Robert West describe it as “an ill-defined new term that had no basis in behavioural science.”5

Greater prominence of behavioural science is a positive development. Much nonsense is talked in the name of behaviour, from how it will end obesity to how it renders face masks ineffective thanks to risk compensation.67 The sector is short of research funding, a neglect that fits with a flawed emphasis on treatment over prevention. Behavioural science is transdisciplinary and is central to tackling this and any future pandemic—and the greater threat of climate change.8

Ironically, the concept of behavioural fatigue is said to be rooted in the evidence.9 But what evidence? If there’s no evidence for it then how did the government follow the science? The behavioural subcommittee advising SAGE and the government’s behavioural nudge unit deny introducing this concept.10 Perhaps David Halpern, the head of the nudge unit, or Chris Whitty, England’s chief medical officer, should explain why behavioural fatigue came to be such common parlance and so influential?

Behavioural interventions can succeed only if the rest of the system operates optimally. But recent experiences from Leicester and Sandwell tell us that the promised world class systems of testing and tracing are bucket class.1112 Local leaders are losing confidence in the government’s ability to deliver them and communicate effectively. With new research casting doubt on the reliability of serology tests for covid-19 at the point of care, the fundamental pillars of a pandemic response—namely, test, trace, and isolate—are wobbly at best.13 None of this provides any confidence in the government’s proposed “radical shake up” of the NHS.14

Nor does divergence in national strategies rebuild public trust that was destroyed not by behavioural fatigue but by Dominic Cummings, England’s most senior government adviser.15 Scotland wants all four UK nations to follow an elimination strategy, aiming for “zero covid.” Northern Ireland has already committed, but England, persistent in its flawed response, is content for the virus to hover around, to hope it doesn’t overwhelm health services, and to play “whack-a-mole” with local outbreaks.