Podcast transcript (Nudges for Social Good) – north east London councils using behavioural insights to address local health inequalities

Transcript of episode 14 of our behavioural insights podcast – Nudges for Social Good – in which Vickie Rowland (former public health practitioner at the London Borough of Havering) and Stéphanie Renucci (managing director and founder of insight and innovation agency UNPITCHD) discuss how they have been using behavioural insights to address local health inequalities by increasing the uptake of health checks offered by the NHS.


Rhian Gladman: Welcome, everyone, 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 behaviour insights programme here at the LGA. As you know, our aim is to demystify behavioural insights and provide learning from practical projects across the country that you can then try out in your own council. So our regular listeners will recall that, over the past year, we've been working with groups of councils or consortiums to run behavioural change projects. And we've previously heard from the Yorkshire and the Humber Consortium project to increase sustainable travel. So today is the turn of the councils from the Northeast London Consortium and we're going to hear about their project to address local health inequalities by increasing the uptake of NHS health checks. And it's great to have Vickie and Steph here with us today. Good afternoon, how are you both?

(00:00:58)
Stephanie Renucci: Hello, hello, thanks for having us.

(00:01:02)
Vickie Rowland: Hi, thank you for having us. I'm good, thank you, how are you?

(00:01:03)
Rhian Gladman: Great stuff, thanks for the time this afternoon and, you know, spending your time sharing your learning about this interesting project with all of our listeners today. So over to you ladies to introduce yourself. Vicki, over to you first, please.

(00:01:16)
Vickie Rowland: Right, hi, yes, I'm Vickie Rowland and, during this project in particular, I was a public health practitioner at the London Borough of Havering in the public health team. I'm now currently working with the behavioural science specialist in the behaviour change unit at Hertfordshire County Council and my background is I'm a health psychology trainee and I'm just about to complete my professional doctorate. So yes.

(00:01:47)
Rhian Gladman: Congratulations on that, I know you've been working hard on that, effects and stuff. And Steph, over to you.

(00:01:53)
Stephanie Renucci: Yes, hi. So my name is Stephanie Renucci, I'm the managing director and founder of an insight and innovation agency called UNPITCHD, we're based in London and, as part of this project, I've been very much the point lead and director.

(00:02:14)
Rhian Gladman: Great stuff, welcome, Steph. And so, just to, sort of, kick us off, I'm keen, Vicki, to get an understanding of the background from the council's point of view of the motivations of applying to the LGA's behavioural insights programme and this project in particular.

(00:02:31)
Vickie Rowland: Yes, of course. I mean, as I've mentioned, I'm a health psychology trainee so I've got quite an in-depth interest in behavioural science and particularly applying it at a population level. And I started working in the public health team at Havering and it was quite clear that they were quite keen to embed more behavioural science into the work that we were doing but it was just working out, sort of, how we were going to do that as a local authority and still be able to keep up, obviously, with all of the usual public health work that we do. I'm a firm believer that behavioural science is in the work that we do anyway but it was really nice to make it explicit. So, actually, I saw the programme advert on your website, on the LGA website, and I took it to our director for a study at the time, as I thought it'd be a great opportunity for us to do that, sort of, embedding that behavioural science into the work that we do. And he was really quite keen and so, before we put in a bid, we obviously knew that this was a consortium-type programme, we would have to do it with other councils. So I attended the monthly Northeast London director of public health convention meeting and, sort of, presented what this programme might look like for us. And how it'd be beneficial for all of the Northeast London public health teams. And actually, I was really pleasantly surprised with how enthusiastic everyone was about doing this project and I was really pleased that that interest was there. So that's how it, sort of, came about and we then started discussing around quite a few different topics, around health inequalities, access to healthcare services, cancer screening, and we actually put in quite a few different bids. And I linked up with June (ph 04.46) from City and Hackney, who helped me create the expressions of interest.

And then that's when it came up around, sort of, the health inequalities, the health inequalities bid that was really, we were quite keen on, actually, because of what was happening at the time with COVID really exacerbated those health inequalities that were already there and I think it was, sort of, opening everyone's eyes, saying, 'Wow, we really need to do something about this.' So that's how it really all came about for Northeast London.

