This week Richard Thaler, who wrote ‘Nudge: Improving Decisions About Health, Wealth, and Happiness ’, published “Nudge, Not Sludge” in Science. He gives the example of a company that offers customers their money back, but makes it procedurally complex to get it back so that few actually go through with it. I’ve written about nudging on here before because it is a major idea in healthcare policy, but sludge has been discussed much less.
“Sludge” has been contrasted with nudges in a few different ways previously, but I think this definition is wonderful. I love the tactile feel of sludge. Thaler says:
“sludge” just mucks things up and makes wise decision-making and prosocial activity more difficult.
It’s a big thing in UX, a tech word for User Experience. This amazing blog is full of examples of companies introducing sludge to stop you doing what you want to. This is arguably even more important in Medicine, where we value patient autonomy highly. I think we have good and bad sludge.
One example of bad sludge is my personal bugbear: difficulty registering with GP practices. It wastes money and keeps people away from care if patients have to find all kinds of paperwork and documents in order to get basic healthcare.
Getting a GP appointment is another example. The NHS App being spearheaded by Department of Health and Social Care aims to cut out the early morning phonecalls needed to get an appointment. Conversely, every couple of years somebody suggests a ‘nominal’ £10 charge per GP visit. This clearly intends to add some sludge and prevent people from visiting the practice with such ease, and to promote reflection.
This raises the question how far ‘access to a GP’ is part of healthcare autonomy. Do patients have a right to access care without sludge? How much sludge is reasonable? Having to think twice about seeing the GP is not necessarily a meaningful barrier to autonomy. In one sense, forcing people to think more carefully about an appointment increases the exercise of carefully considered autonomy and keeps them safe from unnecessary medical interventions.
I don’t agree with Thaler that Sludge is always bad. Sludge can slow people down and force them to think carefully. Alternatively sludge can just stop them doing things they have a settled intention to do. If we accept the former in healthcare we need to make sure we minimise the latter.