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Is patient engagement the new blockbuster drug? 

• Patient engagement improves outcomes
• The future is not a continuation of population based medicine
• Personalized medicine requires effective patient engagement
• Doctors are the main obstacle to enhanced patient engagement

If patient engagement were a drug, it would be front-page news, and malpractice for doctors not to use it. A significant and growing body of opinion believes that an effective way to scale care, and enhance outcomes is to develop patient engagement, but this requires a cultural and behavioral change on the part of doctors, which is not happening fast enough.
 

Low patient engagement means poor outcomes 

Each year payers spend billions on treating avoidable chronic lifetime diseases, yet the incidence of such diseases continue to escalate inflicting devastating personal, and social hardships on people and communities. Some wealthy regions of the world, such as the United Arab Emirates, where diabetes is spiraling out of control, have invested in “cathedrals” of diabetes healthcare staffed by experts, but still do not have the costly burden of diabetes under control. See, Diabetes threatens the future stability of the UAE
 

Tackling causes 

In other regions of the world, the treatment costs alone for avoidable chronic lifetime diseases are expected to bankrupt healthcare systems in the near future. The reason for this is simple. Despite eye watering investments in state-of-the-art treatment strategies, and despite some doctors’ initiatives to engage patients, no healthcare system yet has effectively engaged large proportions of patients living with lifetime chronic diseases, and successfully nudged them towards changing their diets and lifestyles, which are the root causes of a substantial proportion of such conditions. 

Dr Seth Rankin Managing Partner of a London based NHS primary care clinic, describes his efforts to engage patients living with diabetes in order to improve outcomes:

       
               (click on the image to play the video) 
 

Behavioral techniques 

Rankin’s endeavors to engage patients benefit from behavioral techniques, which explain how people behave, and encourages them to reduce unhelpful influences on their health, and change the way they think and act about important health related issues such as diets, lifestyles, screenings and medication management. See: Behavioral Science provides the key to reducing diabetes

“Our new pathway of care borrows from the behavioral sciences and engages patients living with diabetes. It’s based on very simple technology, which can provide huge reach at low cost. We are keen to extend our pathway to other NHS Clinical Commissioning Groups, and would welcome support from well capitalized diabetes agencies,” says Rankin.
 

Doctors’ support critical

Rankin insists that, “Only when patients are meaningfully engaged in their own health will they continuously learn how to improve care for themselves”. Effective patient engagement enhances the connectivity between doctors and patients, and is a sound foundation for behavioral change. However, for patient engagement to be scalable and effective, it has to be supported by appropriate IT, and patient-generated healthcare information. 
 

Doctors control patient engagement

Patients gather healthcare information from the Internet, and this encourages and supports self-management, and enhanced understanding of prevention and risk. However, the quality of online healthcare information is patchy, and patients have difficulty differentiating between legitimate and bogus information. This is resolved when doctors’ engage with patients to help them with the interpretation. Some doctors welcome this opportunity, while others object. This gives doctors the upper hand. Even if the situation is improved by enhancing patients’ access to premium and reliable medical information, doctors still decide whether such information is introduced into patient care pathways. 
 

Improved healthcare

Objections from doctors suggest that online health information results in longer and fraught doctor-patient relationships, which are a costly waste of time. But this is not necessarily so. Evidence, such as that published in 2008 in Telemedicine and eHealth, suggests the opposite: that patient-generated healthcare information, and effective patient engagement can lead to better understanding of specific conditions and treatment options, enhanced medication management, reduced complications, reduced face-time with doctors, and reduced visits to A&E. Specifically, the 2008 paper’s findings report that online healthcare information resulted in: (i) 19.74% reduction in hospital admissions, (ii) 25.31% reduction in bed days of care, and (iii) 20 to 57% reduction in the onset of complications.
 

Takeaways

Despite evidence to suggest that patient engagement enhances outcomes and reduces costs, it is not happening at a rate and quantum to render it effective. The main obstacle is the attitudes of doctors who fear an erosion of their status. Only a significant cultural and behavioral shift on the part of doctors will change this, and open the door to the many other professional disciplines, such as behavioral economists, software designers, community leaders, data scientists and risk managers, who are well positioned to help healthcare and medicine deliver better outcomes for patients. 

The future of healthcare is not a continuation of population-based medicine with its one-size-fits-all therapies mediated by general practitioners. The future of healthcare is personalized medicine, which recognizes that patients and medicines are complex and adaptive, which require smart and adaptive systems. This includes greater patient engagement.