(00:05:21)
Stephanie Renucci: Yes, I think for us, being the supplier, we got the challenge and the brief a little bit later on, right? After all the councils and the consortiums had been mulling on this problem of how do we increase access to healthcare, how do we correct inequalities in access to healthcare. In, well, not quite the aftermath but after the first, sort of, two waves of the COVID pandemic, I think that's where one of the key challenges of this project lied, is that we had to deliver a public health programme and intervention, really, in the middle of the pandemic, actually. And I think there's really quite a lot that was learned from that perspective. So, when we, sort of, kicked off the project with the LGA and the consortium, the objective and the intent was very clear, reducing access inequalities in access to healthcare. But the question of how and what challenge exactly, you know, how do we reposition around that challenge, that was really the first thing that we had to uncover. So our first step very much was to say, 'Okay, what exactly are the barriers that we're seeing in access to healthcare? How is that manifesting itself, what are those, sort of, where is the rich hunting ground where those inequalities are manifesting themselves more?' And we had a really long list of potential areas that were brought forward by the councils. It went from, sort of, increasing childhood immunisations to increasing access to cancer screening or even increasing access to dental health, if you remember. And so, yes, we landed on increasing access and increasing uptake of the NHS health checks for a number of reasons. The first one, of course, is because there was a prevalent issue in all the councils in our consortium. It was, you know, something that was very high on the public health agenda and still is, but also because it was the practical choice, right? We knew that we would be able to really create and launch an intervention that we'd be able to monitor quite well over a short period of time, and consistently across all our councils. So that's, kind of, how the NHS health check statement came about.

(00:08:10)
Rhian Gladman: So there's, I guess, the story there is around a long list from the councils and then, obviously, it's the first time we've worked across consortiums of councils in this manner, isn't it? So can you tell me a bit more about how you did get that consensus, really, around that one challenge? Because that's obviously, for other councils listening and thinking, 'How could we replicate this?' Would be something they'd be keen to hear about.

(00:08:35)
Stephanie Renucci: Yes, absolutely, and that was very much challenge number one, the alignment. So the one thing to perhaps highlight even more is that, in designing a behavioural-led intervention, we really need to focus, right? We really need to find this area of focus and, to drive alignment and identify those issues across councils. We took two approaches, right? One was to say, 'Where is the data, what is the data telling us?' You know, what are the most pressing issues that you're seeing? And then we tried to, so that's from the, sort of, the public health lens, and then we applied a number of filters going down a funnel to bring more and more precision. And through each of those layers, we worked down different questions. So, you know, where are the most pressing problems, is this something that is being worked on elsewhere in the council? In which case we wouldn't have approached that because we didn't want to double up on resources. Is this something that, you know, we know is a problem that is most prevalent with the most deprived parts of the population? Because this was about, you know, decreasing inequalities in access to healthcare. So we had a list of, sort of, successes criteria that each of the councils could apply. And so what that meant is, when we had the, sort of, one or (TC 00:10:00) two final possible challenges identified, the alignment was quite easy because we followed the data towards that. And so the alignment was almost natural, I think, at that point. There are perhaps a few councils I had to make concessions but we agreed in the room to, sort of, disagree and commit, and that we knew that, whichever challenge we would have chosen anyway, we would've worked towards this overall goal of decreasing inequalities in access to healthcare anyway, so yes.

(00:10:37)
Rhian Gladman: Yes, and I think, from a public health perspective, I think, Steph, you have touched on that. I think, for us, it was also, you know, what was a common driver for each of the councils? And, you know, NHS health checks, it's a statutory service that we all have to deliver and we all do commission. So we thought that actually makes a lot of sense because we're all quite-, we all have involvement in NHS health checks to some capacity, all of our teams, whether it was the person on the consortium or not, there was that link with NHS health checks. We knew we had some access to the data, obviously, you know, having a contract for NHS health checks. So that was something that really drove that and I guess, for me personally, I was quite driven, I'm quite keen for NHS health checks, I think it's actually a really fantastic preventative service and I think, with what was happening with the pandemic and services being impacted, this was one that was quite significantly impacted throughout that, obviously, people weren't getting their checks because they weren't able to do them. You know, the NHS were under so much pressure so when we were at a point where we perhaps could decrease these inequalities but also help with the uptake of NHS health checks in the same time, it just made sense, for me. And I think you're right, Steph, I think the majority of councils were onboard with that. I think there were some other areas that would have been absolutely fantastic and really great and interesting, but this one just seemed to make sense for everyone, actually.

(00:12:32)
Stephanie Renucci: And I think, as Rhian, you know, mentioned many times, the point was can we create, can we trail blaze in the approach and almost then, sort of, bank those challenges and say, once we've done it once, let's go back and do it all again on another challenge together. So we weren't necessarily closing the door, I think we were just trying to prioritise the, sort of, the most pragmatic and sensical challenge at the time.

(00:12:59)
Vickie Rowland: Yes, absolutely.

(00:13:01)
Rhian Gladman: I really like that, Steph, disagree and commit. Yes, I like that.

(00:13:08)
Stephanie Renucci: I think I stole it from Jeff Bezos, so you know, not exactly an original.

