The art of letter writing: using behavioural insights to reduce hospital waiting times

WHO/Europe is helping health authorities to create impactful letters that encourage people to act for their health. Action may include getting vaccinated, or having a cancer screening or a health check-up. For those on a waiting list for a treatment, it may entail replying to a letter checking whether treatment is still needed. If someone responds to say they had the treatment in another hospital, feel better or no longer want the treatment, they can be taken off the list. In-demand hospital appointments can then be better allocated and scarce resources in health systems used more efficiently.

However, this validation method only shows results if people respond to the letters. While a letter alone cannot change complex health behaviours, an evidence-informed letter may increase the response rates among motivated people when services are easy to access. A new WHO policy brief shows how to apply behavioural science to make action more likely.

A case study from Ireland

In Ireland, the Department of Health used behavioural science to redesign and test different letter formats in hopes of encouraging more people to engage with the validation process and ensure treatment slots are used efficiently. Evidence had previously shown that 1 in 4 people never replied to the letters they received and resources were not being used optimally, while many were experiencing long waiting periods.

The results of the recent test showed that with a redesigned letter, nearly 20% of non-responders (1 in 5) changed their behaviour and responded. The higher response rate was achieved with simple changes such as including a clear call for action, simplifying and personalizing the language, and, importantly, including an apology for the waiting time and explaining the reason why the letter was sent.

Assessing the impact of the study, Robert Murphy from the Department of Health says, "By applying evidence from behavioural science we substantially increased patient engagement. The redesigned letter template is now used by all public hospitals. This makes the process clearer for patients and more efficient for staff. The demonstrated impacts of using behavioural science also inspired other applications to health services in Ireland."

Designing impactful letters

Acknowledging the importance of improving the quality of health letters in the WHO European Region, WHO/Europe's new policy brief lays out 9 considerations from the behavioural and cultural sciences:

• ensure a clear call to action
• keep a letter short and simple
• address the barriers to and leverage the drivers for a behaviour (for example, clarify when services are free of charge)
• draw on relevant psychological mechanisms such as social norms
• adapt a letter to the cultural context
• attract a readers' attention with an email subject or letter envelope
• use the right sender and signatory
• test the letter and engage with intended recipients
• use reminders.

With these simple and clear steps, letters can achieve what they were written for - to help people act for the benefit of their health or use the scarce resources of health systems more efficiently.

Robb Butler, Director of the Division of Communicable Diseases, Environment and Health at WHO/Europe, points out, "Improving the quality of health letters is a small investment with important gains. As a patient, I have received a lot of letters with room for improvement. Evidence from behavioural science can help address this challenge and help design letters that make people act. I hope many people will use the simple advice in our new policy brief."