The end of doctors 

• A second technology revolution threatens the future of healthcare
• Healthcare systems that ignore evolving technologies will collapse
• Most healthcare systems are trapped by three basic failures
• Doctors are the interpreters and not the processors of medical knowledge
• Will a computer decide to turn off a life support machine?
• Who owns the medical information on the Internet?

The role of doctors is about to change more than it has in the past two centuries, as the technology revolution enters a new era. 
 

Radical change 

This is the conclusion of Richard and Daniel Susskind in their book, The Future of Professions, published on 22^nd October 2015 by Oxford University Press. They argue that, over the next 20 years, “the second future”, dominated by artificial intelligence (AI) and the Internet, will drive radical changes in healthcare systems, which will involve the transformation of how medical knowledge is made available.

Today, computer systems can delve into vast amounts of patient data, identify trends and make more accurate predictions than doctors. Machines such as IBM’s Watson, which can attain high levels of intelligent behavior is already being used in medicine. In parallel, the Internet provides people with new and effective ways to build communities and share healthcare information. 
 

Never too big to collapse 

Some doctors argue that their activity will never change because it depends on deep expertise, creativity and strong interpersonal skills; none of which can be replaced by computer systems. Earlier, managers of global companies that dominated world markets made similar claims before there enterprises grew obsolete and collapsed.

Twenty years ago, the failure of global companies to meet transformational challenges resulted in 74% of them leaving the Fortune 500 as new technologies and innovations opened the way for agile start-ups and entrepreneurs. The list is long, but here are a few examples. Digital Equipment and Wang Laboratories, once leading computer firms, disappeared completely. Even resurgent giants such as Apple and IBM stared into the abyss of irrelevance, and made painful changes before clawing their way back to the top.
 

In the 1980s the advent of digital photography, software, file sharing, and third-party apps ended Eastman Kodak’s world market domination, during which time Kodak made breakthrough technologies, which included the Brownie camera in 1900, Kodachrome colour film, the handheld movie camera, and the easy-load Instamatic camera. Motorola, another global giant, that developed and built the world's first mobile phone, and dominated that market until 2003, failed to focus on smartphones that could handle email and other data; and as a consequence, rapidly lost share to newcomers such as Apple, LG, and Samsung.

 

Dr Devi Shetty, world-renowned heart surgeon, founder, philanthropist, and chairman of Narayana Health, India’s largest hospital group is viewed as the person who will have the biggest influence on 21^st healthcare. Here he describes how information technology is set to radically change healthcare:

    
        (click on the image to play the video) 
 

Healthcare systems not immune

The Susskind’s agree with Shetty, and believe that healthcare systems, predicated upon antiquated patient-doctor technologies, face a similar demise to that of large companies that failed to adapt and change. The more successful healthcare systems will be those, that copy large companies who survived by collaborating with smaller, agile firms either as suppliers or partners. Rigid bureaucratic healthcare systems that find it more difficult to innovate will fail.
 

Three reasons for failure 

Failure to address three major challenges accounts for the failure of most healthcare systems. The first is the continued investments in failing antiquated systems, and the consequent failure to pursue fresher, more relevant ones. The second is psychological: healthcare systems and doctors fixate on what made them successful in the past, and fail to notice when something new is replacing it. The third challenge is strategic: healthcare systems that only focus on today, and fail to anticipate the future will fail.

Previous HealthPad Commentaries have illustrated these three failures by the billions spent on failing diabetes education programs over the past decade, while the incidence of the condition escalated. This is because diabetes education and awareness programs fixate on antiquated systems, and fail to embrace, smarter and more effective ones. See: Behavioral Science provides the key to reducing diabetes
 

The concentration of medical expertise

A doctor’s raison d'être is to provide solutions to problems that people do not have sufficient specialist knowledge themselves to solve. Previously doctors were the ‘processors’ of medical knowledge, but with medical information becoming ubiquitous, increasingly doctors are becoming the ‘interpreters’ of medical knowledge. Doctors are gateways to specialist medical information.

In most healthcare systems, doctors are a huge and increasing expense, a large proportion of them use antiquated methods, and the expertise of the best doctors is only enjoyed by a few. This is changing by technological innovators finding ways to make medical expertise more widely available. Also, technology is enabling clinical expertise to be broken down into smaller tasks, which can be better achieved with a machine; telemedicine is just one example.
 