(00:13:15)
Rhian Gladman: So we've landed on our challenge as a consortium, it's all about increasing health checks and we've got the consensus there. The next step is obviously to understand what is driving the behaviour of people not taking up the health check and what can we do to encourage the behaviour to take it up. So could you say a bit more about how you went about finding out what the barriers were to behaviour we wanted to encourage?

(00:13:39)
Stephanie Renucci: Sure. Should I go first? Yes, so I think this was, really, the next phase after align, right, if we go back to our plan, comes to, sort of, identify, right? So we've done a primary data exploration at that point, where we've quantified the, sort of, the issue in access to NHS health check. What we didn't know at that point was who is most likely to not participate in the NHS health check and why? You know, what are the barriers, what is the behaviour, what are the behaviours that the, sort of, the people not accessing the health checks are more likely to exhibit? And so what we embarked upon at that point was a, sort of, a big primary insights campaign where all of the consortiums, everyone in the council went and tried to understand who our targets would be, right? Whose behaviour we are going to try and change through the intervention, sorry? And so, for that, we ran a number of focus groups, we had actually-, Vicky very helpfully helped us launch a survey within a newsletter that was launched by the council so that we could understand the attitudes towards NHS health checks in the, sort of, the wider population. I think we did quite a mad number of interviews, if we think about it, something close to, sort of, the 50 people that we surveyed qualitatively and we got close to 200 responses in that survey, a very popular newsletter that Vicki sent. And what that data has done for us is that it's really enabled us to zero in on the who, right? Who we will be targeting for this intervention and what behaviours they were exhibiting. Let me talk about that before I go into the detail of that, so in terms of the who that was a really interesting demographic profile. Surprisingly or unsurprisingly for listeners, what we found is that gender was really driving, sort of, the health-seeking behaviour. So men primarily were much less likely to attend an NHS health check. Younger men, amongst those who are invited at the health check, where invites started at 40, and so it was really the men between 40 and 59 who were least likely to attend those NHS health checks with their GPs.

And we found that it was those men in the, sort of, the most deprived deciles one to four who were exhibiting that sort of behaviour. We did not find a significant difference in behaviour, at, sort of, at the level of ethnicity. So that was really interesting for us, so we kept the, sort of, the target behaviour at that, men between the ages of 40 and 59 in the lower deprivation deciles. And, in terms of the behaviours that they were exhibiting, that's where it's interesting, right? So what was leading those men to basically feel very overconfidence about their health or just, you know, just disregard the services, the texts that they were being sent or that letter that perhaps they were receiving through the mail. And so that's where we found, if I remember correctly, about twelve different types of barriers, of behavioural barriers. The first one of which was the total unawareness of the NHS health check. That was the biggest, sort of, barrier that we found. And, you know, one that was extremely interesting for us but that one that ultimately we couldn't do very, very much about or we can't do very much about directly. Then I think there were a lot of barriers related to general perceptions of the NHS. Both positive and negative, and remember this was all at the time of COVID. So, in the middle of the pandemic, we had basically two types of behaviours and perception. One people thought, 'Oh, I am young, I am in health and the NHS is absolutely overwhelmed, particularly at the minute, they do not need one more healthy, relatively healthy young man to come in, they just need to, sort of, carry on with what they're doing.' And then other types of perception which were a bit more negative, which was where, 'What is, sort of, one test going to be able to do, what is the NHS going to be able to do about monitoring my health once every X years?' And there were, sort of, quite a lot of negative reception around the potential efficacy of those tests and the validity of those tests.

We found a number of, sort of, more administrative and practical barriers around people anticipating issues with booking, so that was both real or imagined but thinking, 'Oh, it's going to be a nightmare to get in, I'm not going to be able to take time off work, this is not something that, you know, often,' particularly in the affluence profile that we're targeting could not afford to take time off work. So that sort of thing, and then, finally, I think quite a lot of, as you'd expect, quite a few barriers and biases that, sort of, displayed a bit of an ostrich effect, right? What I don't know doesn't hurt me (TC 00:20:00) or, you know, the overconfidence around one's health, we're in our forties and going, 'I'm in good health, I'm young, this isn't going to happen to me.' So that was the, sort of, the landscape at the time.

(00:20:19)
Rhian Gladman: Vicki, were there any surprises in terms of those findings? Anything, you know, obviously you'd looked into this type of research before, is anything from this particular bit of insights gathering that you, sort of, thought, 'Oh, I wasn't expecting that'?

