Nudge, nudge is no longer just a phrase out of Monty Python, it is now an arm of Government policy. In November 2010 the health secretary, Andrew Lansley, told us that they would 'nudge' rather than 'nanny' us to better health. The Government is also trying to 'nudge' businesses to behave differently, through voluntary agreements rather than regulation.
It is a reaction against the 'nanny state' so beloved by the last Government. Unfortunately, as with so much that Andrew Lansley says, it all sounds plausible, but one is left wondering what exactly he means – until recently that is. A few weeks ago NHS Bedfordshire said there could be a saving of £700m if missed GP patient appointments were ended.
In a project carried out in the county, researchers looked at the impact of using behaviour change techniques to reduce the number of 'did-not-attends'. It was all done by nudging rather than nannying. The techniques used in the study were: getting patients to confirm their appointment by verbally repeating the details to the receptionist, getting patients to write the appointment down themselves, and placing positive messages around the GP practices that attending appointments is the 'social norm'. In addition they were rung the day before.
The theory behind it, as I understand, is that people are more likely to respond positively and keep their appointments if they have committed to doing so publically, even if the 'public' in this case is just a receptionist. In the normal way of making appointments, the patient is asked whether such-and-such a time is suitable, if so their name goes in the book (or more often on screen), the receptionist writes (or prints out) the appointment card. So the patient is largely divorced from the process and does not feel involved.
The researchers suggested that these techniques could apply to overcoming obesity, giving up smoking and taking on other healthy messages. The public affirmation is a characteristic of such organisations as Alcoholics Anonymous and Weight Watchers. It is not so much making a public statement, as taking responsibility for one's own health and actions.
So does this message have any relevance in dentistry? Is this an approach we could usefully use with our patients to cut down their confectionery intake or get round to flossing? One has to admit it is not generally how we do things and it is not what patients expect from us. They expect to come in, have their mouth inspected and be told what needs doing. Or what they have to do, what we used to call 'oral hygiene instruction'.
Instruction is, however, the very antithesis of the new 'nudge, nudge' approach. Probably what we should be doing is getting them to say out loud: 'I will only eat sweets after meals' or 'I will brush my teeth twice a day'. The theory is that if they say the words out loud they will feel they are committed to act on them. Perhaps as with drinkers many years ago we should get them to 'sign the pledge'.
But patients are only human, which is another way of saying they can be awkward. What happens if they say: 'Look here, I come here so that you can fix my teeth, not to tell you how I intend to change my life. Frankly that is my business not yours.' Perhaps the new, new contract based on prevention not treatment is another way of saying our patients need a nudge, not a filling or scale. Pity no one is telling the patients.