Who owns medical knowledge?

Online healthcare information empowers patients and threatens doctors by providing people with medical knowledge that previously resided in the minds of doctors. Such knowledge, which can help to diagnose illnesses, is free, increasingly common, and controlled by users. An important unresolved question is, who owns this medical knowledge?
  

Takeaways

Doctors exist to provide solutions to medical problems. If technology provides better more reliable solutions, the need for doctors dissolves. However, the most convincing objection for the displacement of doctors is an ethical one. Is it morally wrong to leave the decision to turn off a life support machine to another machine?

The debate is just beginning. 

The importance of measuring the impact of diabetes care

• Bill Gates says that measurement is key to reducing disease
• Type-2 diabetes is the fastest growing health threat of our time, it is preventable, but not properly measured
• Expensive diabetes programs fail to dent the burden of the disease
• Taxpayers have a right to know the annual impact of diabetes care and education on the incidence, outcomes and costs of the disease
• Healthcare agencies must agree and report clear goals that drive progress

Bill Gates is right. Measurement is central to the success of reducing the global incidence of diseases. Can we learn something from Bill Gates to help reverse the epidemic of type-2 diabetes: a preventable disease, which is spiralling out of control, and set to bankrupt healthcare systems?

Dr Syed Sufyan Hussain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Clinical Lecturer in Diabetes, Endocrinology and Metabolism, at Imperial College London, describes the challenge:

      
             (click on the image to play the video) 
 

The UK

Similar to other developed nations, diabetes in the UK is the largest and fastest growing health challenge of our time. Since 1996, the number of people living with diabetes in the UK has more than doubled: 3.9 million people now have diabetes, another 9.6 million are at high risk of getting type-2 diabetes, and every year, that number is rising dramatically. If nothing changes, in 10 years time more than four million people in England will have diabetes. This suggests that current diabetes care programmes and education are failing.

Diabetes is expensive, and current annual treatment costs alone are about £10bn - some 10% of the annual NHS budget - and 80% of this is spent on managing avoidable complications. For example, diabetes is the most common cause of lower limb amputations, and over 6,000 happen each year in England alone. The result is frequently devastating in terms of social functioning and mood, and poses a considerable cost to healthcare providers, while the financial burden on patients and their families can be enormous.

The total annual costs of diabetes, which includes both direct and indirect costs, such as the loss of earnings because of illness, are difficult to measure, but are estimated to be about £24bn per year. If nothing changes, these costs are projected to rise to nearly £40bn in 20 years. This further suggests that current diabetes care programmes and education are failing. 
 

Doing more of the same 

In its 2015 State of the Nation Report, Diabetes UK (DUK), a large and influential charity, urged the UK Government and NHS England to do more in order to ensure that people with diabetes get the support and education they need to manage their condition. However, if the UK government and NHS England do more of the same, nothing will change, and diabetes will continue to escalate, destroying lives and costing billions. Let us go back to Bill Gates.
 

Measures to drive progress

“I’ve been struck again and again by how important measurement is to improving the human condition. You can achieve amazing progress if you set a clear goal and find a measure that will drive progress toward that goal . . . . This may seem pretty basic, but it’s amazing to me how often it is not done,” says Gates.

The UK government, NHS England, Public Health England and DUK do not share an agreed set of indicators, which measure and report on the impact of diabetes care and education. Given that each year billions are spent on diabetes, these agencies should be obliged to report annually on the impact that their diabetes care and education programs have on the prevalence, outcomes and costs of diabetes. Let us return to Bill Gates, and his efforts to reduce the global burden of HIV.
 

Bill Gates 

The 2013 annual report of the Melinda and Bill Gates Foundation stresses that it, “Enhances, the impact of every dollar invested by improving the efficiency and effectiveness of our HIV program, [which] supports efforts to reduce the global incidence of HIV significantly and sustainably, and to help people infected with HIV lead long, healthy, and productive lives. The global incidence of HIV has declined 20% since its peak in the mid-1990s.” 

Now, tweak the above paragraph to create a gold standard annual report of the state of diabetes in the UK. The government, NHS England, Public Health England and DUK, “Enhances the impact of every pound invested in diabetes by improving the efficiency and effectiveness of our diabetes programs and education [sic], which support efforts to reduce the UK’s incidence of diabetes significantly and sustainably, and to help people living with diabetes to lead long, healthy, and productive lives. [Notwithstanding,] since 1996, the UK’s incidence of diabetes has increased by 110%, complications have increased by 115%, and annual treatment costs have increased by at least £2bn.”
 