(00:20:32)
Stephanie Renucci: Yes, I think what was interesting was the relationship with the GPs and the, I think one of the biggest drivers or causality links, basically, between some one who would attend their health check versus someone who would not was just a level of closeness that they had with their GP. And, actually, that was one that was difficult to action for us, right, because it was, sort of, a vicious or virtuous cycle, whichever way you put it. But I think there was the biggest pre-determinant in saying, if someone is going to attend and basically go to their GP, is whether or not they go there already. So this is not so much a surprise but, sort of, an added layer of challenge for us when we're designing the intervention. I think the surprise, really, probably, had more to do with the, sort of, the divergence in those perceptions of the NHS. How you could basically have, within one population, sort of, two separate and such extreme and diverse beliefs around what the NHS can do for them or couldn't, indeed.

(00:21:54)
Rhian Gladman: And does that echo, Vicki, your-, from the council point of view?

(00:21:58)
Vickie Rowland: Yes, I think, for me, I was surprised at how many were unaware of the health check and I think it's, sort of, opened my eyes to, I guess, my own assumptions that, obviously having worked in that area, I just assumed it was-, I didn't assume everyone knew about it but, actually, I was surprised that the number of people who hadn't heard about it, particularly with people who had potentially should've been invited, sort of, two, three times by that point. Considering, you know, that they're invited once every five years, and so, that, for me, I was a bit like, 'Oh, so how are we going to increase the uptake if people don't know what it is?' Really, and that was the biggest thing, I think perceptions around health were quite clear and I think I wasn't hugely surprised about the differences in the perceptions, necessarily. But yes, I think, from a public health perspective, I thought, 'Wow, that awareness, it's just not there, which was quite impactful, for me.

(00:23:15)
Rhian Gladman: Yes. So we've got our challenge, we've done our insights and research, we're understanding the twelve barriers that are, sort of, driving against the behaviour we want to see. So what are the next steps from there?

(00:23:30)
Vickie Rowland: So, from there, in a way, I want to say the fun begins, right? Because you've got your challenge, you've identified your behaviours to change, then what we needed to do was go into ideation, you know, and say what are the possible solutions? And, you know, our agencies are insights and innovation ones, so I think we always placed quite a lot of importance on the, sort of, the stimulus and the ideation part of the process. Or anyway, that's what I'm saying, that's where the fun began. I'm very biased, obviously, but what did there with the consortium is that we embarked upon an exploratory research, but we did ask the programme managers and the councils to have a scan around, you know, how could we basically nudge people towards adopting the, sort of, challenging those barriers that we'd identified, try and understand from other industries how businesses were achieving that. There were great examples from, obviously, other behavioural science interventions, so try and get some stimulus around that.

Then we had this, sort of, this one ideation session where we came up with a long list of possible, potential behavioural interventions. I think, by the end of which, we had seven to choose from and they ranged from, you know, above the line campaigns where we thought, 'Well, maybe if we have a line of communication with a superhero, right, that would come and help break the barriers around this overconfidence bias of feeling invincible,' you know, as a man in your forties. If we have a superhero who comes on-screen or on paper and says, you know, 'I, too, go to the NHS health check,' we could break this invisible-, invincibility bias perception, that was one idea, for instance. We had others that were more, sort of, around the targeted messaging to improve the response rates to the invites, right? Because what we'd identified is that people didn't receive, actually, quite a lot of comms around the NHS health check, they just weren't responding, they weren't booking that check. They weren't booking that appointment. So then we explored a number of things from referral schemes to, sort of, testimonials and that's where we landed on the voice notes.

(00:26:27)
Stephanie Renucci: Which was the one we chose, do you want me to go through it?

(00:26:32)
Rhian Gladman: Yes, please do. Please do.

(00:26:33)
Stephanie Renucci: So, okay, so one of the barriers that, well, the many barriers that we've identified, is that people don't go to the health check because they have the, sort of, health receptions, those biases, feeling overconfident, feeling that, if they don't know, it's better. And feeling that, basically, people like that don't need to go to a health check, a behavioural science technique that's, sort of, proven and very efficient is to say, 'Well, if someone like you tells you that it's been useful for them, you'll be more inclined to go, right?' That's, sort of, the-,

(00:27:14)
Vickie Rowland: Social norms.

(00:27:14)
Stephanie Renucci: Exactly. And so, what we thought we would do is that, sort of, testimonial mechanism but, instead of having it as part of a leaflet or an email or even spelled out in the text, we tried out a voice note, actually, to make it even more personable because we know that hearing is one of the most, sort of, intimate forms of conversation. We know that voice notes are also increasingly, sort of, popular as a way of communicating more than SMS, and so we thought, 'Let's update that invite, that text, that SMS text, make it even more compelling and let's attach to it a voice note that is recorded by a man in-between the ages of 40 to 59 within our affluence target,' and attach that to the invite for I think six to eight weeks and see what happens.

(00:28:25)
Rhian Gladman: So we're using that, sort of, messenger effect, again, that we've spoken about on previous episodes of the podcast and just really carefully choosing who the messenger is. Who's delivering that voice note and matching it to our target profile both in terms of gender and affluence, as well. So how was that message delivered, what was the mechanism by which the nudge got out there into the community?

