Tuesday, 23 August 2011

Does having diabetes make you ordinary or extraordinary?

An eye-catching news item about disabled people has made us stop and think. It discusses why disabled people might undertake dangerous or gruelling (or both) activities, such as trekking to the Arctic or running a marathon.

Diabetes magazines and websites often feature people with diabetes doing extraordinary things, like climbing Everest, trekking in a rainforest for weeks or – yes, you’ve heard of this one – winning many gold medals at the Olympics. You could almost be forgiven for thinking it was obligatory to ‘overcome’ the condition by proving that you are somehow extraordinary. Leaving aside the obvious question about whether these activities do have a life-enhancing, diabetes-defeating effect, the fact is that in reality, doing these things is off most people’s radar screens, whether they have diabetes or not.

So do you have to prove yourself somehow ‘normal’ if you have a condition like diabetes? Our thinking about this is that having diabetes doesn’t make you any more or less able to do ANYTHING, and nor does it mean that you have to prove anything. 

There will always be people who enjoy and succeed at ‘super ventures’. Having or developing diabetes might uncover your desire for these, or if that desire is already present, it will not stop you, and for this we salute you. But there are many more less adventurous souls who are happy just to get through each day and count its successes and blessings – this seems to us equally worthy of celebration and it would be great to hear a bit more about the ordinary life achievements, as well as the extraordinary!

What’s your view? Are you an adventurer or a get-through-the-day-er?  Has diabetes made a difference to how you view life?   The discussion is open!

Monday, 15 August 2011

There's a nudge coming your way very soon!

How would you respond if you were told that an aspect of your behaviour was different from that of most people, for example that most people were taking more physical activity than you each day, buying more fruit and vegetables each week, or even paying their tax bill more quickly than you? 

This may or may not concern you, but whether it does or not, you will be seeing more of these kinds of messages in supermarkets, letters from the tax office or at work very soon, because these ‘nudges’ are firmly built into health and social policy ideas for the next few years.

Where does nudge come from?
The idea of behavioural nudges was developed by two American professors and published in a book, unsurprisingly called ‘Nudge’. It describes how we might be prompted to change our behaviour by our environment, but without restricting our right to choose. And the UK Government has taken up this message in a very big way. One of its first actions when coming into office was to set up a ‘behavioural insight group’ to look at ways health and social behaviour could be influenced, and the authors of Nudge are said to be advisors to the group. 

So far, the group have raised several nudges that will come into regular use in the near future. These include a change to the wording of an overdue tax letter and an automatic opt-in to pension schemes. Other ideas being discussed are working with supermarkets to reorganise products and messages on their shelves to make it easier to buy healthier products, and inviting you to make a charity donation when you are withdrawing cash from a hole in the wall.

How do nudges work?
The theory is quite straightforward. As humans, we behave in certain ways, for example:
1.   It’s known that our choices are influenced by what’s immediately available in the environment
2.   We tend not to opt in to something, but once in, we tend not to opt out
3.   We respond to rewards
4.   We like to feel similar to other people, rather than different

So, putting this evidence into practice may result in strategies that help us successfully change our behaviour.

If you’re thinking ‘so what’s new?’, you are not alone. We already know the effect of peer pressure, and in recent years we have all seen desirable or special offer products being positioned near checkouts to tempt us. We have also all got a purse or wallet full of reward cards. So in commercial terms, we are often ‘nudged’. However, nudge theory has not yet been applied to creating national health related policies.

In pursuit of this, the aforementioned behavioural insight group have recently published a document discussing how nudging could be applied to health, using examples from many areas, including diabetes. It cites one pharmaceutical company’s blood glucose testing product, which offers points on popular computer games for each test completed. Apparently, as a result, more tests are done because the user feels less pain and forgets about the experience more quickly when it is coupled with playing the game, which is a distracting and enjoyable activity.