Changing demographics

In the above paragraph we used indicative numbers to show direction. Some, but not all, of the reported increases can be explained by demographic changes. For example, over the past 20 years, the UK’s population has increased by 5.5 million and aged, and now more than 18% are over 65, and this cohort is rising. According to the Office of National Statistics, 60% of the population increase is due to immigration. David Coleman, a professor of demographics at Oxford University, suggests that this mass influx of migrants has given the UK, Europe’s fastest-rising percentage of ethnic minority and foreign-born populations, and by 2040 foreigners and non-white Britons living here will double and make up one third of the UK population. 

This has important healthcare implications because type-2 diabetes is more than six times more common in people of South Asian descent, and up to three times more common among people of African and African-Caribbean origin. Studies show that people of Black and South Asian ethnicity also develop type-2 diabetes at an earlier age than people from the White population in the UK, generally about 10 years earlier. All these factors have a knock-on affect for healthcare. According to the Institute of Economic Affairs the changing demographics in the UK has created a “debt-time bomb’ that will require the end of universal free healthcare. 
 

Takeaways

Diabetes plays a prominent role in the health of the UK, and not all of its rising burden can be explained by changing demographics. The escalating burden of type-2 diabetes can be reduced and prevented by effective management and education, which engage people living with, or at risk of diabetes, and changes their behavior. Current education programs fail to do this. 

Instead of asking the government and NHS England to, “do more”, is it not time for those responsible for diabetes care to learn from Bill Gate, and, agree and report annually, measures that inform on the impact that diabetes care and education is having on the incidence, outcomes and costs of diabetes? 

DUK and HealthPad agree on the importance of diabetes education

• Diabetes in the UK is spiralling out of control
• People with diabetes are not receiving the care they need
• Education for people living with diabetes must improve
• CCGs need to increase the effectiveness of diabetes education
• Policy makers must be more open-minded about digital health
• Policy makers should prepare the UK for the digital future

DUK and HealthPad

Diabetes UK (DUK) and HealthPad are on the same page in recommending more effective education to reduce the escalating burden of diabetes. DUK insists that, “Clinical commissioning groups (CCGs) need to increase the availability and uptake of a range of diabetes education and learning opportunities”.

Managing My Diabetes

HealthPad has developed a cost effective digital diabetes education service specifically for CCGs to: (i) increase the connectivity between local health professionals and people with diabetes, (ii) enhance patients’ knowledge of the condition, (iii) propel people with the condition towards self management, (iv) slow the onset of complications and (v) reduce face-time with doctors, see: Reducing the burden of diabetes by online video.
 

The state of the nation 

DUK’s 2015 State of the Nation Report laments that the incidence rates of diabetes continues to spiral out of control, and people with diabetes is now at an all time high of 3.9 million, with a further 600,000 estimated to have undiagnosed type-2 diabetes. Further, 2015 National Statistical Office figures, show that 67.1% of adult males and 57.2% of adult females in the UK are either overweight or obese, and therefore at risk of type-2 diabetes. 

There is no way of preventing type-1 diabetes, which occurs as a result of the body being unable to produce insulin, and usually develops in childhood, affecting 10% of sufferers. However, type-2 diabetes is the result of bad diets and sedentary lifestyles, and is preventable with effective education. Left unchecked, diabetes can result in devastating health complications such as kidney and heart disease, blindness and amputations. Also, diabetes costs the NHS nearly £10bn each year, 80% of which is spent on managing avoidable complications.
 

“Gaping hole” in effective education

DUK director of policy Bridget Turner said, "There is a gaping hole when it comes to diabetes education . . . . This is despite strong evidence that giving people the knowledge and skills to manage their diabetes effectively can reduce their long-term risk of complications . . . . We must get better at offering education to people who are living with diabetes." Dr Sufyan Hussain, a lecturer and clinical registrar in diabetes, endocrinology and metabolism at Imperial College and Hammersmith Hospital, London, has used HealthPad, a digital platform, to develop a portfolio of educational videos for people with diabetes. Here is one about insulin: 

      
                (click on the image to play the video)
 

Calling on the NHS

DUK said that it is “calling on” the NHS to do more. One difference between NHS England and HealthPad is the emphasis they respectively place on digital platforms for delivering diabetes education. Currently, digital platforms are not widely used by the NHS. One possible reason for this is because the NHS is a sanctuary for technophobes. Patients however are not technophobes. General attitudes towards digital healthcare are rapidly changing. The over 65s are becoming increasingly tech-savvy, and quickly adopting digital channels as a source for healthcare information. Research from the Office of National Statistics shows that, between 2006 and 2013, Internet use of the over 65s more than tripled, and their demand for digital health services grew significantly.

