A&E Behaviour and AttitudesPatient Research at North Middlesex Hospital, Mar 2010

Catherine Shovlin, Director, customerinterpreter.com

cmshovlin@gmail.com

“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

Report contents

Objectives

Methodology

Summary of research results (context, patient

types, recommendations)

Detailed research results (GPs, profiles and

needs of patient types)

Applying research results (healthy nudges)

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

Part 1:

Summary of the research results

Key conclusions

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

Patient types

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 managersproactive, organised,

busy

Use A&E “correctly”

Two main patient types emerge, according to

attitudes and behaviour

Key conclusions

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

*Nudging is the application of subtle signage, messaging

and environment details to encourage individuals to

follow appropriate behaviour patterns.

SEE Thaler & Sunstein, “Nudge”

Part 2:

Detailed research results

How did they get here?A&E is bearing the brunt of GP shortfall

Why they are in A&E

Specific 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

State of Mind

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.

The A&E balance for the Health Manager

Shame / sense of weakness

4 hours waiting time (should be at work)

A&E likely to resolve the

problem

Avoid A&E unless

situation is dire

Benefits

DOWNSIDEs

“I can sort this out myself”

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)

Aspect Self manager Health victim

Language and Behaviour 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

Health

ManagerHealth

Victim

Part 3:

Applying the research results

“Structuring choice sometimes means helping

people to learn they can make better choices on

their own” Thaler & Sunstein, Nudge

Recommendations

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

Recommendations

AIM: Help the patient make good choices

“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

Recommendations

AIM: Apply the art of healthy nudging

“Structuring choice sometimes means helping people to learn they can make better choices on their own” Thale and Sunstein, Nudge

Nudge Condition A&E

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

Nudge recommendations

1. 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.

Nudge recommendations 2. Understand mappings, increase co-responsibility

Use social norms to emphasise the “right” behaviour

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

Nudge recommendations

3. 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.

Nudge recommendations

4. Use first choice bias

Always offer options in NHS preferred order

PICK THE CHAIR

YOU NEED

1. Pink chair if you feel a GP can

probably help you

2. Grey 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

Practical recommendations

5. 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

Practical recommendations

5. Give feedback

Applying the results

Communications that change mindsThe Language and Behaviour 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... Not things like...

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

Patients may respond to nudge

techniques to tip the A&E balance and

these can be trialled and impact measured

Appendix:

Additional data and verbatims

Who we observed and spoke to

77 patients were

classified by

demographics

30 were interviewed

More females: 63%

vs. 37% males

(excluding children

under 10)

36% black, 25% white

Eastern Euro, 20%

white UK, 19% Asian

Age range: baby to

87 year old, average

age 35

Age profile

Other observations

New building generally liked“they are 30% more efficient since they have been in here”

but

“they should have spent the money on staff instead, they

are understaffed”

Line of doors to consult rooms cause mixed feelings:“at least you get some feedback with that light above the

door. It tells me the doctors are working for us”

“It’s like the checkout at the supermarket. Mostly not

occupied plus big queues for the ones that are”

“I’ve been wondering what happens to you once you go

through that door. People seem to come back out very

quickly so I’m worried they don’t treat you there either”

Car park causes anxiety as they have to prepay but don’t know how long they will be. Can it be changed to

postpay?

The waiting: passive and no sign of

co-responsibility

Less than 5% of those

observed were engaged

in an activity (reading,

writing, crossword)

55% of adults were staring

into space

35% were

talking/interacting with

the people they had

come with

5% were watching TV

NB: In the children’s

waiting room there was

more activity (kids

playing)

It’s a lovely building.

It’s nice here

You just sit here and

wait. You don’t have

a choice

It’s good they have

the children’s TV. We

don’t mind waiting

It’s worth waiting

because you believe

they can help you

Patient Quotes

THE GP ALTERNATIVE

EQUIPMENT

• I need a scan and the GP can’t do it.

PERSONAL SERVICE / CONVENIENCE

• I don’t want to see just any doctor, I want to see MY GP, the one who

knows me.

• I live 9 miles from my GP and work near here. So this is easier

• I went to my GP practice first. The doctor I saw was very thorough and

offered to organise an ambulance to get me here

APPOINTMENT AVAILABILITY

• I’m in too much pain. My GP couldn’t see me

• Why would I go to the GP and then they send me here? Why would I wait

in two queues instead of one?

