Minister for Health publishes “10 Practical Areas for Behavioural Science to Improve Productivity in Health”

Behavioural Science is central to improving productivity in the health sector.

The Minister for Health, Stephen Donnelly today published a discussion paper “10 Practical Areas for BeSci to Improve Productivity in Health”. This paper proposes areas where insights from behavioural science can be applied to improve productivity in the health sector and is an input into the work of the Productivity and Savings Taskforce.

The Productivity and Savings Taskforce was established by Minister Donnelly in January 2024 and is chaired by the CEO of the Health Service Executive (HSE) Bernard Gloster and the Secretary General of the Department of Health, Robert Watt. Its remit is to ensure that the unprecedented increases we have seen in spending and workforce in the health service, in recent years, result in treatment for as many people as possible, as quickly as possible.

Commenting on the publication, Minister for Health, Stephen Donnelly said:

The 10 practical areas outlined in the paper are:

1. Increase hospital productivity by changing default options, such as changing the default to day case rather than inpatient for certain hospital procedures.

2. Increase hospital productivity by reducing readmissions and average length of stay by using improved discharge templates and additional supports.

3. Increase productivity by reducing did not attends for hospital appointments by using behaviorally informed content (shown to increase patient engagement) in correspondence such as appointment offer letters and text reminders.

4. Increase productivity by growing uptake of online services and improving administrative processes by reducing administrative burden through use of sludge audits.

5. Increase productivity by using behavioural insights to support use of key good practices in elective care such as using low-complexity pathways for low-risk patients, using enhanced recovery practices, and increasing throughput in theatres by measuring, communicating and managing the number of cases per theatre session.

6. Reduce influenza’s influence on demand and supply by increasing flu vaccination uptake with behaviourally informed letters / correspondence for the community, and by using multifaceted approaches for health workers.

7. Reduce unnecessary demand for Emergency Departments and outpatient consultations by using audit and feedback with checklists for GPs and by providing written guidance for patients and parents.

8. Reduce unnecessary antibiotics prescribing in general practice through greater use of behavioural interventions shown to reduce unnecessary prescribing, such as education, communication training, point of care testing, other decision support tools, and delayed prescribing. This will result in both financial and health gains, as reducing unnecessary antibiotic prescribing is central to reducing antimicrobial resistance.

9. Reduce future demands and costs by growing cancer screening through better correspondence by incorporating insights from behavioural science into screening offer letters and processes.

10. Reduce future healthcare demands and costs through better food choice architecture by using calorie posting on online menus for fast-food chains, front of pack nutritional labelling for food products in supermarkets, and recommended portion sizes supported by using reduced size tableware in canteens in public buildings.

What is the purpose of this paper?

In this Discussion Paper a selection of areas is identified in which insights from behavioural science can be applied to improve productivity and efficiency in the health sector.

Why is behavioural science relevant?

Behavioural science applies the inductive scientific method and psychological insights to the study of decision-making. A key takeaway from behavioural science is that people’s decisions and behaviours are not always optimal. Our behaviours and decisions are often driven by rapid, intuitive, and non-conscious cognitive processes. This is particularly true in scenarios where people have limited time, attention, and cognitive capacity – all characteristics of busy healthcare environments. For this reason, changing how information is presented, simplifying processes, and altering the environment in which decisions are made can change behaviour and outcomes. These changes, even if they appear small, can have a large impact when scaled up across the health system.

What are the suggestions in more detail?

1. Increase hospital productivity by changing default options.

Default options are pre-set courses of action that take effect if nothing else is specified by the decision maker. Defaults do not restrict the decision maker in any way, but since defaults do not require any effort by the decision maker, defaults can be a simple but powerful tool. Areas of particular relevance include setting virtual follow-up as the default for low risk patients and changing the default to day case rather than inpatient (overnight stay) for certain hospital procedures.

2. Increase hospital productivity by reducing readmissions and ALOS by improved discharge.

International research shows that improving hospital discharge processes could reduce readmissions, adverse events, and costs. Behavioural change interventions such as changing existing templates for discharge with enhanced presentation of information are likely to support improved handover. Additionally using behavioural evidence on ways to improve adherence to good practice is also likely to help improve the discharge process. Areas to focus on include improved discharge templates and additional supports.

3. Increase productivity by reducing did not attends through better correspondence.

When a patient unexpectedly does not attend an appointment (a DNA) it results in the inefficient use of staff time, worse care for patients, and increase waiting times for patients. Work has already been undertaken in this area in Ireland through the Better Letter Initiative (e.g., with the BLI projects for validation of waiting lists, the system now uses behaviourally informed validation letters, and a behaviourally informed online response option via POLAR). However, productivity could be increased further by ensuring national implementation of findings from BLI projects (such as hospital appointment offer letters, and text reminders), and by the adoption of a BLI approach to other areas (e.g., dental appointments and an app for hospital appointments).

4. Increase productivity by growing uptake of online services and improving administrative processes through sludge audits.