(00:28:53)
Stephanie Renucci: So what we did was attach it, I think one thing to be mindful of when we're talking about delivering an intervention in the, sort of, the public health space, right, is that it's obviously heavily regulated, right? So it's not like we could go and find a number of phone numbers and, sort of, start sending out invites on our own. We have to work very closely with the CEGs, with the councils, with the GP practices and ensure that, you know, we would be able to improve the message, the existing invite but within the existing framework, right? Hence your question, and so we've had a lot of help, actually, from not only the councils but partners in the various CEGs who helped us understand how do the invites go out, how they're being (TC 00:30:00) written, the softwares that are being used to do that. And how we could target as much as possible those new invitations, so what we did was we recorded, we had a few councils record for us messages and we selected the one that we thought was, sort of, most spontaneous, right, which was a testimonial, right? So this was a man in his forties basically saying, 'I've just been through an NHS health check and it's been really helpful, you know, they found out that I've had to make some tweaks about my diet, I'm really glad that I did it,' right? So something like that, and we've attached that to the invite, the councils helped us recruit sixteen practices and what we did was design an intervention, sort of, trial, with a control group and an intervention group to make sure that we could not only send out those messages but monitor the effect that it would have on actual attendance.

(00:31:21)
Rhian Gladman: So, sorry, Vicki, you were going to come in there?

(00:31:24)
Vickie Rowland: Yes, I was just about to say what Steph had said anyway about actually NHS health checks, invitations are generally sent by GP practices, if that's the model they use, that's not the only model that councils used but that's the model that Northeast London GP practices were using at the time of this project. So GP practices would send out invitations and these invitations could be via letter, text message or could even be a face-to-face invite. So, like Steph said, we worked very, very closely with those GP practices to ensure that it was in-line with how they already worked because we were quite mindful of not wanting to creating any more work for them with implementing this intervention as well. Just obviously, again, we work, obviously, implementing this during the pandemic, I think we started the third phase, you know, third wave at this point. So it was a bit of a tricky time and so we didn't want to create, obviously, more work for them then, but also, you know, just be mindful of what capacity they also had with actually carrying out the NHS health checks. So yes, it did require a lot of that, a lot of close collaborators working with them. So yes, it was just that's all I was going to say.

(00:32:51)
Stephanie Renucci: Yes, yes. Right, because it's easy to gloss over the, sort of, the administrative side once it's done but then suddenly it was quite a lot of logistics involved.

(00:33:03)
Rhian Gladman: I think I just want to pick up a point there, Vicki, around obviously busy GP practices, you talked there about, you know, being mindful of reducing administrative burdens in order to, sort of, get them onboard. Where there any other tips to share about how you encouraged busy GP practices to take part in this project with everything else that they-, the pressures they were under?

(00:33:25)
Vickie Rowland: Yes, I think, actually surprisingly, a lot of GP practices were quite keen to get involved anyway. So, sorry it's not a very behavioural answer, but the interest was there. And they were keen to improve their uptake, the uptake of NHS health checks more generally as well. So it was quite good to get those GP practices but, you know, I must admit there were obviously other GP practices saying, 'We absolutely do not have capacity to do this,' and completely understandably so. So again, we just had to work, just let them know that we're absolutely mindful and that was fine. But I think, for me, it was having those close relationships initially with those GP practices, as well. You know, having worked with them previously on NHS health checks and different other capacities, obviously really brought those relationships and that trust that we already had with them out. So that was really, really helpful and, obviously, so we knew how they worked and they knew how we worked, so yes.

(00:34:43)
Rhian Gladman: Yes, that's a really important point to highlight, that takes work, and as you were saying, Steph, it doesn't happen by accident. There's a lot that goes into that so I just wanted to really pull out how you'd done that, built those excellent relationships with your stakeholders. So how long did the intervention last for?

(00:35:02)
Stephanie Renucci: It was live for eight weeks and I think the, yes, absolutely, the, sort of, the relationships that each of the councils had with the surgeries were absolutely foundational in helping us not just recruit the GPs but then launch intervention as well as monitor, right? Because I think it's one of those things, even if, in this instance, it was a text message and a voice note, there was quite a lot of tech involved in the background. You know, sort of, again, which software do you use? And there's, sort of, two types of software that are being used, by and large, in that, sort of, geographical area, and then ensuring that the GP, the surgery, and we know how busy they are and especially how busy they were coming out of the omicron wave, who spent time every week with our project managers and our councils, sort of, checking in, saying, 'Are more people coming in?' You know, is there, sort of, a technical issue, when do we end it? So I think that was, you know, sort of, a quieter eight weeks, perhaps from the outside but very much one where, actually, all those relationships need to be in place and everything needs to be monitored very closely.

