A behaviour change programme minus the behaviour change: What happens when health services are run as businesses?
In austere times, outsourcing health services to private providers is becoming more common. To ensure service-users aren’t short changed and public spending isn’t wasted, commissioners need to take a much more hands-on approach
Changing eating habits is often an element of a behaviour change programme
Recently, I spent a period working as a clinical psychologist in a health and well-being service, commissioned by a local authority in response to the UK’s obesity rate. The service is run by a small private organisation and was set up to promote healthy lifestyle behaviours. One of its aims is to support people to achieve a healthy weight to reduce the risk of preventable weight-related diseases and the human and economic costs associated with these. It does this with programmes designed to change people’s behaviours around food and eating and increase their physical activity.
Aspects of the service were very encouraging. The team deployed creative ways of engaging local communities, statutory services and charities, ensuring a steady stream of suitable people referred to the service. It had established a strong presence in the community by taking part in health and wellbeing campaigns. The programmes were delivered by an enthusiastic though overstretched team that strongly abided by the “code” of the healthy lifestyle behaviours they promoted. A particularly exciting aspect of the service was that commissioners had recognised the role psychological and psychosocial factors play in the development and maintenance of obesity and behaviour change – hence the opening for a psychologist. I was excited to get stuck into my role, supporting this already vibrant service by integrating psychological theory and practice into the service delivery.
Alas, my enthusiasm was short-lived. As I gained insights into how the service functioned, a nagging sense of unease took hold. A feeling, I now think, that stemmed from a tension created by the outsourcing of public services to private providers. It is hard to believe that the consequences of this tension are limited to this particular service - after all, in current economic times, this model of service procurement is becoming the norm. In fact, while writing this article, I had numerous conversations with colleagues working within the public and education sectors who found my experiences resonated with their own. This further convinced me to share my experiences as I hope they will stir up a further discussion.
What is a behaviour change programme?
Within the context of public health, a behaviour change programme refers to efforts to change people’s behaviours and habits to prevent disease. The main emphasis of such programmes is the prevention of disease to save healthcare and human costs. The National Institute of Health and Care Excellence outlines 8 main principles for the development of such programmes, within the domains of planning, delivery and evaluation.
One of the first things that struck me was the lack of theoretical understanding of behaviour change models and the processes of achieving behaviour change across the organisation, though the term was often used. There was little acknowledgement of the interaction between biological, psychological and social factors that play a role in health and in particular, obesity - or even curiosity about these. Little attention was given to the characteristics of service-users, their cultural and socioeconomic context and how harmful behaviours might be caused and maintained by a complex interaction between external determinants and internal processes. No thought was paid to differences between service-users and delivery staff nor how these differences might affect engagement. Instead, the team positioned themselves as “experts” in relation to service-users, who needed to be educated on what was good for them.
The lack of understanding and conversation around the wider issues meant that staff, who often found themselves at a loss as to how to engage clients past the initial assessment meeting, had a tendency to blame service-users, characterising them as lacking motivation or not owning the responsibility to change. Attitudes were foisted on the whole group – “they did not care” about their health or were “unmotivated” to make change and instead “made excuses” not to. This process of “othering” service-users created a division between us and them, which fed into stigmatising scripts about people who are overweight. There was no support for staff, who by no fault of their own, had been assigned a task that often took them out of their comfort zone, causing anxiety but also a sense of complacency and hopelessness. As such, frustrations were left unacknowledged and unprocessed. This was covered up by the need to be positive and press on with a focus on the solutions - on doing.
Us vs them
And the service was certainly good at doing. As the weeks went by it became clear that the teams operated within a highly performance driven environment. I was astonished to hear staff across all teams talk about the number of “starters” they needed to sign up to the programmes by the end of each quarter. Everyone was aware of the day-to-day performance of the service and the need to push on when they were not meeting the average monthly target. On the ground, this meant that clinics were booked back to back with no breaks for staff, who spent their time with clients collecting outcome data before signing them up to the programmes. When targets were achieved, staff were rewarded financially. Everyone worked hard and was very committed to meeting the key performance indicators, or KPIs, set by the service commissioners. However, the more time I spent observing, experiencing and learning about the processes of the service, the more I realised that this activity seemed somewhat hollow and that something important was amiss.
Signs that things were not all that good were noticeable. The delivery team felt unsupported, overworked and burdened by high caseloads as well as repetitive and duplicative administrative work. The relentless pressure to achieve targets allowed little space for them to engage service-users in meaningful conversations about their behaviours. There were high drop-out rates from the programs, a threat to service performance which increased anxiety among the team, as well as heightening the “us” vs “them” mentality.
Despite these frustrations, on paper, the service was doing very well. The reports showed consistent achievement of the set KPIs. Yet when I completed an audit of one of the pathways through the service it revealed this was belied by a different kind of consistency: a systematic lack of reliable data collection and coding practices that had huge implications for the validity of the data analysis. One of the most worrying practices was the use of “zero” for missing data. For example, entering zero for missing data on symptoms of anxiety after the programme had been carried out means the intervention was so successful that the individual no longer experienced any anxiety. Whereas in actual fact, the meaning of the zero is the absence of data. When included in the entire sample, this drives down the average anxiety level, resulting in a “false positive”. As a scientific practitioner, I was shocked by such practices.
