Rhian Gladman: Welcome to the latest episode of the Nudges for Social Good podcast, from the local government association. My name is Rhian Gladman, and I manage the behavioural change programme here at the LGA. So, the aim of our podcast is really to demystify behavioural insights and provide learning from practical projects from other councils across the country that you can then pick up and try in your own council. So, today I'm joined by Claire Thompson from North East Lincolnshire Council. Hi, Claire, how are you?
Claire Thompson: Hello, I'm good, thank you.
Rhian Gladman: Great stuff. Thanks for being with us today. If we could just start, could you introduce yourself and your role at the council, please?
Claire Thompson: Yes, I work for North East Lincolnshire Council, as you said, and my role is community insights and marketing manager for the council. I also work on a partnership that I have with the NSPCC called Together for Childhood, which is looking at changing things in two of our most deprived wards around neglect and abuse, so understanding those communities and supporting community development.
Rhian Gladman: Great stuff. So, as I said in the introduction there, really what we're looking for the listeners, to provide them with examples, really, of how councils are using behavioural insights, and you worked with us in the previous round of the LGA funded programme, didn't you? So, really, if you could just start from the beginning and just talk us through the behavioural insights project that you ran, and I'll pick with any question as we go through.
Claire Thompson: Yes, so we saw that was the LGA programme and we'd been trialing some insights work as a team within the marketing team, and really looking at how insights can make that difference to the decisions that you make as an organisation, and when the programme came out, our chief executive suggested that we have a look at whether or not we had something that we could work with at the LGA and the Behavioural Insights organisation on, and one of our key areas within the organisation that we hadn't tackled with an insight-led approach, and cancer screening rates was the one that stood out for me. I spoke to our public health team and colleagues within CCG as well about whether or not we should take this forward, and we decided to work on that together across marketing and public health. So, we put that bid in and were successful, which was great.
Rhian Gladman: Great stuff. So, what was the original challenge that you were looking at?
Claire Thompson: Okay. Late presentation is an issue in some of the wards in North East Lincolnshire, and so we decided to have a look at where the screening rates were different and to try and use a behavioural insights approach to try and make a difference to that.
Rhian Gladman: Okay, so it was two wards? The East of the area. So, how did you go about gathering those insights, and how did you go about understanding more?
Claire Thompson: So, working with behavioural insights team, once we'd got that successful, the bid to the LGA fund, we worked with the behavioural insights team to really try and understanding why there was that difference in presentation for screening, and we got underneath some of that. Some of the things we knew already, there are some issues with people being afraid of screening, some fatalism around, you know, 'I don't really want to know I've got that,' a lot of areas of the borough where screening rates are low are actually in areas where people don't go to their GPs anyway, they aren't either registered with GP practices.
Rhian Gladman: So, the original project is around how you can increase cancer screening rates in two specific wards in the borough. Can you say a bit more about how you undertook the research to understand more about what was driving that behaviour?
Claire Thompson: Yes. So, once we'd identified the two wards, those targeted communities, we did some work to look into the practices that served those wards to try and understand what those particular screening rates were for those practices, and then what behavioural insights team worked with us to do was to actually go out and do some more on the ground research. So, working with some community groups and visiting different practices to start to get underneath some of that. We also looked at some previous literature, which behavioural insights had done before, they'd done some academic reviews in the past which had identified some of those barriers, which as we've said, are around fatalism, a lack of knowledge about what screening is, some embarrassment, and also people who just did not use GP services, had an issue with authority and didn't want to be in those buildings anyway. So, that's around trust and confidence. And what we found was that when we had the conversations with residents and with GP practices, a lot of that was borne out in what people were telling us.
Rhian Gladman: Yes, so there is a lot there, isn't there, and there are a lot of different behaviours coming out of this. So, bringing that altogether, what behavioural intervention did you come up with for your project?
