For nearly a decade, governments have been using behavioral nudges to solve problems — and the strategy is catching on in health care, firefighting, and policing. But is that thinking too small? Could nudging be used to fight income inequality and achieve world peace?
Almost ten years ago, a quiet revolution began in London, in the very heart of the U.K.’s central government. This revolution promoted something that shouldn’t really need promoting: policy-making based on empirical evidence.
After all, wouldn’t it make sense for governments to design policy based on data-driven solutions rather than on opinion polls or personal whim or (worse yet) the demands of the highest bidder? This was the revolutionary idea behind the establishment in 2010 of the Behavioural Insights Team — or as it’s more commonly called, the Nudge Unit.
Its mission was to translate the best current social-science research into simple and inexpensive policy changes that would help collect taxes more efficiently, get the unemployed back to work faster, and perhaps even increase happiness and well-being. So far, the unit has had plenty of successes (as well as a healthy supply of failures), has been exported to or imitated by many governments around the world, and also inspired a new generation of behavioral practitioners, often in unexpected places.
Since its founding, the Nudge Unit has worked on a variety of societal problems. One particularly successful intervention concerned the notices that the U.K. tax agency sends to people who haven’t yet paid their taxes. The Nudge Unit found that simply informing late payers that everyone else pays their taxes on time was a highly effective nudge.
“Adding that one line — ‘Nine out of 10 people pay their tax on time’ — would that lead to people just paying up without further prompt? With no further action?” asked David Halpern, the chief executive of the Behavioral Insights Team. “And the answer is yes, it did.”
Among some of the Nudge Unit’s failures: various grit-based interventions designed to improve academic outcomes for teenagers, which produced some positive effects on attendance but not on pass rates. Halpern’s team has also been unable to persuade people to use public transit to get to the airport. Another intervention designed to nudge people into getting their homes insulated actually backfired, and made them less likely to take the desired action. But for Halpern, the failures are just as valuable as the successes.
“Everybody wants to celebrate and talk about the examples that work,” he says. “The fact is you should expect the majority of things you try, if they’re innovative and quirky, will not work… We need to be open about that. And actually, we need that list so that we don’t keep [failed initiatives] and repeat them.”
The Nudge Revolution has spread widely in the U.K., to some unlikely places, including firefighting. Sabrina Cohen-Hatton is the chief fire officer of West Sussex Fire and Rescue Service; she also has a PhD in psychology and is the author of The Heat of the Moment: Life and Death Decision-Making from a Firefighter.
Over the last decade, Cohen-Hatton has been researching decision-making in high-stakes situations. Firefighters, she says, are often afflicted by “decision inertia,” which she defines as paralysis in the face of “all of the thoughts about what could happen and the repercussions and the accountability on yourself.” Cohen-Hatton and her collaborators have developed some techniques to improve decision-making in these dangerous situations.
As she explains: “The decision-control process is essentially a rapid mental check where commanders ask themselves: Why am I doing this? What’s my goal? How does this link up with what I’m trying to achieve? And they then ask themselves: What do I expect to happen? And then finally: How does the benefit justify the risk?”
Cohen-Hatton trained fire commanders in this decision-making process — first in a classroom setting, then in simulations, and then in staged fires in derelict buildings. She found that the training didn’t increase the length of time it took to make a decision (which is a good thing in an emergency setting) and did increase levels of situational awareness.
Police officers in the U.K. have also started to experiment with nudges. Alex Murray has been a policeman for more than 20 years and recently became commander for specialist crime with the Metropolitan Police in London. He is also the founder of the Society of Evidence-Based Policing. In one experiment Murray oversaw, the police in a large U.K. city’s police department passed out door stickers with large dogs to houses that had recently been burgled and also to the houses nearby. (If you’ve been burgled once, you’re more likely to be victimized a second time, as are your neighbors.) Then Murray and his collaborators compared crime rates in the areas with the door stickers to a similar control area.
“There was less repeat victimization in the test area compared to the control area,” Murray says.
Just like David Halpern, however, Murray has overseen a few failures as well. His favorite concerned an experiment on the effects of plastering inspirational graffiti all over the walls of a jail cell.
“If you go into a police cell in the U.K… you sit and you look at a blank wall for up to 24 hours… ’” Murray says. “So we thought — well, captive audience. And we put graffiti on loads of cell walls, and this was growth-mindset graffiti. Positive messaging purporting to be from an offender who’d previously been in there and graffitied on the walls.”