If my GP was interested in helping me I’d happily go there

Patient Quotes

OTHER ALTERNATIVES TO A&E

Walk in

• They told us to go to the Walk In clinic but we couldn’t afford the bus fare

to Edmonton so we came here. It’s nearer.

• We would have gone to a walk-in centre but he is visiting from Manchester

so he’s not registered here.

• We went to the walk-in centre last time and we had to wait for 5 hours

NHS Direct

• I know we could phone NHS Direct but I prefer face to face. I like to see

who I’m dealing with.

• When you call NHS Direct you get put through from one person to

another, sometimes 3 or 4 times. You’re on the phone for half an hour.

• I don’t speak good English for NHS Direct

Patient Quotes

BEHAVIOUR CHANGE

CONDITIONS FOR BEHAVIOUR CHANGE

• I would go to the GP if they were helpful and interested

• I would go to the GP if I could see them the same day

• I would got to the GP if I could get an appointment and they could see me

and sort things out

• I would go to the GP if I didn’t have to pay to phone them (0844 number)

DIFFERENTIATED SERVICE

• If when we arrived, we had to classify ourselves as critical or can wait, some

people would lie but most people would do the right thing

• I would change the way it is organised because there are different needs.

Some are real emergencies and have to be seen first. Others, like me, can

wait. Strange that we are all in the same system.

• I only need to see the nurse. Would be better to have the chance to choose

a queue when you arrive – simple things or complicated things. Like going in

the stamps only queue at the Post Office vs. a passport application

• They should differentiate the problems. We asked but they just told us “it’s the

process, it’s the way it is, we treat everyone the same”. I’m not happy with

the service. What if they do nothing again today then we’ll have waited 6

hours (three hours last week and three hours this week) for nothing

• Seems odd that it’s only one queue for everything from a sore finger to dying

Patient Quotes

A&E SERVICE RELATED COMMENTS

BUILDING

• It is good that they have invested in the building. It is good that they have

thought and put some colour, some art here. It will help us all.

• You come here and it’s this beautiful building and the reception is all hi-tech

then you sit down to wait and it’s all back to basics.

• I wasn’t sure what to do because I don’t know the system, it’s my first time ever

in an A&E place

PARKING

• The parking is expensive and how do you know how long to buy your ticket

for?

• We’ve bought a ticket for three hours but what if it takes longer? It’s a worry.

Luckily there are two of us so she can go and get a new ticket but what if it

was just me? What if I missed my turn while I was getting a new car park ticket?

OTHER

• Good idea to have a GP here (all those questioned)

• Lady with one year old son with dislocated elbow: I asked how long we’d

have to wait and they said they didn’t know. Well obviously they’ve got to

give priority to life and death cases. That’s fine. But I was really worried. And he

was crying and nobody told me what was going on. They just seemed really

disorganised. It’s not the individual staff member’s fault. They work as hard as

you like but the system doesn’t seem to work.

Patient Quotes

A&E SERVICE IMPROVEMENT SUGGESTIONS

NAME BOARD

• Last time I was here they called out George something. Three Georges went over. The person couldn’t pronounce the surname and they all thought it was there turn. In the end the person showed the Georges the full name and one of them was the right George.

• My friend is Chinese and they pronounced her name wrong so she waited for 4 hours before she asked and found she had missed her turn. At home we get a card so we know when it is our number.

• One time I was here and after 3 hours I went back to reception and they said they’d called out my name but I’d missed it so I had to go to the back of the queue and wait another 2 hours.

• Why do they call out the names instead of having a sign like they do at the GP? They can’t pronounce our names anyway and elderly patients might miss their name.

TICKET SYSTEM

• I wish we knew how long we would have to wait. A ticket system like they do in Bloods.

• It would help to have some sense of moving up the queue. Of course urgent cases will get priority, we understand that.

• It’s hard to not know how long you are going to be waiting. It makes you more anxious.

• Of course some people need to get priority and jump the queue. We understand

that.

• The system of triage first then seeing the doctor is better

Patient Quotes -HEALTH VICTIMSGP ISSUES

NOT ENOUGH CARE

• The GP just says “he’s OK, go home now”. He’s not really interested

• I’ve been to the GP 4 or 5 times,. They do nothing. They say nothing. They tell you what’s wrong but not how to fix it.