Claire Thompson: We had a bit of a journey with this, really. We started off looking at whether or not reminder letters or texts might work with some of this, and decided that we would try a text reminder, once those invitation letters had gone out and people hadn't come along for those, or booked their appointment, we thought a text might work. But when we started to look at that, we realised that quite a lot of the practices that we were working with didn't have the capability to do text or didn't have their phone numbers, because a lot of these people, as I've said, aren't people who regularly go into practices and therefore their details weren't being updated on systems. So, they weren't able to do that. So, we moved on quickly from a text approach to using letters, and the idea originally was to do a controlled trial to send out those letters to people after they'd missed an appointment, or after they'd not got in touch to book an appointment, to ask them to get in touch. That's where we started, and then we started to go through the process of how we move forward with a trial like that within the remit of working across Public Health England and the review boards and NHS ethics and things like that. So, we agreed that we would do the letter, but then the next steps were getting approval to do that.
Rhian Gladman: So, that's interesting, isn't it, jumping back. So, you've got loads of different behaviours there that you've picked through your research and your insight, a lot going on, and then there's, sort of, the ideal what you'd like to do is to do a text messaging service, would be the ideal thing to do, but actually quickly realising that the data that the GP's hold just isn't going to allow you to do that, not having the phone numbers, and then quickly moving to a letter approach. There is a big partnership approach in this project as well, isn't there, that you set out at the start there. How did you keep everyone onboard really in that partnership, with things changing so quickly?
Claire Thompson: Well, early on, we met with some of the people who were already working in cancer screening within the CCG and within the authority, and we brought together a board of people who would be our reference group, really, for the project as we move forward, the cancer screening lead within the CCG, the deputy director of public health. And we also, right at the beginning of this, she's not working with the council and CCG anymore, but there was a lady who was already leading some work within practices around increasing uptake of screening as well, so she was involved in that too and she could tell us about some of the social marketing projects that had already taken place. So, we just kept that group updated all the way through, and we had regular calls with yourselves at the LGA and with behavioural insights as we moved forward with the project.
Rhian Gladman: Excellent. So, yes, real strengths within the partnership approach, but communicating regularly and working really hard to keep all the partners onboard as well? Great stuff. So, the intervention decided upon was letters. Can you tell us a bit more around the content of the letters and how they ended up looking?
Claire Thompson: Yes, the decision was made that the behavioural insights approach that we took with those letters was to look at this from an anticipated regret point of view. So, it was really about if you didn't get screened and then you found out you had cancer later, would you regret it? It was found that was the best one that would work with some of the behaviours that we'd already uncovered with some of that. We found that the best way to send the letter out would be directly from the GP, one of the things that we found with cancer screening letters previously is that they go out from the screening hub and it's from a named person that they aren't aware of, so actually this was a personal letter from the GP practice that they knew, and the GP that they were aware of. So, that's how that was created, that letter, and again we did that in partnership, that was shared with all of the partners and tweaked as we move forward. One of the things that we did do was the original letter that we created was to have an incentive within it, we talked about using a lottery incentive and as we move forward through the approval process for that letter, we found when we went to NHS ethics that was something that they weren't happy with, and also we had conversations with Public Health England as we moved forward too, and their recommendation was that we remove the lottery from that letter. So, we just went for a straight forward anticipated regret letter.
Rhian Gladman: Yes, and I think we talked about the lottery approach as well, didn't we, from ourselves at the LGA. I think it's the replicability, if we're encouraging other councils to pick things up and use them, not every council could do a lottery or replicate that potentially, so there was another dimension there. So, you were going to talk more about getting it through approval and that journey, that part of the journey.
Claire Thompson: Yes. When we first went to NHS ethics, we got a round of those clarification questions, and one of the things that came back was around the trial itself, the randomised controlled trial, and the questions we received about the numbers we were looking at, because when we actually started working with practices and understood the numbers of people who weren't taking forward their cancer screening, the numbers we needed for a randomised controlled trial were a lot higher than that. And because we were working with only several practices within two wards of the borough, we couldn't go much higher than that to keep it in those two areas, so what we did was we looked at that from an NHS ethics point of view and we had those conversations with Public Health England at that point about how we could change this, and make sure that we could move forward with it. And so, Public Health England recommended, when we went to visit them, that we made this a pre and post study, so looking at the numbers beforehand and understanding the people that were responding to that in the previous few months and then the numbers that responded to that, the letter, once we did that.
