This is part three of a series about call and recall. In part two I wrote about how call and recall can let hard to reach groups down. In this article I write about how behavioural science can teach us to create better call and recall processes for everyone.
Before working in primary care, I was an economist, and I had a particular interest in behavioural economics.This is the branch of economics interested in ‘choice architecture’ and the human drivers that underpin the decisions we make. This background has allowed me to think about this under-appreciated corner of primary care through the lens of a behavioural scientist. And call and recall is, at the end of the day, a behavioural exercise: practice staff are contacting a list of people in an attempt to get them to participate in an activity which the recipient may not know (or care) about.
When it comes to call and recall,I think the best behavioural tool at our disposal is BJ Fogg’s BMAT framework.
Behaviour = Motivation Ability Trigger
For any behaviour to take place, an individual must have three things: the motivation to perform the behaviour, the ability to carry out that behaviour and a trigger, telling them it is now time for that behaviour to take place.
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These three elements, motivation, ability and trigger, are all equally important. But, too often, call and recall processes elevate the trigger and pay little and less attention to an individual’s motivation to take up the appointment in question or their ability to book and attend it.
Sometimes, a trigger is all you need. This is particularly true when motivation and ability in an individual is already really high.
For example, people who have high levels of health literacy or who already self-identify as people who live a healthy life are much more likely to respond immediately to any letter that comes through the letterbox inviting them to book a health promotion appointment.
Similarly, when the thing that the person is being invited to do is easy, and doesn’t impose a high cost to doit, they are much more likely to do what is asked of them.
Missing: the motivation, the ability or the trigger?
Unfortunately, those situations(where motivation and ability are high) are very rare in preventive healthcare.A factor that is perhaps more problematic is that motivation and ability are not equally experienced by everyone. Things like misinformation and low health literacy negatively affect motivation, whilst factors like digital exclusion impair an individual’s ability to book and attend an appointment.
Let’s take the example I gave in part two of this series, where I frustratingly missed the opportunity to book a woman into an asthma review because of a language barrier.
The practice had employed me to act as a trigger, calling patients one-by-one to invite them to book an asthma review. In that woman’s case I was a highly effective trigger as I had got heron the phone. It’s difficult to say too much about her motivation – it is hard to be motivated by an offer that she probably didn’t understand. But where the call and recall process really fell down was ability. In this case, by having someone who did not speak the woman’s language call her, she had no real ability to book the appointment.
Moving to more inclusive call and recall processes
It really is critical that any call and recall process meets all three criteria, motivation, ability and trigger, if it is to create high public participation. And we need to remember that these criteria are personal – what works for one person will not necessarily work for others.
A more inclusive call and recall process would be more specialised. It would take a behavioural approach, ensuring that everyone’s needs are met so that they can meaningfully access the care that they need to stay healthy. It would also give particular attention to the groups that would especially benefit from this care – groups who, because of the inequality that pervades our society, are more at risk from chronic and long-term conditions. This is similar to Michael Marmot’s ‘universal proportionalism’ recommendation in the Marmot Review.
If primary care is to play the role outlined for it, so that the NHS can deliver the effective preventive and public healthcare that is required for its sustainability, it must get to grips with the behavioural aspects of achieving high public participation for everyone. But it is especially important that we engage the hard to reach, who are most likely to benefit from any preventive or health promotion activity that they are eligible for.
In the next and final article in this series we will go into more detail on our vision for a more effective and inclusive call and recall process.