Changing the logic in A&E / ER

“It’s not only doctors or the Chief Executive

who have responsibility for this hospital. We

all must look after our society. This is a

public service and we are all part of the

public”

Afghani patient

Understanding and

changing patient

behaviour at A&E

Based on staff and patient

research in North Middx Hospital

Report contents

Objectives

Methodology

Summary of research results (context, 2 patient

types, key recommendations)

Detailed research results (GPs, profiles and

needs of patient types)

Applying research results (healthy nudges and

practical ideas)

Conclusion

Objectives

Understand patient attitudes and

behaviour when choosing to use the

Accident and Emergency service

Explore what it would take to change

this behaviour

Methodology

30 patients interviewed between 10am and 5pm

on 15.03.11 about their A&E story

Sample: male and female

12-87 years old

range of cultures including Afghanistan, Afro-Caribbean, Eastern Europe, England, Ireland, India, Poland, Sri Lanka,

Taiwan, Turkey

Ethnographic observations of waiting room

behaviour

Staff discussions with admin staff, matron and

security

1.1 Context

1.2 Two patient types

1.3 Two sets of

recommendations

Part 1:

Summary of the

research results

Key conclusions

1.1 Context

Medical expertise rarely

challenged.

Habits have shifted :“one

stop solution”

There is a lack of alignment

between NHS needs and patient needs.

Little room for patients to

participate in the solution.

First Class

ECONOMY

Key conclusions

1.2 Patient types

Note: Parents of children under 12 are a special case: over-reacting is seen as good parenting in absence of soothing support network (eg recent migrants). 100% of these parents were Health Victims

Health victims passive, needy, under-

confident

Use A&E often

Health managers proactive, organised,

busy

Use A&E “correctly”

Two main patient types emerge, according to

attitudes and behaviour

Key conclusions

1.3 Recommendations

1. Practical changes to reduce patient anxiety (and

therefore improve efficiency of dealing with them)

2. NUDGE* ideas that can help to increase a sense of co-

responsibility and therefore shift behaviour

Nudge...

*Nudging is the application of subtle signage, messaging

and environment details to encourage individuals to

follow appropriate behaviour patterns.

SEE Thaler & Sunstein, “Nudge”

2.1 GP gap

2.2 Patient MindSet

2.3 Implications

Part 2:

Detailed

research results

GP referral

NHS call back

Self - GP unavailable

Self - GP no good

Self - GP inconvenient

Self - "too serious"

Self - no local GP

2.1 GP gap A&E is bearing the brunt of GP shortfall

Reasons patients give for being in A&E

2.1 GP Gap Patient quotes relating to GPs

I needed to see a doctor today and the first appointment he had

was next week

The GP is no good. He never finds a solution

I don’t like hospitals but my GP said he

couldn’t see me for 3 days

The GP just wants you out of their office. They start writing a

prescription before you’ve even finished explaining

My GP was very thorough, then she said I needed

to go to A&E

2.2 Patient MindSet Patients feel like Victims or In control

• The position an individual feels they hold in the world is always important

• Language and Behaviour (LaB) profiling of this group shows 2

types

• physical cause to be in A&E

• emotional but not necessarily a medical need

Health Victim (c70% of sample) More likely to have self-referred

for convenience / reassurance / a belief in hospitals (vs. GPs).

Health Manager (c30% of sample) Confident, informed,

proactive, better educated, impatient, busy.

2.2 Patient MindSet The A&E balance for the Health Manager

Avoid A&E unless situation is dire

Shame / sense of weakness

4 hours waiting time (should be at work)

A&E likely to resolve the

problem

Benefits

DOWNSIDEs

“I can sort this out myself”

2.2 Patient MindSet The A&E balance for the Health Victim

4 hours wait time (but I have

plenty of time)

A&E will solve the problem

Feel relaxed / safe, “at home”, cared for, welcome

Being a good parent / daughter

Free service

Go to A&E

“Life is a struggle... Now look what happened to me...”

Benefits

DOWNSIDEs

Patient types comparison (caution: tendencies only, based on small sample)

MindSet profile Proactive, solution focused, know what to do

Passive, problem focused, want to be told what to do

Attitude Self-responsible Self-righteous

Support network Yes No, lonely, isolated

Education Level 2 + Below Level 2

Citizenship Established More recent migrants

Lifestyle Employed, retired Parents of young children, unemployed,

Activity in A&E Reading / talking Staring

Age 40+ 20s, 30s, some >70s

It’s the process, we treat

everyone the same

(member of staff) Health

Manager Health

Victim

3.1 Recommended approach

3.2 Nudge ideas

3.3 Practical ideas

Part 3:

Applying the

research results

3.1 Recommended approach AIM: Increase co-responsibility

“This is a public service and we are all part of the public”.