My role as a psychologist meant that I worked with both management and delivery staff, which gave me the opportunity to reflect upon the split between the two teams. I noticed that staff team dynamics seemed to mirror what was happening in the patient group - that a parallel process of “us” vs “them” had emerged. At the delivery level, I was struck by how the service KPIs had crept into the weight management materials, disguised as service-user goals. Service-users were encouraged to work towards a “10% reduction in weight” or to “increase their score” on a diet questionnaire. At managerial levels, there was a preoccupation with the need to ensure continued funds and reduce costs, which translated into role restructuring, diversifying the business plan, and spending money on performance management software and external expert advice on digitalising work processes.
As a psychologist recruited into the service to provide psychological thinking and put evidence into practice, I began to realise that this was only welcomed if it maintained the status-quo and resisted when it was felt to impinge on the established system. Even though my tasks and objectives had been agreed with management, I found that the work I needed to do to achieve them was not fully supported. The more I questioned and challenged established thinking, the more isolated and unsupported I felt in my role. This reminded me of yet another parallel process – of how complex and challenging change is at an individual but also an organisational level.
A clash of tasks
So how did we get here? How had the focus of the service become so rigidly about data collection and outcome monitoring rather than meaningful behavioural change? How had it become all about the service rather than the service-users? In an economic period defined by austerity, perhaps this focus isn’t surprising. Outsourcing services to private providers is one way to save resources while fulfilling responsibility.
To ensure resources are spent appropriately with the desired result i.e. disease prevention, commissioners outline the service they want and a set of KPIs that the provider must meet to demonstrate effectiveness. The latter is achieved by collecting and reporting outcome data. Commissioners do this to commission cost effective, evidence-based programs (their primary task). For a private provider, a decision to bid for a public service will largely depend on the profitability of the contract and their competence to deliver the program in a way that meets the KPIs at a profitable margin, thus ensuring their continued income (their primary task).
This is standard procedure and, on the surface, it is nothing untoward; there ought to be accountability for how taxpayers’ money is spent, and it can be argued that the competition this creates makes service delivery more innovative. The trouble is that this introduces a competing set of tasks between the provider and commissioner, and those responsible for achieving them on their behalf. The unavoidable consequence is that the service is no longer a service, but a business. Thus a conflict between the tasks of the delivery team (providing the behavioural change interventions) and the management team (ensuring steady income through targeted performance management) is created.
I wonder if a lot of the issues I came across can be traced to the set-up of these public-private partnerships. The focal point for both the commissioner and the provider is the set of KPIs. The provider is usually left to decide and manage how they achieve them. They outline their approach in the bidding process but it is usually not what the commission hinges on. In other words, the contract prioritises the what over the how.
But the how is significant. Behaviour change programs are undoubtedly complex interventions, and require careful consideration of many factors. These include what needs to be achieved (the behaviour change), the theoretical understanding behind it (how that change happens), the methods required to achieve it (the “active ingredients”), the variance in the population as well as consideration of how best to monitor progress (how the behaviour change is measured) and evaluate programs (can we identify what is working and capitalise on this to refine the program?)
The what is also significant. As others have pointed out, the outcome of a behaviour change program is a behaviour. But too often what is considered an outcome and crystallised as a KPI is a consequence of the behaviour (weight loss), not the behaviour itself (eating more vegetables). There are many reasons for this, but it is health behaviours that such behaviour change programs need to focus on. Focusing on the wrong outcome can have serious implications. At my service, designing programs focused on weight loss unintentionally contributed to weight- and obesity-related stigma.
Where do we go from here?
It seems justified to worry that businesses might not have the skill set and understanding needed to develop complex behaviour change interventions. To manage the possibility of this knowledge gap, I think it is reasonable to ask commissioners to take a more hands-on approach. This could mean giving clearer direction about the evidence-based practices that providers need to perform. Appropriate outcome measures and methods of evaluation could be discussed upfront. These should be informed by appropriate theories to avoid over-reliance on simplistic and potentially harmful KPIs. A simple example would be for commissioners to set a KPI as “Have 300 people attend 75% of the behavioural change program” as opposed to “Have 300 people signed up to a behavioural change program.” The end result might be the same but the process of getting there is different: one engages people and one recruits them.
Service-users should be involved at all stages of the program development, delivery and evaluation to ensure that they have a voice and opportunity to shape services according to their needs. Commissioned programs could be evaluated by an independent group of health and social science practitioners with a sound understanding of the theories of behavioural change. Paying more attention to the process underlying behaviour change could help the field long-term. A robust continuous evaluation of and shared learning from such programs would help identify “active ingredients” that facilitate behaviour change across diverse groups, informing theoretical understanding and leading to improvements in service development and practice, generally.
It has been frustrating to witness private providers with next to no knowledge of behaviour change winning public health contracts based on business models designed predominantly to perform well financially. KPIs are a useful accountability tool but only when they are set as meaningful guides to service delivery. As I witnessed, when they don’t accurately reflect the complexity of the work needed, this can have negative consequences for staff, commissioners and service-users. One thing feels certain - we should be talking about what makes us uncomfortable at work, about what shocks us. If we don’t speak out, we’ll never realise how sick our services are, nor work out what we need to do to make them better.
Over to you
The author of the blog wishes to remain anonymous. If any of the themes raised resonate with you or if you have a different take on what is needed, please comment in the space below.
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