(00:36:37)
Vickie Rowland: I think you're right, Steph, I think Lauren, the project manager for UNPITCHD really stepped up in terms of building relationships and that's the core and meeting with ours, as well, every week, and constant contact with the GP. It's not too much so to overwhelm them or overburden them but just enough to be able to maintain that relationship and say, 'If you do need any support or help,' I actually think that was probably pivotal in this intervention implementation, definitely.

(00:37:14)
Stephanie Renucci: Yes, absolutely. Thanks, thanks Vicki.

(00:37:18)
Rhian Gladman: So we often get asked about the data in these projects and, you know, how did you monitor, how did you measure the success of the trial?

(00:37:29)
Stephanie Renucci: That is a very good question which has many layers in this instance. So the first question is how would we measure the impact of an intervention on GPs just following the pandemic, right, through a very, very, very dramatically, sort of, that's changed the shape of the data in all the GP surgery and the NHS in any case. So that was our first challenge, we thought, 'Okay, what can we compare it with?' It's not like we can just go and say, because, you know, we ran in the spring and we couldn't go and say, 'Well, let's go and monitor what happened last year in the spring,' because that previous year was the pandemic year. And the previous one as well, so that was a statistical challenge from one. And we decided to approach to take, sort of, a different and different approach and compare the data we collected during those eight weeks with 2019 baseline data before the pandemic. So that was number one, statistical challenge. Then there is a, sort of, I would say, a regulatory challenge, right?

So how can we safely access non-identifiable data? And, sort of, get to, still to a level of granularity that is enough to enable us to run some analysis and perform analysis that's going to be meaningful. And that was the second challenge, so what we've done there is heavily relied once more on, sort of, the friends of the consortium who have been able to introduce us do the right clinical commissioning groups, the right CEGs, the right people in the primary care network to find a pathway to data and very kindly, sort of, the same Mary Suzie (ph 39.45) has done the data extraction for us on their main software, which is EMIS. And they've done the, sort of, the data extraction for the 2019 baseline data, looking at booking and attendance and they've done it (TC 00:40:00) also for the time of intervention. Looking at various demographic, sort of, attributes across gender, age, deprivation and ethnicity, and using that in addition to the, sort of, the contextual observational data that we got from the GPs who were running the trial, we've been able to assess the impact of the intervention.

(00:40:31)
Vickie Rowland: Yes, and can I just also add just, yes, we absolutely relied on the CEG to help with this. They actually aggregated all the data before giving it to the councils to ensure that there was no identifiable information in there of patients or anything like that that was sent to us. So it was all aggregated to a level that was not breaching of those. So I just wanted to also make that point very clear because that's quite key, I think, particularly when doing interventions in such sensitive areas such as health. It's really something that needs to be considered.

(00:41:18)
Stephanie Renucci: Absolutely, and I think this could've been a big stumbling block for us had we not had the, sort of, the right contacts lined up with the information governance officers in your council and, sort of, other areas, Vicki. And yes, the pathway to data, I think, in ensuring that it's clear from a regulatory perspective is really, really important.

(00:41:42)
Rhian Gladman: And the CEG is, what does that stand for?

(00:41:48)
Vickie Rowland: Clinical Effective Group.

(00:41:49)
Stephanie Renucci: Clinical Effective Group, and the one that particularly helped us and that we must mentioned is one of Queen Mary University of London and they've been an absolute ally for us in this data collection and ensuring that not only we could have access to the data but it was in the, sort of, the most confined way.

(00:42:11)
Rhian Gladman: That's, yes, I think that whole point around finding the allies, finding the wider team across the consortium earlier on who're your stakeholders who can help you in terms of data, who can help you in terms of comms and getting the message out there. Like, that's a key learning we're finding from the councils going through our consortium approach, is to build that team around you as a project manager within your council so that you have that support back at base from the work you're doing with the consortium. So really, really important to put that one out, and so what were the results?

(00:42:45)
Stephanie Renucci: What were the results indeed, I think the best way to describe the results of our intervention is that it worked a little too well. And by that, I mean that we were targeting, as a reminder, we were targeting those men, ages 40 to 59, in, sort of, a certain deprivation decile. And what we found through the data and through analysis is that our intervention had worked on them, right, and they had, during their attendance to health check had improved, sort of, slightly during the period of intervention. However, what we also found is that, in comparing the results from the intervention surgeries with the control surgeries, that those patients who had received a text and voice note but who were not within our demographic target, namely women, particularly women, or women of BAME ethnicity particularly, actually attended less the health checks. And so it had a dissuading effect on those who did not feel targeted by the message, so that's a really interesting one and I think, in a way, I'll repeat that, it worked a little too well. The behavioural principle at play, which is, in its simplest terms, is, sort of, saying, 'I'll be influenced by people like me,' worked but the counter dependent of that is that you will be dissuaded by people who are not like you. And this, sort of, lack of representativeness in the message was really very much a double-edged sword. And I think there's loads of conclusions that can be drawn from that and, yes, sometimes there's, sort of, more value in the negative value than in the positive one. But yes.