Not all health providers are technophobes, and some acknowledge that the NHS has failed to make the most of digital technologies. Changes that these enlightened health providers suggest are contentious; because of the lack of competitiveness the NHS reflects its fragmented single entity, and NHS policy makers stress harmonization rather than competition. This results in the quality of healthcare in the UK becoming a postal code lottery. The NHS cannot expect to improve while there is still a lack of competition and such fragmentation.
               

Network effects

A significant challenge for the NHS is how to deal with digital healthcare platforms: the search engines and websites that constitute the metaphysical health providers in the digital age. What drives new healthcare platforms are economies of scale in gathering and distributing healthcare data and information, which patients want in order to manage their conditions better. The network effects of digital platforms result in more patients finding digital healthcare services ever more compelling. Platforms engage patients, and encourage them to return for updates and more information about their condition. 

Takeaways

It is time that the NHS started to assess the role that platforms can play in the delivery of healthcare. However, the NHS does not know enough to opine with confidence on digital health and the knowledge economy. This does not only result in NHS policy makers being unable to pick technological winners; it also means that technological losers are picking the NHS.

Healthcare and the educational needs of patients must to be conducted in a more open-minded spirit, not simply reflect the status quo, and fall prey to vested interests. The task of healthcare policy makers should be to prepare the UK for the digital future, not to try to stop it happening. 

• NHS England is to spearhead a national diabetes prevention program
• The program aims to prevent diabetes in high risk people by 2025
• 35% of adults in the UK are living with pre-diabetes
• The program MUST report outcomes NOT delivered services
• Type-2 diabetes devastates millions of lives and costs billions
• Big Data strategies can help NHS England improve patient outcomes

Behavioural Science provides the key to reducing diabetes

• Behavioural techniques can help reduce the burden of all chronic non-commuicable diseases

• Each year hundreds of millions are spent on diabetes education that fails

• Each year Diabetes UK (DUK) calls on the government to “do more”

• Each year the personal, social and fiscal burden of diabetes increases

• Wandsworth CCG is implementing a new pathway of care for diabetes

• The new pathway of care benefits from behavioural science

• DUK should advocate behavioural techniques that change behaviour

To reverse the diabetes epidemic, and slow the vast and escalating cost of the condition, Diabetes UK (DUK) should promote behavioural science techniques for diabetes education such as those, which are now being implemented by Wandsworth CCG.
 

Current strategies are failing

According to DUK diabetes is the fastest growing health threat of our times, current care models are not working, and the condition is currently estimated to cost the UK £23.7bn annually. This figure is set to rise to £40bn by 2035 if nothing changes.
In August 2015 Barbara Young, CEO of DUK, warned that diabetes is being allowed to spiral out of control. “With a record number of people now living with diabetes in the UK, there is no time to waste: the government must act now,” she said.

The poor state of diabetes education and care in England is leading to avoidable deaths, record rates of complications, and huge costs to the NHS: 1.2 million more people have diabetes now than a decade ago (a 60% increase), and DUK has warned that its cost could, “bankrupt the NHS”. 

DUK, NHS England, and Public Health England (PHE) spend millions on diabetes education, prevention and screening programs, which have failed to dent the burden of the condition.
 

Diabetes

Diabetes is a chronic condition and, if poorly managed, can lead to devastating complications, including blindness, amputations, kidney failure, stroke and early death. To prevent, detect, and slow the progression of complications, best-practice guidelines say that people living with the condition should regularly receive nine checks, which include: weight, blood pressure, eyes, HbA1c, urinary albumin (indicates kidney function), feet, serum cholesterol (level of cholesterol in the blood), smoking, and serum creatinine (indicates kidney function). Official audits of NHS care in England and Wales show that some 33% of people with diabetes do not receive these checks.