Is nudging a good thing?
Although it’s important for people to make choices that are right for them personally, nudging could be a useful way to make people aware of options they hadn’t yet thought of, and so there would definitely be some value in ‘moderate nudges’. There’s no doubt that there’s a big need for change in some areas of our lives, particularly health related – you only need to look at the growing size of the nation (literally!), concerns over the livers of teenagers, and the lack of physical activity in the population to know that. We also know that conventional ‘telling people what to do’ doesn’t work in the long term, and many of our good and healthy intentions only last a few months before we relapse back into our old ways. Anyone who’s tried to lose weight more than once will know this so well! So maybe a well-placed reminder or two to do the right thing will really help and there’s a fair bit of evidence for that.  Also, nudging focuses on providing only choices that result in a positive outcome.  Applied to health, where often only the negative aspects of taking certain actions are presented, nudges could be a particularly welcome development.

On the other hand, what about our right to choose and not to have our behaviour psychologically manipulated? Where will it end? The cash machine telling me to spend my money on attending Weight Watchers instead of buying wine? My driving licence only being issued if I agree to donate my organs if I die in a car crash? My doctor’s surgery restricting my appointments because I haven’t performed as well as other people with the same condition as me? Obviously these are extreme examples, but then nudge is based on the fact that human behaviour is somewhat irrational, and also that we tend not to opt out if we are automatically opted in… so perhaps we need to be aware of these possibilities and be alert for that ‘nudge too far’?

A more intriguing question for us and one which is consistent with our philosophy of enabling people to make the right choices for themselves, is ‘could people nudge themselves?’ Knowing a bit more about nudging and knowing what our priorities for change are, could we arrange things in our own lives to make it easier for us to make different choices? For example, making ourselves more aware of our unhealthy behaviours by counting the number of our friends who don’t smoke, or who do eat 5 a day, or who have successfully lost weight? Setting a mobile device to regularly ask us about the amount of physical activity we have undertaken? Even reorganising the shelves in our cupboards or fridge so the healthy options are easier to reach? Then again, if it was that easy, perhaps we would already be doing these things - so perhaps we DO need the bony elbow of the health ministry to help us!

What’s your view about nudging? What would ‘nudge’ you - or are you un-nudgeable? This topic is now open for discussion…

Friday, 5 August 2011

Blood Glucose Testing Savings...or not?

An article in a diabetes nursing journal last month described how a PCT was able to reduce its costs by £500,000 over 2 years by cutting back on the number of blood glucose meters offered to people with diabetes and thereby the amount of blood glucose testing strips being prescribed. This is extremely impressive and hopefully the money saved will be ploughed back directly into diabetes self management education. The article did not state whether this would be the case, but did say that blood glucose monitoring should ‘only be used as part of self management education’.

This begs the question for us ‘What parts of diabetes care should not be used as part of self management education?’ Hospital and GP practice based consultations? Diabetes specialist nurse consultations? Foot clinics? Dietitians? Retinal screening? Pharmacy prescriptions and medicines reviews? If we are going to pick and choose who should and who shouldn’t do blood glucose monitoring on the basis of self management education, perhaps we should also start limiting many of other aspects of diabetes care which very often do not promote self management? That would save as much money if not more, plus the incalculable cost of time, stress and wasted journeys. 

More than once we have heard about consultations where someone is told off or given limited information to help them self manage their condition. Many times the attitude of ‘patients don’t do as they are told, they are simply non compliant’ comes through the stories of health professionals. It’s particularly hard for people with diabetes who have attended diabetes structured education and learned so much about managing their condition in all its carb counting, insulin adjusting, hypo treating, correction bolusing glory, who then visit a clinician who simply tells them off for having an HbA1c outside the recommended range and accuses them of not sticking to their diet!

Obviously if we simply applied the cost-cutting principle to all these other aspects, we may end up with fewer services all round. But what if the money saved were redirected to investment in services which were truly self management orientated? That would really be something. There are welcome suggestions of this in the current health reform aspirations, but we have yet to see which ‘babies’ are thrown out and which survive the metaphorical bathwater that is the Health Bill.

So, back to our question: why should it only be blood glucose monitoring that is offered in the context of self management education? Surely every single aspect of diabetes care should ‘only be offered’ in this aspiration? Blood glucose monitoring limitations can bring eye-catching savings in the short term, but without a proper, self management focused strategy alongside this decision, the real costs of doing so will start to become evident in the long term. We also need to bring more accountability into the ‘people’ cost of diabetes care provision, and make sure that we are investing our money to provide real self management support and services.