Making it easier to access to primary care services is a priority for patients across the UK. Earlier this year, the UK government announced a Primary Care Recovery Plan for England.123 The plan proposes new policies to help remove some of the barriers patients encounter when accessing healthcare and reduce the bureaucratic burden on primary care staff by, for example, making it easier to book a GP appointment and supporting pharmacists to treat infections like urinary tract infections (UTIs). This announcement suggests that NHS leaders may have started thinking in terms of “sludge,” a concept recently developed by behavioural economists. The strategy provides a template for clinicians elsewhere to begin “de-sludging” our health systems.
Richard Thaler, an economist and professor of behavioural science, coined the term “sludge” in 2018, building on his popular idea of “nudge.”4 If nudges make it easier for citizens to access helpful services (like retirement savings or cancer screening), then sludges make it harder, for example, through frustrating delays, confusing messaging, and onerous, repetitious forms.4 Sludge also impacts frontline public servants, including doctors, through convoluted pathways for referrals and communication. In healthcare settings, sludge can result in delayed diagnoses or missed appointments. Thaler’s “Nudge” co-author Cass Sunstein argues that hours wasted on hold or filling forms should also be considered a meaningful harm impacting staff and citizens.5 At times of ill health, people are especially likely to be anxious, confused, stressed, and upset by the delays imposed by sludge.
The primary care recovery plan for England included a promise to improve pathways for patients to self-refer for some services and reduce requests to GPs, and a plan to improve communication between patients and primary care.2 Patients will no longer be asked to call back repeatedly and will also be able to obtain some medications from pharmacists without seeing a doctor.2 In all these situations the problem is sludge: multiple sick note visits; time-consuming communications between primary care and secondary care; phone line bottlenecks; and multiple clinician contacts where one would do. The plan’s proposals aimed at “de-sludging” the health service, but there is an opportunity for all doctors and healthcare leaders to extend this principle at every level.
Staff and patients have been concerned about healthcare bureaucracy for a long time, but those who objected to complex processes have sometimes been seen as ignorant or old fashioned. Recent developments in behavioural science have highlighted two behavioural biases which suggest that de-sludging should be actively pursued by clinicians.
The first behavioural bias is called “opportunity cost of time neglect.”6 When we spend money we are reasonably good at considering the alternative options that we could spend that money on, but we often overlook opportunities to spend people’s time more effectively. For example, when carers spend a whole morning queueing to visit multiple professionals for a simple problem, we forget that they could be spending that time on paid work, other caring activities, or precious leisure time.
Evidence from behavioural science has also shown that people are inclined to solve problems by adding solutions rather than exploring ways to remove steps.[7] The key implication of de-sludging policies is that removing a sludge is often better than adding a nudge. In fact, a connected advantage of de-sludging is cost-saving. Creating outreach programmes or employing more administrative staff can help overcome barriers to accessing or providing care, but if those barriers can safely be removed then there might even be a saving to be made, both in terms of time and cost.
De-sludging our clinics
Some hospital teams have begun exploring opportunities to de-sludge their pathways. A team in Virginia recently measured all the sludge in their colorectal cancer screening booking procedures: they found some patients had to complete the same form three times during the pathway and that staff had to make between 14 and 30 clicks on the electronic health record to request screening for a patient.8 One colleague they interviewed commented “There are many confusing steps and I am concerned about people who have limited knowledge of health care or have a lot of other barriers to care … I worry about how it creates disparities, actually.”8 This process helped the team identify where they were wasting time and improve their pathways.
The same approach can help clinicians “de-sludge” our own clinics. We must actively notice wasted patient or staff time. We should be wary of always adding and think instead about simplifying systems because that doesn’t come naturally. The term “sludge” helped the team in Virginia consider and evaluate systems affecting staff and patients and it can help teams in the NHS too.
Of course, there are risks to the “desludging” approach. An excessive focus on sludge could distract attention from structural funding and staffing issues.9 Reducing the burden in one part of the system could overwhelm other services, such as pharmacies. Evaluation is essential. But if implemented well and evaluated rigorously, de-sludging has the potential to improve patients’ experience of care and clinicians’ experience of caring right across the health system.
Footnotes
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Competing interests: None declared.
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Provenance and peer review: not commissioned, not externally peer reviewed.
