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Nudge, dementia friendly communities and consumer behaviour

Should companies be looking to make money out of the concept of ‘dementia friendly communities’ and should charities be using this concept to position themselves against their competitors? If we’re not a nation of shopkeepers, we might be increasingly becoming a nature of consumers rather than citizens. With the promise of unified personal budgets, this consumer-oriented nature of healthcare is likely to gather some momentum. But the relentless drive towards consumerism, I feel, does threaten to play havoc with this policy plank.

As a useful starting point, I feel it’s helpful to consider the work of ‘dementia friendly York’, led the Joseph Rowntree Foundation to propose a model for realising a dementia-friendly community. With the actual voices of people at the heart of the process, they believe that communities need to consider four ‘cornerstones’ to test the extent of their dementia friendliness.

These are:

  • Place – how do the physical environment, housing, neighbourhood and transport support people with dementia?
  • People – how do carers, families, friends, neighbours, health and social care professionals (especially GPs) and the wider community respond to and support people with dementia?
  • Resources – are there sufficient services and facilities for people with dementia and are these appropriate to their needs and supportive of their capabilities? How well can people use the ordinary resources of the community?
  • Networks – do those who support people with dementia communicate, collaborate and plan together sufficiently well to provide the best support and to use people’s own ‘assets’ well?

I have in fact mentioned this in the penultimate chapter of my book ‘Living well with dementia’ available in all good bookshops.

But the way the corporates wish to play this policy I feel has more than a slight twang of ‘Nudge’ about it. “Nudge: Improving Decisions about Health, Wealth, and Happiness” was, of course, the highly publicised book written by Richard H. Thaler and Cass R. Sunstein from the Chicago Law School.

At the heart of nudge theory is the concept of “nudge“. This was originally defined by Richard Thaler and Cass Sunstein as follows:

“A nudge, as we will use the term, is any aspect of the choice architecture that alters people’s behavior in a predictable way without forbidding any options or significantly changing their economic incentives. To count as a mere nudge, the intervention must be easy and cheap to avoid. Nudges are not mandates. Putting fruit at eye level counts as a nudge. Banning junk food does not.”

One of the main justifications for Thaler’s and Sunstein’s endorsement of libertarian paternalism in “Nudge” draws on facts of human nature and psychology.

Sunstein and Thaler use their notions of nudges within the context of choice architecture to propose policy recommendations that they believe are in the spirit of libertarian paternalism. They have recommendations in the areas of finance, health, the environment, schools, and marriage.

I feel that “nudge” has somehow diffused through the ecosystem of ‘dementia friendly communities’ in a rather unhelpful way through the influence of corporate citizens. Thaler and Sunstein believe these problems in decision-making can at least be partially addressed by improving the choice architecture.

They cite ‘daylight saving time‘ – when you “change the label of the time on the clock” when the clocks go backwards as a simple ‘nudge’  with the effect of changing behaviour. Indeed, uring his time as an American envoy to France, Benjamin Franklin, author of the proverb, “Early to bed, and early to rise, makes a man healthy, wealthy and wise”, anonymously published a letter suggesting that Parisians economize on candles by rising earlier to use morning sunlight. This 1784 satire proposed taxing shutters, rationing candles, and waking the public by ringing church bells and firing cannons at sunrise. There is apparently ‘no such thing as a neutral policy’?

The way in which this initiative is presented at all is interesting. If we’re talking about “nudge”, we’re talking about ‘libertarian paternalism’. Libertarian paternalism is the idea that it is both possible and legitimate for private and public institutions to affect behavior while also respecting freedom of choice. Private organisations can use ‘nudge’ on their own, but can of course be vicariously applied through private organisations. Private organisations and the Department of Health are currently implementing “Dementia Friends” – a wide-ranging scheme, with good motives.

To help ‘nudge’ succeed in various guises, it helps if influential people are there somewhere. The current Prime Minister David Cameron, launched the plank of the global dementia friends policy plank  as the branded ‘Dementia Friends’, which is led by the Alzheimer’s Society. Through this people will be given free awareness sessions to help them understand dementia better and become Dementia Friends. This is also led by ‘top influencer’ Jeremy Hughes, the current CEO of the Alzheimer’s Society.

The scheme aims to make everyday life better for people with dementia by changing the way people think, talk and act. The Alzheimer’s Society wants the Dementia Friends to have the know-how to make people with dementia feel understood and included in their community. It is hoped that, by 2015, 1 million people will become Dementia Friends. The £2.4 million programme is funded by the Social Fund and the Department of Health.

To help to implement this policy, quite heavily promoted by parliamentarians, the ‘bandwagon effect’ will help – and this is known of course to Thaler and Sunstein. The general rule is that conduct or beliefs spread among people, as fads and trends clearly do, with “the probability of any individual adopting it increasing with the proportion who have already done so”. As more people come to believe in something, others also “hop on the bandwagon” regardless of the underlying evidence.