More co-creation / co-responsibility. Choose your queue

Behaviour will only change if the Health Victim’s practical and

emotional needs are met in new ways. This will require:

1. Practical changes to redress the imbalance that currently pushes them towards A&E

2. “Nudge” changes to increase their sense of ownership

“Conceptual models are critical to

good design... Without feedback one is

always wondering whether anything

happened”

Don Norman, The Design of Everyday Things (and Apple VP of Advanced Technology)

EG1: when “WAIT” doesn’t light up we

keep pressing EG2: it is much easier to choose the right knob to turn on the red hotplate on the right hand hob

3.1 Recommended approach AIM: Help the patient make good choices

“Structuring choice sometimes means helping people to learn they can make better choices on their own”

Thale and Sunstein, Nudge

Nudge Condition A&E idea

1. Incentives to change Increase salient costs

2. Understand mappings Think like a patient

3. Get defaults right Status quo bias

4. Structure choices 1st choice bias

5. Give feedback Beepers, queue number

3.1 Recommended approach AIM: Apply healthy nudging

3.2 Nudge recommendations i. Increase salient costs

Clarify consequences of their actions to patients by

showing information in the waiting room.

Last year our

ambulances received

1,325 calls and

attended 742 people.

Not all of them really

needed an

ambulance.

So for Bob it was too

late.

Sorry Bob.

Jack and Jill both

got injured.

Jack went to the GP

and got help which

cost our country £75.

Jill went to A&E and

got the same help

but it cost our

country £265.

Thanks Jack.

Sample communication

3.2 Nudge recommendations ii. Understand mappings, increase co-responsibility

Use social norms to emphasise the “right” behaviour

But only

3% needed

to

10% came

at least

once

DID YOU KNOW?

90% of the population did

not come to A&E at all

last year

Ask our

advice

on using

A&E well

Sample communication

3.2 Nudge recommendations iii. Understand mappings

Use status quo bias by expecting patients to

see a GP in A&E

SUPPORT: Coaching session if visit was not

necessary (good

parent?)

SELF HELP: Touch screen app

FACE SAVING: Easy to leave without seeing

somebody

CAN YOU HELP?

• Avoid unnecessary visit,

save £145

• Avoid unnecessary

ambulance, save £575

It’s your A&E.

So save it

for a rainy

day.

Sample communication

3.2 Nudge recommendations iv. Use first choice bias

Always offer options in NHS preferred order

PICK THE CHAIR

YOU NEED

1. Green chair if you feel a GP can

probably help you

2. Amber chair if you are in too much

pain

3. Red chair if you feel you need help

urgently

I can wait

Severe

pain

Urgent &

critical

If they had one queue for emergencies and one for other things,

most people would stand in the right queue.

Sample communication

They couldn’t

pronounce my name

and I waited an extra 2

hours unnecessarily

3.3 Practical recommendations

i. Give feedback

I don’t hear so

well and I worry

I’ll miss my

name

Introduce LED display with next patient’s name and room rather

than staff calling out name

Introduce deli style

ticketing system

sense of how many

people are before you

I don’t mind the wait

so much as the

anxiety of not

knowing how long or

if I’ve been forgotten

I’ve been dying

for the loo for an

hour now but I

daren’t leave the

room

3.3 Practical recommendations

ii. Give feedback

3.3 Practical recommendations Communications that change minds

The MindSet profile of the Health Victims is important to bear in mind when creating communications for them. In particular they are:

More interested in problems than solutions

Feel safer with clear procedures than multiple options

Like to be directed, not proactive

Do say things like... Don’t say...

There is always a right way to deal with any health situation. Ask us for guidance

First fill in this form then...

The problem is too many people

come here when they don’t need to

Don’t get stuck in the wrong queue. Fill in the form correctly.

We have many ways we can help you here at the hospital or at your GP, online or on the phone

Our goal is for every patient to get the best treatment

Our aim is to have an excellent package of health options

Fill in the form correctly for quick service

Conclusions

There are two main patient types: Health

Victim (about 2/3) and Health Manager

(1/3).

Misuse of A&E by Health Victims is driven

by

GP issues (unavailable, uncaring, unable)

Emotional need for reassurance / certainty

No penalty for choosing the “easy” option

There are nudge techniques that could tip

the A&E balance and these can be

trialled and impact measured