TOO SLOW

• Takes too long to get a GP appointment and if you want one the same day you have to be there at 8am. What if you don’t know you are going to be ill that day?

• I was going to see my GP but they postponed the appointment till next week. But I have hurt my ankle and need to know if I can still be in a dance performance next week

• No GP appointments available so they told us to go to the hospital.

GP SEEN AS UNABLE TO SOLVE PROBLEM

• I was attacked by a dog, it’s too serious for the GP. I haven’t been here for a long time

• I’ve had chest pain and a numb arm for a while. The GP just gave me antibiotics which didn’t help. There’s a family history of heart disease. We’re here as a last resort. If the GP had resolved the problem we wouldn’t have had to come here

• I need a scan and the GP can’t do that.

• I wasn’t feeling too well and I wanted a proper check up. The GP just starts writing a prescription as soon as you walk in. And he doesn’t have any equipment to do a proper check up. It’s OK here. I haven’t got anything else to do today. I don’t mind waiting.

GP COSTS MORE

• My GP has switched to an 0844 number. I get local calls free but now I have to pay to call my GP and be waiting on the line for ages, paying all the time.

• I have been here before because my brother suffers from high blood pressure (my father died from that), I cared for an elderly neighbour who died last year and my mother has osteoporosis. Because of that we have prepay prescriptions to save money but now my GP keeps telling me to buy things over the counter and won’t write a prescription.

Patient Quotes -HEALTH VICTIMSEMOTIONAL NEEDS

GOOD PARENTING / DOING THE “RIGHT” THING

He shut his fingers in the door so I called an ambulance. His nail was bleeding. I

was panicking. My baby was crying

• When it’s your child it always feel critical. We will do whatever it takes for our

children.

• Health is the most important thing. We will do whatever it takes to get treatment

• My daughter has a rash on her face. We phoned the GP but it was too late for a

same day appointment and it needs to be seen. We accept that we will have

to wait. That’s ok. Feels safe here and there’s a toilet and the TV. Better since it

was separated.

• Yes we’ve been here before. A lot. Today it’s because she has a stomach ache.

It might be because she swallowed a coin. We’re quite happy here. We feel at

home.

• My 6 year old son banged his head at school and they told me to bring him to

A&E. They always say that.

• My nephew got CO poisoning at work (training as gas engineer) and he’s very

tired. We came last night but there was a huge queue so we came back today.

PASSIVE

• We have to wait, we have to be seen in the right order

• My elderly mother phones for an appointment and they give her something in three weeks time then by the time it comes round she has forgotten and they phone her up and make her feel guilty about it. But they don’t remind her.

Patient Quotes - HEALTH MANAGERSGP ISSUES

• We don’t need A&E. we just need to see a doctor but we could only get an

appointment in two weeks.

• I’ve recently moved and needed to see a doctor today. I phoned a GP to

register and they said they couldn’t give me an appointment and the best option

was to go to A&E. I disagree. This is a waste of my time and theirs.

• Normally I would go to the GP but this is too serious. The cut is too deep. I did it at

work. IT will need stitches. I showed the receptionist and he agreed it was serious. I

hope I get seen soon.

• I went to my doctor first but I had to wait a week for an appointment. I couldn’t

wait that long. I’m in too much pain. I would rather the doctor had sorted it out

but I had no choice.

• She has a piece of glass in her foot. We went to the GP but they couldn’t find it

without an X-ray so they sent us here. She is bipolar and epileptic so she often has

accidents and we end up here.

• She’s pregnant and she’s bleeding. We’re very anxious. This is our second visit, the

GP told us to come straight here.

Patient Quotes - HEALTH MANAGERS

INCONVENIENT BUT NECESSARY

• I know I will be here for 3-5 hours. I had to stop everything, cancel appointments,

not go to work.

• I’m missing college which I don’t like. But I’m in too much pain, something has to

be done.

• I came in a week ago by ambulance because I thought my ankle was broken.

They told me to come back a week later for an X-ray. I just want to get my X-ray

and then get out of here. I don’t like waiting and I don’t like hospitals but the pain

is bad.

• I’d always go to my GP at home but I’ve just moved here and they couldn’t see

me today. This is such a waste of time