(00:45:05)
Vickie Rowland: Okay, I think, for me, as well, I think it's fantastic that, obviously, we'll got such good results but I think, for me, this really, really highlights the issue of unintended consequences. Something that I perhaps personally, sort of, not considered too much during the project, and this is a huge learning curve for me and something that actually really actually needs to be considered right at the beginning of a project. And, for all its really, like, useful for us to know, like you say, Steph, actually learning, you actually almost learn more by that by we really need to be considered of, actually, if we do try and decrease these inequalities here, what are we doing over there? And what wider impact is that actually having on maybe the system or the individuals, and so it's really, I think that's really quite stark for me, that it came out and a really important thing for all to consider doing any sort of project beyond behavioural projects. Just understanding what the unintended consequences could be, they don't always have to be necessarily negative but it's just considering what wider impact that might have.

(00:46:27)
Rhian Gladman: Absolutely, absolutely. And it's really hard to see behind corners, right? I mean, ultimately, that's the challenge here.

(00:46:37)
Vickie Rowland: Yes, of course.

(00:46:38)
Stephanie Renucci: But I think, as we help, sort of, build up the base knowledge, right, that exists, and hopefully through literature reviews and through thorough research, we can at least take comfort in the fact that, even with this podcast, we're helping other people see behind that corner, you know.

(00:47:04)
Vickie Rowland: Absolutely, you've got to start somewhere, you know, you're not going to know everything and there are going to be unintended consequences that you can't foresee, but it's something to be mindful of throughout, I think. Absolutely, yes.

(00:47:19)
Rhian Gladman: Definitely. And that's what we want, are the councils listening in to be mindful of that and learn from your-, it was a pioneering project we hadn't done before, so we definitely want to share this story around unintended consequences. And that point, you say, Vicki, around at the very start of the project when you're thinking about data, where are we going to get our sources from, where are we going to understand the barriers and get our insight from, there is that other piece around what potentially could be the unintended consequences. Almost your risk register at the start of a project and the majority won't come to anything but it's part of that designing a trial, isn't it? So it's really an important point, so.

(00:47:57)
Vickie Rowland: Yes, absolutely.

(00:47:59)
Rhian Gladman: So, bearing in mind those results, Steph, you talked about some conclusions and recommendations, you know, what are the conclusions, recommendations for the councils to take forward based on those results?

(00:48:10)
Stephanie Renucci: Yes, so I think there are, sort of, recommendations that have to do with replicating that sort of approach. And we know that some councils have gotten together ever since the trial's finished and, you know, they're aiming to apply those learnings, which is fantastic. So I'll go through those, and then there's really learning, sort of, typically how to increase attendance to NHS health check, really, which those are the practical learnings. So when it comes to that, I think what our recommendation would be, they're, sort of, around saying, 'Well, let's have some more gender-specific voice notes,' right? In the future, to also be targeting women, there's also a very clear, sort of, cultural lens what we would love to do or we would love to see in a future intervention is to have the, sort of, the format replicated but be available in more languages. As to bridge, sort of, attendance inequalities for various communities.

We also found that the language that they use in the SMS that was attached to the note was meant to basically ease concerns around difficulties of booking, right? So we said, 'Yes, I've reserved a spot for you in the practice,' and whilst it made quite a lot of people feel special, right, if that text was not met with practical availability in the practice, actually, it raised quite a bit of frustration. So there's also a lesson there around aligning availability with the messaging where (TC 00:50:00) possible and encouraging the practices to tweak those messages are actually in a more agile and frequent way. I think we, very much, I think we stand behind this idea of improving the SMS and adding the voice notes, where we'd love to see, and in terms of recommendations, it's, sort of, try different angles, try and target it as much as possible because this is really where the operating behavioural science principle could work and could really drive access to health checks.

