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

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 pressingEG2: it is much easier to choose
the right knob to turn on the red
hotplate on the right hand hob
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
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

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

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.

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.

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
ii. Give feedback

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

Changing the logic in A&E / ER

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