Sludge is anything in a process that hinders service users or staff. Administrative burdens, such as complicated multi-step processes can make it harder for people to do what they want. Behavioural science can help us understand how best to reduce administrative burden, remove sludge, and reduce friction costs. This would be especially useful where staff administer processes which can be done more efficiently online or where there is the option for the public to avail of online services, home testing or monitoring. Therefore, a key area is sludge audits of offline/manual facilities that could move online and of existing online facilities to increase their use. It could also be useful to hold sludge-a-thons, these are events where burdensome processes are nominated by, for example, staff or service users, and experts come together to rapidly develop solutions. The latter could be particularly relevant to the upcoming transition to Health Regions, which involves the integration of acute and community services across the country.

5. Increase productivity by using behavioural insights to support key good practices in elective care.

A UK report identifies four practices as being particularly important in elective care, namely: stratifying patients by risk and creating low-complexity pathways for low-risk patients; increasing throughput in theatres by measuring, communicating, and managing the number of cases per theatre session; using enhanced recovery practices (including optimising analgesia, hydration and post-operative mobilisation); and providing virtual follow-up for low-risk patients. These are process-level interventions which may already be implemented in some cases, but incorporation of findings from the behavioural science literature into the design of these interventions could help to maximise their impact on productivity.

6. Reduce influenza’s influence on demand and supply by increasing vaccination with behaviourally informed interventions.

The flu is a problem for the health system in terms of illness for patients and staff. Some of this additional demand for health services and loss of supply (due to loss of workdays) could be reduced if flu vaccination rates were increased. Areas to examine are behaviourally informed letters / correspondence for the community, and multifaceted approaches for health workers.

7. Reduce unnecessary short-term demand for emergency departments, and outpatients through decision aids.

International behavioural evidence suggests that interventions that could support GPs in their gatekeeping role, include provision of audit and feedback with checklists to GPs to help to reduce unnecessary referrals for outpatient consultants, and audit and feedback along with decision aids to help reduce non-urgent referrals for emergency departments. Provision of written guidance and decision aids for patients / parents could help to reduce non-urgent attendance at emergency departments. Introducing interventions to reduce unnecessary referrals, follow-ups, or investigations should be done with care, ensuring that reductions occur only in unnecessary and not necessary cases, and to always maintain a clinician’s discretion to decide based on the clinical presentation of the patient.

8. Reduce unnecessary antibiotics prescribing (hence costs) through behavioural interventions.

Resistance to antimicrobials (AMR) leads to higher medical costs to treat complications caused by resistant infections, prolonged stays in hospital to treat resistant infections, increased mortality due to resistant infections, and lower economic output due to reduced workforce participation and productivity. One of the drivers of AMR is the unnecessary use of antimicrobials (e.g. consumption of antibiotics for infections that are not bacterial). Not only does this unnecessary use lead to AMR but it also involves avoidable costs where costs are covered through the State. The Department in collaboration with the University of Limerick is in the process of completing a literature review to identify behaviour change interventions to reduce unnecessary antimicrobial use in the community. This study shows that interventions can reduce unnecessary prescribing and use of antibiotics in the community. Therefore, it is important to get the most from interventions for which the evidence supports their effect such as education, communication training, point of care testing, other decision support tools, and delayed prescribing.

9. Reduce future healthcare demands and costs by growing uptake of screening through better correspondence.

Early detection of cancer, via screening, helps to improve health outcomes and reduce future costs. High uptake of screening is important for it to be effective. Invitations have been found to be an effective way to increase cancer screening uptake. In Ireland the three national population screening programmes operated by the National Screening Service (BreastCheck, CervicalCheck, and BowelScreen) follow this evidence-based approach of sending letter invitations. Nevertheless, it might be possible to increase uptake further (and hence earlier detection) by incorporating behavioural insights into screening offers. This is particularly true of bowel cancer (also known as colon, rectal or colorectal cancer). This is the second most common newly diagnosed cancer in men and the third most in women. Take up of bowel screening is not high in Ireland relative to international comparators. An important area is to incorporate insights from behavioural science into screening offer letters and processes. Following circulation of a draft of this Discussion Paper, it has been agreed that a Better Letter Initiative (BLI) project will aim to use behavioural insights to increase uptake of BowelScreen.

10. Reduce future healthcare demands and costs through better food choice architecture.

Overweight and obesity is a growing challenge for Ireland’s health sector. There are healthcare, social, and economic costs associated with overweight and obesity. There are multiple causes of the increase in overweight and obesity. These include individual differences and biological factors, changes to the environment in which people live, increased availability of food, rapid urbanisation, motorisation, sedentary jobs, changes to sleep, changes to costs of food and cultural shifts. Energy-dense, low nutrition, cheap foods became widely available and were pervasively advertised to potential consumers during the latter half of the twentieth century. Addressing obesity and overweight requires a wide range of responses and policy initiatives including those that create a healthier food environment and enable individuals to make healthier food choices. Three behavioural interventions that could help to facilitate healthier food choices and to help to reduce the rate of increase in overweight and obesity are: calorie posting on online menus for fast-food chains; front of pack nutritional labelling for food products in supermarkets; adopting a policy of using recommended portion sizes supported by using reduced size tableware in canteens in public buildings.

What happens next?

This paper is an input into the activity of the Productivity and Savings Taskforce. Having considered suggestions in this paper, the Task Force’s Action Plan now includes a measure to adopt day cases as default for certain hospital procedures. The suggestions in the paper will continue to inform the work of the Task Force. The recently established Productivity Unit in the HSE will consider the range of suggestions in the paper as it develops its work programme to increase productivity and efficiency.