We’re Getting BISI!

Healthcare systems worldwide are concerned with keeping their populations physically, mentally and socially healthy in an effective and sustainable manner. Since 1950, the cost of new drug development has doubled every nine years. Medical expenditure has become dominated by expensive later life secondary care, rather than preventive treatment. Defensive medical practice and overtreatment have contributed to these rising costs. At the same time, as we transition to a world in which chronic conditions prevail over acute diseases, many years of healthy life are now lost as a result of preventable behavioural risk factors related to lifestyle, such as smoking, an unhealthy diet and a lack of exercise, as well as inappropriate care-seeking and delivery.

Singapore is no exception. While Singaporeu2019s life expectancy has steadily increased (currently over 80 years), gains in healthy life expectancy have stalled. Singaporeu2019s health system has historically been regarded as highly efficient but driven in part by the pressures of an aging population, healthcare expenditure has quadrupled within ten years from S$2 billion in 2006 to S$8.5 billion in 2015, with an expected increase by at least another S$3 billion in the next three to five years. The level of transformative change that is needed to address these new challenges requires revisiting how we conceptualise healthcare, and how we design and implement interventions that are effective and sustainable for the long term.

The field of behavioural insights refers to an inductive approach that combines knowledge from psychology, cognitive science, and social science with empirically-tested results to understand such factors, and to design interventions that promote more optimal decision-making at the individual and societal level. For example, the National Steps Challenge incorporates small ongoing financial incentives and builds in lotteries and competitions to nudge individuals into undertaking more daily physical activity, improving their own well-being. At the level of the community, better design can help to guide more socially optimal choices. Singaporeu2019s organ donation programme uses an opt-out default (meaning that all individuals are automatically enrolled unless they decline), a policy that has been shown to greatly increase participation rates while preserving individual choice. At the systems level, tools that focus attention on critical key indicators such as visualisations of cost and quality data help to keep value-driven outcomes at the top of mind for doctors and administrators that may otherwise be invisible in day-to-day operations.

Choice architecture alone, however, is not sufficient to ensure that such interventions lead to desirable outcomes in real-world settings. When evidence-based interventions developed within a controlled environment are implemented in real-world settings, several systemic factors impede their uptake. These include the lack of knowledge, skills and resources, competing demands on frontline providers, misalignment of research evidence with operational priorities and systemic constraints. For example, clinicians need to learn about the existence of an intervention and its potential benefits, how it fits patientsu2019 needs, make the decision to replace current practice, become well-trained in this intervention, adjust current routines or practices, use this new innovation effectively, and continue its use if it works as intended and if the need persists. Implementation science provides critical strategies (i.e. a set of planned and intentional activities) to promote the uptake of such interventions. At a systems level, these strategies apply to policymakers, practitioners and organisational leaders seeking to improve the integration of effective patient, professional and policy focused interventions (e.g. system change interventions, training, supervision, quality monitoring tools) into existing health systems and practices.

For example, an innovative health and development screening programme was initiated by the National University Hospital -Child Development Unit to improve health outcomes in preschool children from disadvantaged family backgrounds. A paediatric team provided screening and health checks within the community setting (with selected preschools) to improve reach and early intervention. However, the attendance rates of families at these screening sessions and subsequent treatments at tertiary institutions (e.g. the Early Intervention Programme for Infants and Children programme or dental care at Health Promotion Board) have been low. Applying implementation science frameworks, this community outreach programme will explore implementation barriers systematically, identify solutions and work with engagement teams to improve outcomes.

Translating evidence-based interventions into a real-world setting thus requires both behavioural and implementation science, working hand in hand to design interventions and ensure that they are disseminated effectively, implemented as intended and sustained as routine practice to improve the quality and delivery of healthcare services.