Rhian Gladman: Okay, Claire, really important point you raised in the previous section there that I just want to jump back to is around the messenger effect, it's a key part of behavioural change, isn't it, who is delivering that message to you to encourage that behavioural change. So, you mentioned that the decision was taken to be the message coming from the GP directly, can you say a bit more about that? I'd just think all the councils would be really interested to hear more about that.
Claire Thompson: Yes, so, as you said, that's a key part of behavioural insights thinking, when you start to look at who people are most likely to best receive a message from, and one of the things that we've found with lots of the behavioural insights work we've done within the council is that we often find that people will receive a message better from people that they know, people that they respect, and that they look up to, and so the absence of that in some of the cancer screening letters was one of the things that we really focused on, a point of doing that from their own GP, somebody they knew at the practice, and we hope that would make the difference.
Rhian Gladman: So, you've started off, you've decided what your challenge is, you've done your insight, working with the behavioural insights team, you've got the reasons that are driving that behaviour, you've then designed your intervention and you've got that through ethics approval, you spoke to Public Health England regionally and nationally, you got your partnership all onboard. So, you got your letters, so when did it go live, how long for, can you tell us a bit more about how the intervention actually played out in real life?
Claire Thompson: The letters went out at the back end of 2019, September was the time that we agreed, after we'd been through ethics and Public Health England approval for this, we finally went out with the letters in the September of 2019 and agreed to run that study for a three-month period, and the way that we did it was we used people who had been non-attenders or non-bookers of appointments with bowel screening for the previous twelve months. And so, those letters went out and we began to measure at that point, the trial finished at the end of 2019 and we got the results through January time in 2020.
Rhian Gladman: And just in terms of the messaging, were the GPs involved in designing any of the messaging, or was it purely you did it through your partnership with local health partners, that way?
Claire Thompson: To start with, we did it through local partners, working with behavioural insights team, but one of the things that we found through all of this was that the GPs were really onboard with some of this, a lot of GPs had wanted to try this, we worked with actually one practice who had already tried to do something similar and had a great result with that, but it had not been done in a study point of view, so it wasn't part of things that were happening in wider primary care networks or other practices. So, yes, the practices were involved, behavioural insights right at the very beginning of this went to meet with all of the practices to ask them if they wanted to get involved with some of this and they were sent the drafts of the letters and the study procedures and the processes and things like that at that point. And then, when we started the project off again after the pause we'd had around ethics, I went back out and had conversations with all of those practices again, and we shared everything with them as we moved forward. So, they were all very happy with what we did, I think, on the final.
Rhian Gladman: I think, yes, that co-design approach has been key to the success of that, really, and you've got a group of people and GPs who want to do something in this space, and you've come along with a solution and involved them in the design of it. So, onto the big question. What were the results?
Claire Thompson: Okay. So, looking at it from a pre and post, the way we did it was we looked at the numbers of people who normally return their bowel screening, and have a definite cancer diagnosis. That was the way we had to do it, so we were looking what the difference we could make through this and, obviously, I mentioned I think we sent the letters out to 1,300 people and in the study two patients had returned their kits out of those numbers. Two patients had returned their kits in the pre-intervention period compared with 54 patients after the letter was sent. So, even in a study with, sort of, those relatively low numbers that about 2-3% of people who take part in bowel screening would have a diagnosis. We know that even in those low numbers between one and two people would have had some sort of cancer diagnosis, so it is statistically significant but actually if it's up-scaled to a much wider number or other practices or authorities use this across the UK you could see a real difference between not doing this and doing this in the future.
Rhian Gladman: It's just huge, isn't it? If one to two actually do take up the screening appointment on the back of this it's all been well worth it. Like you say, and if you extrapolate that up across the rest of your borough and other councils as well. And the key thing is you know because you've measured it, it's not done any harm. It's not made the rate go down, it's only improved it. So you know, rather than in a more traditional sense of we want to do something in this space, let's just have a go at this letter and, sort of, see what happens. By taking this more scientific, measured approach that behavioural insights can do for you, you know it works so therefore you know that if you roll something out you're doing it with confidence that it's measured and it works.