(00:50:42)
Vickie Rowland: Yes, absolutely. And I, if I can add on just a few thoughts from my end, as well, from a public health perspective, I think it's really key to understand that, obviously, when you're doing a behavioural science project, you have to be very specific. You have to be very targeting of what the behaviour is going to be, who you're going to target and all of that. And actually, there was a lot of findings that we had at the beginning that we weren't able to address, which was also really important for us to take forward as council. So things like this unawareness of NHS health checks as an initiative, and I think I really would encourage people to just not forget about that initial work that you already had done, that real key insight work that, for all you might not necessarily be able to take all of it forward, actually, we can go back to that and it just shows how important really understanding the population is. So, for us, you know, I've fed back to our council around the relationship with GPs being absolutely key, I think that was a huge recommendation for us. But also this accessibility in booking appointments, that was actually something we discussed as a potential intervention, wasn't it, Steph? What influence did we have in actually being able to change that, and we didn't have that at that time but perhaps that's something someone could take moving forward, so I think, for all those really key recommendations that Steph has mentioned regarding the findings, it's almost as well, like, let's look beyond those as well and look at what we have already in our bank of knowledge and insight and what can we now use with them moving forward with what we've known now from this project. So it's almost like building on that project, which is really exciting, so it's not like it's just done and dusted now, we can then use all of this moving forwards. But yes, so.

(00:52:45)
Rhian Gladman: Great. So coming on to my final question, so we always like to finish the podcast with some practical tips for councils that are listening thing and thinking, 'I really want to, you know, implement in my local area.' So I'll ask you first, Steph, so what are your top three tips to those councils listening, thinking, 'How can I-, I want to implement this but what are the top three tips, you would say?'

(00:53:09)
Stephanie Renucci: Okay. Data will have to be number one, thinking really, really far ahead around access to data, hurdles and, again, particularly when it comes to making sure, or areas where compliance might be an issue. I think trying to get, yes, as much clarity around the pathway to data from an extremely early point, really, it's as early as kick-off would be number one. Number two, we've mentioned allies and allyship, I think, you know, we wouldn't have time to list all the people who've actually helped us beyond the council and beyond our respective teams. I think that finding basically those points of strength, using the connections that each of the PMs, the programme managers, have had within our consortium. You know, we wouldn't have been able to deliver that if it hadn't been for those specific allies around, yes, the CEG, as we've said, the CCG, so that was really essential. And then I think number three is probably around governance and, sort of, clarity on roles and responsibilities. I think especially as the size of the team increases, having extreme clarity around roles and responsibilities around the consortium is essential to make sure that we not only deliver but if we do it with-, instil a great sense of momentum and energy, that'd be that.

(00:55:04)
Rhian Gladman: So that's around, yes, so the councils being clear what they're doing as project managers on it, the supplier being clear, the LGA being clear, you know, getting that roles and responsibilities all into place.

(00:55:14)
Stephanie Renucci: Exactly, exactly. And, as much as possible, sort of, trial that with great visibility ahead. And I think it's always this very difficult balance of discovering a new problem but trying to apply a, sort of, a rather rigid, defined construct around roles and responsibilities. That's the tension.

(00:55:34)
Rhian Gladman: Brilliant, great three points. Vicki, your three tips.

(00:55:40)
Vickie Rowland: Yes, I was just frantically thinking then while Steph was talking. But I think, for me, one key point, really understand what the behaviour is you wanted to change, I think that is absolutely key and pivotal. It's quite often that we do tend to fall into the trap of an outcome being the behaviour, but actually, we're really being specific about what that behaviour is, I think, is absolute key. And also making sure that everyone on the project knows what that is, as well, fortunately we didn't really have that problem but, you know, that can happen. The second point I would say is, particularly coming from, like, a council perspective and perhaps maybe from a perspective of where we might not have behavioural expertise, like Steph's team coming in, if you were to go ahead and do something like this on your own, really have someone who is an expert in behavioural insights and the council helped drive the work. You need that enthusiasm and drive because you do come up against barriers and resistance and it's not because people don't want to do it but it's because it is tricky, I think Steph has alluded to a lot of the logistical barriers that we came up against. It's not easy so I think having that person to really drive that would be-, is key within a council. And I think this, sort of, really aligns nicely with my third point, is don't be afraid of being innovative. Try it, trial it and see where it takes you. Because you learn a lot more by doing it than by not, so that's my advice.

(00:57:28)
Rhian Gladman: I love that. Final point to encourage innovation, brilliant stuff. Right, thank you so much for your time, Vicki and Steph, thank you for being with us today. And we wish you well with your future behavioural insights work and we'll have to speak to you again on the podcast, you'll have to come back and talk to us about how things developed, so.

(00:57:49)
Vickie Rowland: Absolutely, thank you for having us.

(00:57:51)
Stephanie Renucci: There you go, thank you. Thanks, Rhian and thanks, Vicki.

(00:57:55)
Rhian Gladman: Great stuff, thank you all to everyone for listening, please do share this with your colleagues and your networks and we're really keen to understand if there's any potential future topics or speakers you'd like to hear from on the podcast. So please to drop us an email at behaviouralinsights@local.gov.uk and we'll make sure we feature them on the podcast. Thanks for listening.