Happy New Year folks, I hope you had a lovely mindapple-filled winter break. Last week I attended the launch of the Health Equalities Alliance and their inaugural debate Nudge or fudge – can a gentle push really tackle health inequalities? It was the first time I’ve had the chance to quiz members of the Cabinet Office’s Behavioural Insight Team about their recent emphasis on ‘nudge’ social marketing techniques, and it’s given me much food for thought.
Nudge, for the uninitiated, refers to a set of techniques described in the book of the same name by Richard Thayler and Cass Sunstein, about the unconscious influences which “nudge” us make choices in everything from the food we eat to the directions we walk. Anyone designing an environment in which people make choices is a “choice architect” and witting or unwittingly creates factors which influence decision-making – and which can therefore be altered to nudge people to make choices which are better for them.
This is nothing particularly new. The techniques are drawn from the same psychological stock as 20th Century advertising, PR and sales theory and are well-evidenced. The Coalition though sees these tools as pivotal to delivering mass behaviour change in high cost areas – such as public health – at a low cost. When you consider that a recent Scandinavian study (citation appreciated if anyone can find it) suggested the health service contributes only 15% of the overall health of the population, you can understand why nudge theory is so appealing to an indebted Government facing rising demands on an already over-stretched NHS.
The problem though, as many of the panel observed, is that you can’t nudge people out of poverty. To put it more broadly, choice architecture works brilliantly when you have a choice, but is therefore more likely to benefit the wealthier classes with more options than those who cannot afford better food, or who are subjected to abuse or poor living and working conditions. I am skeptical about the capacity of nudge thinking alone to deliver health equalities or even widespread population health improvements, at least beyond the priviledged minority. It must be blended with real progress on the critical social factors that create poor health, and not a substitute for them. I also welcomed the assessment of Phil Coppard, Chief Executive of Barnsley Council, that dividing public health into individual behaviours like smoking, diet and exercise misses the underlying truth that “this is actually about low level mental health”. Nudging people to act differently may alleviate the symptoms, but leave the sickness untouched.
I believe that nudge thinking has an important role to play in improving the design of public systems and spaces, by making designers think more carefullyabout the implicit choice architecture embedded in their creations. For example, my council landlords require me to sort recycling into several piles and take it out into the street, but if I want to send anything to landfill they will collect it daily direct from my door. Then they put up leaflets about the importance of recycling. This is patently absurd, and if nudge thinking can be used to review and correct the nudges that send people in the wrong directions, this is a good thing.
However, I also believe there is a tension between the implicit paternalism nudge thinking and the “empowerment” rhetoric of the Big Society (and more on my personal thoughts on that project over here). Dr Samantha Callan from the Centre for Social Justice cited one example of nudge in action, that of placing a bus stop outside a care home so that if Alzheimer patients ran away from their carers, they would simply wait outside for a bus until they could be collected. So far, so economically efficient. But as one audience member observed, perhaps this is manipulating patients to stay indoors rather than helping them spend more time outside rather than cooped up indoors all day. Sometimes we do things unconsciously for good reasons, even if the result isn’t as effective as we would like. Moreover, nudging people in one direction rather than another still leaves them vulnerable to being nudged back again, and when you consider that for every pound spent on nudge public health marketing there will be ten spent on getting the public to eat Pringles, the economics of this whole nudge thing start to look flawed. Nudge is powerful, but unless it builds conscious agency and involves individuals in the decision-making process, it can only disempower the people it serves.
How can we be trusted to run our communities, deliver public services and control local planning decisions when we cannot also be trusted to make informed decisions about feeding ourselves or raising our children? We cannot be nudged into taking more informed responsibility for our life choices. So are the people who are to be subconsciously manipulated into living healthier lives the same people who the Government is championing as having the power and skills to lead this country into a new era of citizen-led society? Or will we be nudging one part of the population whilst empowering another?
With this in mind, my question to the panel was “have we abandoned learning?” Dr Ronny Cheung from the Cabinet Office (who took more than his fair share of flak from the audience as the only official nudge apologist present) spoke of nudge as more effective at scale than “giving information” – but giving information is simply old-fashioned broadcast style education. There are so many more sophisticated tools for creating learning than giving information, and if we fail to employ any of them in tackling public health issues, we are effectively giving up on having an informed public who are responsible for their own destinies. We need to engage the public in making conscious choices and building personal habits based on knowledge, to empower individuals not only to manage themselves better, but also to resist being nudged in one direction or another. And if we are to capture the support of the current Government, we also need to do it at scale, and cheaply.
This is where I think Mindapples comes in. We want to build people’s conscious awareness of the connection between what they do and how they feel, and help all of us learn from each other what we each want and need to be mentally healthy. I’m sure we’ll be nudging people along the way, but everything we do will always be about helping individuals make conscious, informed choices about what they need, and getting the support they deserve to meet those needs. And we think we can use digital tools, peer recommendations and the skills and networks of our community to do this at scale, and for low cost. When you consider Mr Coppard’s observations about the root causes of many public health issues, an effective and empowering intervention in public mental health could have huge positive implications for public health in general.
Of course, education on its own is not enough. Professor Richard Parish of the Royal Society of Public Health summarised it well last week: “we haven’t abandoned education, but whether education results in behaviour change depends on social factors.” Mindapples and its like can go some way towards helping people get what they need from society, but there is still much that the Government must do to create the opportunities for people to thrive, and the social and cultural context in which good things are easier to do.
Right now though, we seem to be in the strange position of pushing subconsious behaviour change techniques to a passive, unaware population with one hand, whilst the other lifts citizens up to run our communities, take vital decisions and run public services. Is the pragmatic paternalism of nudge politics actually in direct conflict with the lofty aspirations of the Big Society?