As the saying goes, 80% of success is showing up*. And the same is true in public services. Every day, millions of people across the globe don’t show up for hospital appointments, school, job fairs, and so on. It might be as little as a few minutes or hours out of someone’s day, but these missed appointments could be the critical screening test that catches a cancer early, the lesson that helps you pass a critical exam, or the job fair that shapes someone’s career. This not only includes service users, but also public sector employees – as our recent blog post on increasing attendance among teachers and principals in Peru highlighted.
If you’re more interested in system design and efficiency, then it’s also worth noting that missed appointments waste an incredible amount of time, effort and money for government bodies across the world.
Fortunately, there is now a fairly well established evidence base for behaviourally informed text messages increasing attendance across a range of public services, such as health, employment and education. Interestingly, many of these results seem to translate well across international borders.
For example text message reminders for hospital appointments showed strikingly similar results in the UK and Australia, both in terms of the most effective messages (pointing out the financial costs of a missed appointment to the hospital increased attendance most in both Sydney and London) and the size of the effects we saw. This is despite the differences in the health care systems of the two countries and the demography of the people seen at the hospitals.
Six years ago we established BIT’s Australian office in Sydney, which now works with a range of State and Federal governments across the country. Our first and longest standing partnership has been with the New South Wales (NSW) government. Over the last 6 years, the two of us have had the opportunity to work closely with and inside the NSW’s Behavioural Insights Unit (BIU), and have been fortunate to support the team in tackling ever more challenging policy problems and run increasingly sophisticated trials. This week the BIU published its latest batch of results, including trials – that among other things – showed that low cost, text message prompts can increase attendance in a number of very different contexts.
Complex operational environments
One trial demonstrated that text messages can increase attendance at Domestic Violence (DV) hearings.
Few policy trials to date have focused on attendance within the context of DV, and many people, including from within the criminal justice system, believed it would be impossible to run a robust trial in this tricky area, let alone to actually shift behaviour. But thanks to the hard work of NSW Police, the Ministry of Justice and the BIU, we were able to navigate a number of operational challenges and conduct a randomised controlled trial that showed a 23 per cent reduction in non-attendance (4 percentage points).
This also helped speed up the finalisation rate of court processes, reducing both the costs and stress that can be associated with lengthy court cases.
Mobilising support networks
Another trial showed the impact of using text messages to draw on the power of social networks. As we all know, the people around us – our friends, family, and colleagues – have a huge influence on our daily lives. This source of support, however, often goes untapped by policy makers.
In the UK, BIT has run a series of trials in the education space, where text messages sent to students’ nominated ‘study supporters’ (most often their friends and families) helped boost attendance and attainment.
NSW BIU used a similar concept, but this time the text messages were sent to employers, and focused on what their apprentice learnt that week at college. This built on qualitative research highlighting that many employers didn’t know what their apprentice was learning, and as a result may have been less likely to support them in using this knowledge in their day-to-day work, or to encourage them to attend college.
Again, there were remarkably similar effects in terms of impact attendance from these low-cost text message interventions across different countries and context. We will have to wait and see the longer-term impacts on apprenticeship completion rates, but we are excited about these early attendance results.
Showing up isn’t always enough
Of course, not everything works and the BIU’s paper outlines some trials that didn’t generate the desired results. For example, in a trial on childhood obesity, while small incentives generated increases in attendance at a targeted programme for overweight and obese children and their parents, this did not impact on participants’ BMI. The good news was the overall program did have a positive impact on BMI, but encouraging people to show up more often did not produce further gains. The George Institute are conducting qualitative research on the program to try and unpack why, since it’s crucially important for BI practitioners and policy makers to understand what doesn’t work, as well as what does.
Influencing when people show up to work
Sometimes it’s not only about if you show up, but when you show up. In a trial designed to encourage flexible working among public sector workers and reduce peak hour congestion in Sydney, some simple changes, such as changing the default work hours in Outlook calendars, messages from managers, and a team-based competition, successfully encouraged people to come into work outside of peak hours.
Interestingly, these results were maintained even six months after the trial had finished, and the effect was greater for women than for men. We aren’t quite sure why this happened. Perhaps people who wanted to use flexible working arrangements, but never felt that they could, were given the social proof that they could. Maybe it was the case that women are, on average, more responsive to workplace competitions than men (which we have found in other trials). The data doesn’t allow us to tease these factors apart, but the growing body of results – like those in NSW BIU’s report – underline how low-cost behavioural interventions can be used to improve how we design and run our public services, and keep us showing up when it matters most.
*largely attributed to Woody Allen, who was quoted as saying that “Showing up is 80% of life” in a New York Times interview with his Annie Hall co-writer, Marshall Brickman, and journalist Susan Braudy. In a subsequent interview, he also claimed credit for “80 percent of success is showing up.” Despite this minor controversy, all that can really be known is that 0% of success is arguing about the origin of popular quotes.