The graffiti said things like: “Think, what’s the one thing you can do to make sure you don’t end up back here? Remember, and when a door opens, do it.” Or: “What I do is my choice and I chose something else. When I left, I did things differently and it took effort. I won’t lie. But it paid off.”
Murray and his colleagues then assessed whether the people who had spent time in the cells with inspirational graffiti had better outcomes than the others. Unfortunately, they didn’t.
“It might be that we got the messaging wrong,” Murray says. “It might be that growth mindset in a cell wall just doesn’t work.”
Sofirefighters and police officers are trying to use nudges to reduce crime and improve decision-making under fire, literally. How about the medical establishment? Mitesh Patel, a physician and professor at the University of Pennsylvania, is also the founder of the Penn Medicine Nudge Unit — which is thought to be the first such team of its kind. It grew out of an unusually successful and completely unplanned nudge.
As Patel tells the story, his hospital had long wanted to increase the use of generic prescriptions, which are nearly always considered equal to name-brand medicine at a much lower cost. One day, an IT person at the hospital was working on a different prescribing issue and decided to change the system’s default setting. The anonymous IT worker simply added a checkbox to the prescribing form; doctors would need to check the box if they didn’t want the pharmacy to fill the prescription with generics. Almost overnight, generic prescribing rates went from 75% to 98%.
“The next week or so, the health system got a phone call from our largest insurer that said, ‘You just went from last place to first place in generic prescribing. Instead of penalizing you, we’re going to give you a bonus,’’ Patel says. “And the first thing everyone said is, ‘This is not possible. We’ve been last for years.’ And then we realized what had happened: one hour of work resulted in $32 million of savings in the course of two years.”
Another successful intervention at the Penn unit targeted the rate at which doctors manage the aftercare for cardiac patients.
“Typically when someone has a heart attack, we know that exercise is good for them,” Patel says. “There’s actually a structured program called cardiac rehabilitation. It’s a 12-week program. You go in for two, three, or more sessions, and you do exercise and get advice from a cardiologist. It’s like having a free gym membership with a cardiologist available for consultation. There’s essentially no harm to it. Everyone should get it.”
Doctors at Penn, however, were telling their cardiac patients about the program only about 15% of the time. Patel’s team realized the cause: for cardiologists, the referral process was onerous, requiring them to first identify which patients were eligible and then fill out a detailed form with each patient’s medical information. The cardiologists were simply too busy. So Penn started using electronic health records to identify eligible patients and relying on other members of the care team to fill out the forms. Today, when rounding cardiologists arrive at an eligible patient’s room, the referral form is already filled out. Now 85% of eligible patients at Penn are referred to cardiac rehab programs; and the attendance rates of those who are told about the program increased from 33% to 55% because of the extra effort made by clinicians to connect patients with convenient rehab facilities.
Patel’s team is now working on two of the biggest challenges in the modern health care system: convincing people to exercise more and reducing the use of unnecessary tests. They’re also trying to make sure their research helps patients at other health systems.
“Our goal is to hopefully spread this around the country,” Patel says.
Inretrospect, many of the successes of the Nudge Revolution seem quite simple, almost predictable — the low-hanging fruit on the tree of societal problems. Can behavioral science also be applied to more complicated problems like income inequality, market failures, or low levels of social mobility? David Halpern thinks it could be.
“One of the deep ironies of behavioral economics is it hasn’t been applied much to economics,” Halpern says. “I mean, imagine a labor market where you actually knew where there’s a really good place to work — not just what you’ll be paid but how good a boss is, what your progression of opportunities would be, and so on. Most individuals applying, they don’t know the answer to those questions.”
Halpern also hopes to see nudge science applied to bigger problems outside of economics. Problems like: How do you build connections between people from very different backgrounds?
“If we take that simple trust question — ‘Do you think other people can be trusted?’ — it’s a better predictor of national economic growth rates than levels of human capital,” says Halpern. “It’s phenomenally important, how you feel about your fellow citizens.”
Fortunately, universities are great at cultivating both human capital and social trust — at least, among those who leave home to attend university.
“That actually matters, that you break your social bonds from home, and you mix with a whole load of other people of different backgrounds,” says Halpern. “You learn the habits of trust, which you then carry with you for a lifetime.”
And just how far can you take nudges toward social cohesion? Halpern is hopeful that these tools will one day be able to prevent wars.
“It’s not just about whether you pay your taxes on time, important though that is, but will you end up trying to kill your neighbor?” Halpern says. “You know, two wars start a year, typically — why can’t we use these same kinds of approaches to see if you can make it less likely that war will reignite in the future or occur in the first place?”