Claire Thompson: Yes, and I think that the benefit of working with yourselves on this is, and having lots of conversations throughout this journey, was that we-, I think there was a nervousness for us that we wouldn't see huge increase by using this but we know that actually anything over 5% is something that is statistically significant so having that 5.4 or 4.4% increase means that we are in that position we know rolling this out, we will save a lot more than then one or two lives that we could have done by using this. And the most important thing for us was that actually when this it wasn't-, it's not about preventing cancers, it's about catching them earlier and we know that what bowel cancer screening does, or other cancer screening does, is catch that earlier enough to mean that lives are saved and so that we know that in that sample size we've got one or two people within that. So our take from this was that we wanted to make sure that other GP practices could see what we'd done and that's across the whole of our borough but then, obviously, to share that wider with people out there.
Rhian Gladman: Yes and as we've talked about before Claire, I mean, with this programme we're not looking for 20-30% increases in-, that's not what we're looking for with these small nudges they are. It is that 1 to 2 to 3% in the direction that you want to nudge that behaviour in that we're actually after due to the, sort of, scale of these trials rather than if there are million plus people in huge national trials, that's not what we're running. We're running very local, very specific, practical, relevant trials for local government, which is a different area of government, isn't it? So, I think that's a great result. And so what's the impact of that result been to other wards taking this, sort of, approach and also are other councils getting in touch with you about it?
Claire Thompson: Yes I've had several councils get in touch around this. We also within-, we had Cancer Research UK waiting for our case study to come out because they were interested in the way this worked as well. I think a lot of lot of people had been watching for that to go on the LGA website so they've had the study and shared that internally. Yes, other councils have been interested. I think from a perspective of North East Lincolnshire, obviously the time that the results came out we were, sort of, just a month or two before Covid and obviously screening stopped at that point but we did manage to get some training that was already going to take place with Cancer Research UK and the CCG, Cancer Champion Training, to nine of our practices and those nine practices are actually practices representative of all of our Primary Care Networks in North East Lincolnshire. So that letter has been shared with all of our Primary Care Networks now and, obviously, that's part of their training package so we are hoping that as screening has now started again and, obviously, what a lot of our screening programmes need to do now are get through the black-log that's been caused by Covid, that actually that will be taken forward. And they're working on that, sort of, early diagnosis work using that letter as one of the examples of what they can do. And our Deputy Director of Public Health has shared that local public health leads as well around cancer screening. So that's been great for us.
Rhian Gladman: And that's the letter that continues to be used so, again, you can continue to gather that data.
Claire Thompson: Yes.
Rhian Gladman: To continue to assess its impact, so that's fantastic stuff. So you've been on this journey-, you said you've been on a journey with this project and it's been quite a long term project we've been working on together, hasn't it? And I just really wanted to get from you, if you were starting this again, if you were listening to this podcast thinking we really need to do something to increase the uptake of cancer screening, I really like this project, I want to take it on board. What are the three tips you would give to a council officer or an elected member listening to this podcast that would help them to implement this project locally?
Claire Thompson: I think from the point of view of this particular project because it's in the health domain and it was something that we'd not tried before in health, particularly across primary care, what I would say very early doors is to have those personal conversations with GP practices and Primary Care Networks to start with about what you're trying to achieve. Because we're in a position now with primary care where those networks are going to be trying to do things together anyway and I suppose if there's that knowledge and expertise that sits within councils and CCGs around behavioural insights or insights projects to go and say, you know, we're looking to do something and will you work with us on that? And to build those relationships. The other side of things for me-, because this sits in the public health domain and that's where cancer screening sits, to go and have conversations with public health as well because one of the things I think we learnt, didn't we, when we went to have those conversations with public health we knew-, we found out straight away that other things were happening in other areas. They'd already been some learnings with some of this so-, and actually there's a way there of being directed in the right direction. Some of the pitfalls we found with NHS Ethics probably wouldn't have been necessary because we knew that actually if we did the study in the way that we ended up doing, we would have been able to move through this quicker. So I think that's probably only two things I've given, isn't it?
