Public Health White Paper – Do “Nudges” have their own Values?

The Public Health White Paper is a significant document. It shows the wide level of political consensus for tackling health inequalities. The days of 260 copies of the Black Report being published on August Bank Holiday in 1980 with a disapproving ministerial Foreword to the document are long gone.

Key elements of this White Paper include:

• Public Health England will be created as a service that gives more power to local people over their health, whilst keeping a firm national grip on crucial population-wide issues such as flu pandemics.
• Funding from the overall NHS budget will be ring-fenced for spending on public health. Early estimates suggest that current spend on areas that are likely to be the responsibility of Public Health England could be in the range of £4 billion.
• Central Government will not hold all the purse strings. The majority of public health services will be commissioned by Local Authorities from their ring-fenced budget, or by the NHS, all funded from Public Health England’s new public health budget.
• The use of behavioural Nudges to improve public health choices and create positive social norms.
• A health inequalities agenda focused on Health Premiums for poorer areas linked to the achievement of health improvement outcomes.
• More effort to encourage improved health outcomes via the workplace with a voluntary Responsibility Deal for business.

Much of this will be welcomed as Public Health and the associated behaviour change agenda that comes with it, will be put on a clearer statutory footing and not be an adjunct to the “treatment” activity that is inevitably the priority of the NHS. The King’s Fund have set out a range of very useful questions that need to be asked around accountability, funding, inequalities, the role of industry and its place in the Big Society agenda.

If there is any political debate, it will be about whether we have moved on from the “Nanny State” to the “Nudge Society“. However that in many ways is a side-show. The previous government Nudged as well as Nannied, whilst it is hard not to see some proposals today being anything other than Nannying (even if it is likely to be broadly popularly supported Nannying) such as plain packaging for cigarettes and minimum alcohol pricing.

The big question to ask will be, are Nudges enough on their own?

Many Nudges tend to be structural and design changes to the wider environment, or improving incentives based on behavioural economics theory. As a result they focus on people’s ability to conduct a behaviour with the aim to make more difficult the ability to stick to a bad behaviour and easier to take up a good behaviour. This is all very good as part of any behaviour change campaign. However behaviour change research indicates that tackling people’s ability to change is not always enough. It is also whether people’s motivation to change is strong enough and they display enough self-efficacy. If only part of the equation is addressed, then short-term gains are still likely, but change through incentives may not be permanent and thus is value for money for the taxpayer really achieved?

If we need to address motivation then one of the most effective ways to understand this is through values based segmentation. This has added importance if one also hypothesises as to whether Nudges still apply in the same way if people have different needs and values, driving their level of motivation?

Let’s take a classic example of the Schiphol Airport Fly Nudge designed to reduce  spillage in male urinals at the airport. Based on substantial values analysis dating back 38 years, whilst Outer Directed males would see the fly as a clear target, would all Inner directed males with benevolent or universalist values do the same? Would those with Sustenance and Safety values see the fly as dirty and to be avoided at all costs?

When Nudges do seem to be used to address people’s emotions and perhaps their motivations, these are all about framing communications. An example of this sort of Nudge is optimistically expressing a 10% medical survival rate rather than expressing a 90% death rate. Again does this remain the same with values?

All this illustrates the need for future public health research and piloting to test out a range of Nudges and measure them in terms of values as well as traditional geodemographic measurement.

Charlie Mansell is Research and Development Officer at The Campaign Company.