Effective education and care save money

Earlier in 2015 Barbara Young said, “Better on-going standards of care will save money, and reduce pressure on NHS resources. It’s about people getting the checks they need at their GP surgery, and giving people the support and education they need to be able to manage their own condition”.

A better approach

DUK needs to adopt and advocate tried and tested behavioural principles that will lower the risk of T2DM, propel those living with T2DM into self-management, and slow the onset of devastating and costly complications.

Behavioural scientists have generated a set of principles about how people engage in judgments and decision-making, and these have been successfully used by policy makers to explore, understand, and explain existing influences on how people behave, especially influences, which are unhelpful, with a view to removing or altering them. 
 

Tried and tested by governments

The Obama Administration in the US uses behavioural techniques to ‘nudge’ people to make better choices for themselves and enhance public policy. Soon after Prime Minister Cameron took office in 2010, he established the “Behavioural Insight Team” to ‘nudge’ the long-term unemployed into work. If it is good for the White House and 10 Downing Street, it should be good enough for DUK.

Cameron’s Nudge team, which is now well established, found that if staff at job centres texted details of vacancies to the unemployed, they achieved little. But, if they added a greeting such as “Hi Pat”, they produced a better response; and if they signed their name, “Best of luck, John”, the unemployed felt they were dealing with a local friend who wanted the best for them, and they would be more inclined to respond positively. Behavioural techniques such as these have been shown to successfully nudge people to take the right decisions about their health.

“The NHS should consider adding such techniques to its armoury of strategies to reduce the burden of diabetes”, says Dr Ana Pokrajac, Diabetes Consultant at West Herts Hospitals NHS Trust, and DUK Clinical Champion for Diabetes.
 

An important precedent - Wandsworth CCG’s new pathway of diabetes care

Wandsworth Clinical Commissioning Group (CCG) has recently adopted personalized behavioural techniques, following similar principles used in the US and UK, to help make dietary and lifestyle changes in their patients living with T2DM. Wandsworth health professionals are developing and implementing a fully automated new pathway of care for diabetes based on behavioural techniques, which they piloted in 2014, to help reduce the burden of the condition. The pathway is expected to go live in November 2015.

Dr Seth Rankin, the co-chair of Wandsworth CCG’s Diabetes Group says, “We are implementing the first phase of a new and innovative pathway of care for people living with T2DM, which we piloted last year. See; "How GPs can improve diabetes outcomes and reduce costs" The new pathway is aimed to change peoples’ behaviours, and to encourage people to eat healthier diets, lose weight, exercise, stop smoking, educate themselves about the condition, regularly monitor their blood and glucose levels, get their kidneys and feet checked regularly, and attend screening sessions. Behaviours that, in time, we expect will lower the risk of T2DM, propel those living with the condition into self-management, and slow the onset of devastating and costly complications”.

“The fully automated pathway, borrows from behavioural science and is predicated on a rich content library of short 60 second videos, which are clustered and sent by GPs directly to peoples’ smart phones. All the videos have been contributed by local Wandsworth CCG health professionals, and most are accompanied by personalized texts”, says Rankin. 

Figure 1 describes Wandsworth CCG’s fully automated new pathway of care for people with T2DM.
 

Figure 1: Wandsworth CCG’s new pathway of care for T2DM

Diabetes education in need of a new pathway of care

In 2015, the DUK’s State of the Nation Report called on CCGs to set themselves performance improvement targets and implement diabetes action plans. The charity also urged CCGs to ensure that all people with diabetes have access to the support they need to manage their condition effectively, and that the local health system is designed to deliver this. 

“The medical community, including commissioning organisations, need more specific guidance about using technology and behavioural techniques if they are to prevent those at risk from getting T2DM, and reduce the burden of diabetes. Examples like the Wandsworth CCG’s initiative illustrates the strong potential of applying these techniques,” says Dr Sufyan Hassain, Darzi Fellow in Clinical Leadership, Specialist Registrar and Honorary Clinical Lecturer in Diabetes, Endocrinology and Metabolism, Imperial College Healthcare NHS Trust, and Imperial College London.