Or people could join ‘dementia friends’ through simple “peer pressure”. People are heavily influenced by the actions of others. Sunstein and Thaler cite a famous study by Solomon Asch where people, due to peer pressure, answer certain questions in a way that was clearly false (such as saying that two lines are the same length, when they clearly are not).

First of all, it’s helpful to say we’re not talking where people necessarily make deep active decisions to join ‘Dementia Friends’. We’re not even talking about the Joseph Rowntree Model of “The Four Cornerstones”. I’m applying my analysis to how a member of the public, for the purposes of interacting with a high street chain offering involvement with this initiative, might behave as a ‘consumer’.

The simplest example of a successful nudge in the “choice architecture” of Nudge  is the default option. A default option is simply what happens if you do nothing. Normally, nothing happens, but sometimes even when you do nothing, something happens. (Choice architecture describes the way in which decisions may (and can) be influenced by how the choices are presented (in order to influence the outcome.)

The latest incarnation of this initiative is that our high streets, from the end of February 2014, have set to become more dementia friendly following a commitment from major British businesses. It’s said that, thanks to the Alzheimer’s Society and the Department of Health, our high streets are set to become more dementia friendly following a commitment from major British businesses: Argos, Homebase, Marks and Spencer, Lloyds Pharmacy and Lloyds Banking Group.

This is of course interesting in the context of how consumers make decisions about with whom to shop. Firms will be competing, and becoming “dementia friendly” could be a way of simplifying the process of customer behaviour or choice.

The well known “elimination by aspects”, described in the “Nudge” book, is followed by decision makers during a process of sequential choice and which constitutes a good balance between the cost of a decision and its quality. At each stage of decision, the individuals eliminate all the options not having an expected given attribute, until only one option remains. This short cut was first used by Anne Tversky (1972).

For example, “I want to buy a kettle from a catalogue?” Do I choose Argos or Catalogue R Us, if I want to choose a dementia friendly supplier? Answer: Argos.

And the Alzheimer’s Society have not been the only ones making use of the application of this choice architecture. The end of February 2014 was also big for the Torbay Dementia Action Alliance. Apparently now in Torquay and Babbacombe you probably can spot “purple angel sticker”s in a fair number of shop windows.

But the real important question to ask: who is benefiting here exactly?

While nudges can appear desirable when judged from a short-term perspective, in which they are assessed primarily in terms how effectively they steer behaviour, they can appear problematic from a long-term perspective that renders the process of decision-making rather infantile and primitive.

Libertarians, such as New York University Professor Mario Rizzo and California State University Northridge Professor Glen Whitman, have publicly expressed heir political reservations as concerns about nudges being “vulnerable” to becoming tools that support new, straightforwardly paternalist policies. They specifically warn that ‘nudge projects’ could grow expansively, absorb public resources, and primarily further the ends that choice architects (notably, government bureaucrats) deem valuable. At worst, this is what has happened with the mass roll-out of the corporate involvement of dementia friendly communities.

It’s also mooted that the nudge approach can only work on very simple behaviours: ones where the automatic system can be guided without any input from the controlled system; for example, placing a picture of a pair of eyes above an honesty box for coffees and teas can increase payments because people feel on some unconscious level ‘watched’. A voluntary choice to shop with a particular supplier because of a ‘dementia friendly’ emblem is a pretty basic low-level decision, so it’s anyone guess whether ‘nudge’ is indeed appropriate or not.

Also, veering for the ‘nudge’ approach may be taking the wind from the sales of other valid approaches, such as ‘Steer’ from the Royal Society of Arts, Commerce and Entreneurship. Four example, reduction of dementia friendly communities in this specific scenario for the market place could opt a citizen in the general public from engaging with critical pillars of progressive politics which indeed promote a genuine sense of dementia communities and leadership, viz:

  • Autonomy – citizens need to be able to take control of their own lives in order to achieve their fullest potential wherever this is possible.
  • Responsibility – citizens need to be capable of playing their part in ensuring common goods such as a clean environment and trusting social relationships.
  • Democratic engagement – citizens need to be able to view forms of governance (whether national or local) as open to them and as reflecting their interests.
  • Communal action – citizens need to have ways and means of negotiating and collaborating with one another over achieving common goods and dealing with shared problems.

(RSA Steer Report)

I believe it’s important for people to look at what the principles which guide their own behaviour. This might genuinely involve embracing the philosophy of living well with dementia – or not. And reducing the marketplace into those companies which are dementia friendly or not may benefit the companies more than members of the public, when it comes to the basic issue of people ‘understanding dementia’. Of course, it will be argued that the dementia awareness programmes are currently wide ranging. But I think we have to set our ambitions a lot higher than tokenistic dementia friendliness, important though that the policy is (of befriending), and go much more to the heart of ‘The Four Cornerstones’ model.

Turning ‘dementia friendly communities’ as ‘nudge’ on the high street doesn’t do anything for me.

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