So, I think the third one for me is to actually understand, you know, what we've already talked about. This isn't about changing everything and having 50, 60% increases. This is about showing that actually this is one of the tools in a toolkit of increasing something. And it's about even the small percentages make a big difference when it comes to, sort of, particularly in this respect saving lives and making sure that people get the help that they need earlier. So I think maybe don't be too hard on yourselves because it's a piece of work, it's a set of projects where we're actually learning things. And I think one of the things I found through this is I was forgetting some of that along the way. I was hoping that everything worked in the best way possible the first time but actually all of this is about learning about the best ways to do things in local government and move some of this stuff forward. And behavioural insights is new. It's new to a lot of local authorities and one of the things I think we found is that there was a lot of explaining to do to people about what this was and what difference it could make. People who'd never been part of any of this work before, you know, some of us have been on that train and done that learning and are desperate to take some of this forward, but you have to take people with you on some of this so that takes time.
Rhian Gladman: I think that final point's there-, to finish on there Claire-, it's so important is that communication of what it is and I think that's what we're trying to do. Well, I know that's what we're trying to do with this podcast, is that demystifying, that this stuff is very new and the fact that you iterate as you go through, don't you? You were thinking all text messages, but no that's not going to work so we iterate and we go into the letters and you're changing it all the way through rather than just stumbling on the first right answer. I think that's where the learning is richest, isn't it, when you're coming up against these challenges but then you've got to the point where you've intervened and you've got a great result. So, again, just really keen to get those lessons and those top tips from you to encourage other councils to pick up those letters and have a go. So, you mentioned there about, obviously, getting the final results just as we were going into Covid, just be keen to get your reflections on the behaviours that you have seen changing because of Covid-19 in the local communities in North East Lincolnshire and just to say a bit more about that please.
Claire Thompson: I suppose I'd start by looking at it from this, sort of, project perspective. One of the things that we are hearing, and this is anecdotal but we are starting to gather data on that, is that people aren't going to GP practices or calling GP practices at the moment so what Covid has done is obviously reduced numbers face to face. People are tending to leave things later. And, it's that fear. That fear of going out. And the other side of things is around mental health and I know that we're not on our own with this. We've been doing a project recently around social isolation and one of the things that's coming out loud and clear with the Covid information that we're receiving back is that social isolation has increased during Covid. And what's happening is people are now struggling with mental health in a way that they've not before and so we're learning about new ways that we can support people with mental health issues and whether or not the 24 hour helplines are helping with some of that or whether or not we actually need to use a more behavioural insights approach to some of that and offer a new way of people getting in touch. If anxiety's a problem, you know, should we be offering things around a text messaging or social media messaging for people to get the support that they need? I think that we're all seeing some of that and we just need to tweak the way we deliver based on what's happening out there and the difficulties people are finding to actually do things face to face now.
Rhian Gladman: There are obviously some of the real challenging behaviours you're right to say you're not alone in facing as a result of the pandemic. Are you seeing any more positive behaviours that you would like to encourage within the local community?
Claire Thompson: I think the key one for us, and I was involved in the Covid response right at the very beginning of some of this, and the massive community involvement in volunteering, in wanting to support each other, it was huge. The numbers that we were seeing of local communities setting up their own Facebook pages and wanting to find somewhere to register to volunteer and help each other, is something that we know we need to build on. And we need to understand that the thing that made the real difference with Covid on that, because we've looked at increasing volunteer numbers or support in community groups in different ways over that period, we've been having conversations around how we maybe change up what we do. So the issue focus, going back to what I was saying about the work we've been doing on social isolation perhaps what we need to do is share what that issue is and who's facing that. But the call to action actually being around volunteering. You know, you can help with this and what that would do, was not only help the people who are socially isolated that couldn't get out, but actually the people who are socially isolated who at the moment have got not a lot to do because they're not involved in other things. You know, that purpose is really important for some of that. So, for me it's building on those lessons about what Covid has actually done from a positive point of view. The online stuff is huge. Definitely within the council that we all managed to get online within weeks and that's, you know, our IT teams have been absolutely brilliant and, yes we're at home, but in a way a lot of us are even more connected than we were before because we're often, sort of, spending all day chatting to each other probably in a way that we probably weren't before. So, I mean, that's a real positive for me and it's cutting down on our travel time and our carbon and all of those sort of things so it's all great.
