Nudge, Nudge, Public Health England and Behaviour Change

 

“Welcome back Trevor! – As Trevor Hopkins says below following his comment on my recent blog I suggested he might like me to post these as a full blog. Instead he has developed some of his arguments about Public Health England and Nudge. My personal view is that the emphasis on behavioural insights is not as strong or as self consciously planned in Public Health England as the article below might lead some to think and that behavioural insight approaches are not as powerful as we might fear. Nonetheless I think as always Trevor’s arguments are worth reading – if only so that we can be clearer about our own analysis – so read on!”

Mark Gamsu

As a guest blogger can I thank Mark for this opportunity to further explore some of the issues that I raised in my recent reply to Mark’s blog ‘Public Health England, Health Trainers and Health Inequalities’.
In my reply to Mark’s excellent piece I stated that I was not surprised, “when a charity can produce a more coherent narrative on behaviour change than the government’s leading Public Health agency.” I laid much of this on PHE’s lack of a “coherent or up to date” theory of public health. As long ago as 1996 in his book, ‘Health Promotion: Philosophy, Prejudice and Practice’. Professor David Seedhouse famously described public health as a ‘magpie profession’ lacking a consistent theory for their approaches. As you observe in your blog the latest glinting object they have picked up seems to be the ‘behavioural insights’ approach.
The recent LGA publication ‘Behavioural insights and health’ (2016) traces the history of where this comes from,

“Much of the interest in behavioural insights on a policy level stems from the 2008 book ‘Nudge: Improving Decisions about Health, Wealth and Happiness’ which was written by US academics Richard Thaler and Cass Sunstein.”

It has both the look and the witty approach of one of those books on DIY personal improvement you see in airport bookshops.

“Though costumed in the guise of pop economics, complete with a cute logo – Nudge is, in fact, a manifesto for the new paternalism… don’t be fooled. Thaler and Sunstein charm their readers but they are after some very big game. This is a book that measures both the inroads psychology has made into contemporary economics, and argues a compelling brief for the new paternalism. We have ways, say Thaler and Sunstein, of making you happy!”

(from a review by Thomas C Leonard, Department of Economics, Princeton University, published online by Springer in 2008)

Behavioural insights really came to the forefront of government policy though when the coalition was formed in 2010. In fact, the coalition agreement itself made direct reference to the issue, stating that the government would be “harnessing the insights from behavioural economics and social psychology.” So this is quite clearly a Politically (with a big P) driven agenda – some would say, myself included, it looks more like ‘policy driven evidence’ than ‘evidence led practice’. The theory that “libertarianism and paternalism do not have to conflict and that the state can – and should – act as a guiding hand, ‘nudging’ citizens in the right direction.” (LGA – ibid) is highly insidious. Gone is the ineffective old-fashioned finger wagging approach to health behaviour change, in comes state sponsored behaviour change interventions that we will probably be unaware of and certainly, unlike other medical interventions, have not given our consent for.

Perhaps the biggest give-away that this is a Politically driven dogma, possibly an example of lax editing, comes in the 2010 Cabinet Office discussion paper ‘Applying behavioural insight to health’ (forward by Conservative MP Oliver Letwin) which states “The Behavioural Insights Team would like to thank in particular Department of Health Ministers and officials, whose expertise and support were vital.”

So what is ‘dispiriting’ you and me Mark is an ostensibly ’arms length’ PHE resourcing and implementing a paternalistic libertarian approach to health improvement driven by the Behavioural Insights Team based on nudge theory and clearly supported by senior Tory politicians and Civil Servants.

For Foucault the bigger problem is that this is all “predicated on our societal regime of truth, the types of discourse it accepts and makes function as true; the mechanisms and instances that enable one to distinguish true and false statements; the means by which each is sanctioned; the techniques and procedures accorded value in the acquisition of truth; the status of those who are charged with saying what counts as true.” It seems to me that PHE are making all the claims to the ‘the truth’ while ordinary people and communities remain marginalised or ignored in this discourse. In my previous reply I noted that supporters of a fifth wave of public health cited truth as a key issue in their new paradigm.

I will finish with some thoughts from my favourite post-structuralist philosopher and social theorist Michel Foucault that the truth is characterised by important traits, “It is centred on the form of scientific discourse and the institutions that produce it; it is subject to constant economic and political incitement; it is produced and transmitted under the control, dominant if not exclusive, of a few great political and economic apparatuses; finally it is the issue of a whole political debate and social confrontation.” (from an interview conducted in 1976)
To mark his death in 2002 the Journal of Epidemiological Community Health reproduced an article on Ivan Illich’s famous publication ‘Medical Nemesis’ first published in a 1974 issue of the medical profession’s house magazine The Lancet. It contained the following:

“The level of public health corresponds to the degree to which the means and responsibility for coping with illness are distributed amongst the total population. This ability to cope can be enhanced but never replaced by medical intervention in the lives of people or the hygienic characteristics of the environment. That society which can reduce professional intervention to the minimum will provide the best conditions for health. The greater the potential for autonomous adaptation to self and to others and to the environment, the less management of adaptation will be needed or tolerated.”

What do you think?