Below, as part of Wandsworth CCG’s new pathway of care, Roni Shavanu Saha, Consultant in Acute Medicine, Diabetes and Endocrinology at St George’s University Hospital, London provides some dietary tips for people with T2DM:

     
          (click on the image to play the video) 

 

Excursus: behavioural techniques 

Behavioural scientists have generated a set of principles about how people engage in judgments and decision-making. DUK can learn from this. For example, we are strongly influenced by who communicates information (see the illustration above about the long- term unemployed); we are motivated by incentives; we are also influenced by comparisons, and by what others do; we go along with pre-set options, for example defaults; our acts are influenced by subconscious cues, and our emotional associations can shape our actions, we seek to live up to our public commitments; and we act in ways that make us feel better about ourselves. Here are some examples, but first we describe nudge theory.
 

Nudge theory

'Nudge' theory was proposed originally in US 'behavioural economics', and was introduced to policy makers in 2008 by Richard Thaler and Cass Sunstein in their book, ‘Nudge: Improving Decisions About Health, Wealth, and Happiness’. The behavioural principles the authors describe have been adapted and applied widely to enable and encourage change in people, and groups, and have been successfully used to motivate people to lose weight, take medications, exercise, and stop smoking. Let us explain.
 

The influence of others

People are influenced by what others do, and by who it is who communicates information. This knowledge is being used in the US to change the health behaviours and decisions people make. Thus, Wandsworth CCG’s new pathway of care for diabetes uses videos of local health professionals to speak directly to people living with T2DM via their smartphones to nudge them into changing their behaviours. The time individuals spend watching the videos, the frequency viewed, and whether they share the videos, can easily be compared with data across the same indices for their peer group, and the comparisons fed back to individuals. By giving people information about their exercise and lifestyle choices relative to others in their peer group nudges them to change their behaviour and become healthier. 
 

Defaults

Nudge strategies have been used successfully to change health behaviours and decisions through the use of defaults. This exploits the insight that people tend to go with the flow of current options (i.e. defaults). Health providers can pre-set options that promote health and wellbeing and reduce costs, requiring those who want to go against the grain to “opt out”. This has been used successfully in the US by the Center for Disease Control and Prevention, which developed guidelines recommending that opt-out HIV screening with no separate written consent be routine in all healthcare settings. 

Defaults have also been successful in presumed consent for organ donation unless someone has opted out. Austria, France, Poland and Portugal have such systems, and 90 to 100% of their citizens are thus donors, compared to only 5 to 30% in countries that do not use the donor default strategy. Also, defaults have been successfully used in preventative care. In the US, doctors nudge their patients toward regular screenings by giving them a default appointment date and time. Patients must opt out of the appointment. 
 

Memories and subconscious cues

Behavioural science tells us that people are influenced by novel, personally relevant examples and explanations, and such knowledge is being successfully used to change people’s health behaviours and decisions. Emotional associations are embedded in peoples’ memories, and invoking these in images and videos shapes peoples’ decisions and behaviours. Cues can be used to encourage people to make healthier choices through reminders. Nudgesize, a smartphone application, reminds its users to get their daily exercise. Reminders have also been used to nudge people to schedule their screening appointments. 
 

Commitment and ego

Another thing we learn from behavioural science is that we seek to be consistent with our public promises and commitments, and we behave in ways that makes us feel better about ourselves. Several websites take advantage of the fact that people want to honour their public commitments. These allow users to commit themselves to achieve certain goals, such as losing weight, exercising, stop smoking, or eating a healthier diet. One example is Stickk.com, a website where users enter into binding commitment contracts by choosing a goal, such as losing weight in a given time, and appointing a referee to confirm the truth or falsity of their reports. Stickk users, who attach stakes to their goals, enter their credit card information, and if a person fails to achieve his goal, then the card is charged for the agreed amount pledged. According to Stickk it has over 56,000 contracts valued at some US$5.5m; 141,003 workouts occurred that might not have otherwise happened, and 1.1m cigarettes were not smoked that otherwise would have been.

According to a 2005 study reported in the Journal of Geriatric Physical Therapy, commitment strategies have significant influence over peoples’ behaviours even without any financial stakes attached. The study described how 84% of exercisers who signed a contract met their goal, compared to only 31% in the control group who did not sign a commitment pledge. This and similar examples suggest that part of the effectiveness of commitment strategies comes from ego, and our desire to be perceived by others as strong willed and consistent. Ego plays a role in the effectiveness of many nudges. 
 

Conclusion: the way forward

The best chance of impacting on the vast and rising incidence and cost of diabetes in the UK lies in the promotion by DUK of behavioural techniques of diabetes education such as those, which are now being implemented by Wandsworth CCG.