Rhian Gladman: Yes. I would agree there, the community and volunteer one has been huge, hasn't it? A huge response. And on a previous episode of the podcast, actually, we've had North Yorkshire council on talking about a behavioural insights project they did with their comms team in order to encourage the local community to step up and volunteer and actually to maintain that volunteering. And it actually becomes part of your life. As you say, part of your purpose, and then it's something you carry on long into the future would just be a great behaviour and trend to see coming out of this, wouldn't it?
Claire Thompson: Yes and the other thing I'd like to add is, and a lot of us within the council and the CCG have noticed this over this period, is the way that we've worked together in a completely different way. Microsoft Teams has made that even more possible but the pulling together of the groups that were looking at Covid which happened very, very quickly included voluntary and community sector organisations straight away. We're all working on a level to get a job done in a way that we've been hoping to do for such a long time and it just worked, and loads and loads of us who've been involved in that, I think across leadership and everywhere else, don't want to lose that. We don’t want to lose the possibility of everyone coming together in a room or on Teams to solve a problem across all sectors and that's something that we've definitely taken forward into the project that I've been working on most recently.
Rhian Gladman: Excellent. So where next, Claire, for behavioural insights in the council, in your role? Where next are you looking to take what you've learnt through this project?
Claire Thompson: Okay, so I have recently moved on onto a project where we're actually looking to learn from how we can use insights differently by bringing data and community insights together so bringing together the qualitative and the quantitative to actually improve the way we learn about particular issues or particular services areas and that work's ongoing. We've been working with an organisation called FutureGov. They've been with us until a couple of weeks ago and what we're hoping to do with that is look at how we change things as a council for the future. So it's all about the way we commission and the way we make decisions, not just across our organisation but with the sector as well and making sure that the community voice is heard in everything that we do. And what we hope to see from that is that when we look at an issue we actually really get underneath that issue. We get underneath the numbers and we also get underneath what the community are telling us about those things, so that when we decide on what the solutions might be it's really based on that community voice. And so the solution may be a behavioural insights solution. It might be a campaign solution. But it might actually be a service solution. It might be something that we've not even thought about doing. It might be something that's based within the community rather than in a service delivery. So that's where my role sits at the moment, we're just, sort of, working through what the next steps with some of this is.
Rhian Gladman: So hopefully it'll go from strength to strength and you've got a really good example to build advocacy around, look, this is what we've achieved. Such an important piece of work and, like you say, saving lives. Saving lives in your local community. So thank you so much for sharing today with us and thank you for your time, Claire, and being on the podcast. We really do appreciate it.
Claire Thompson: Thank you.
Rhian Gladman: So I cannot recommend enough that you go on to our website and have a look at the letters and the report of the project that Claire has set out there. So if you go to our website which is www.local.gov.uk and search for behavioural insights, you will see the North East Lincolnshire cancer screening trial there. Please do feel free to use the letters. As I say, they've been tried and tested and have worked. If you're actually faced with this challenge locally please do use that nudge from North East Lincolnshire. So we have a host of other nudges for social good that you can learn from and use on that web page as well. Please do share the podcast as well with your friends and colleagues and many thanks for listening.
Rhian Gladman: So I cannot recommend enough that you go on to our website and have a look at the letters and the report of the project that Claire has set out there. So if you go to our website which is and search for behavioural insights, you will see the North East Lincolnshire cancer screening trial there. Please do feel free to use the letters. As I say, they've been tried and tested and have worked. If you're actually faced with this challenge locally please do use that nudge from North East Lincolnshire. So we have a host of other nudges for social good that you can learn from and use on that web page as well. Please do share the podcast as well with your friends and colleagues and many thanks for listening.