“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 patientA&E Behaviour and AttitudesPatient Research at North Middlesex Hospital, Mar 2010Catherine Shovlin, Director, email@example.com
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
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 conclusionsPatient types Two main patient types emerge, according to attitudes and behaviour Health victims Health managers passive, needy, under- proactive, organised, confident busy Use A&E often Use A&E “correctly” 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
Key conclusions Recommendations1. 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”
How did they get here?A&E is bearing the brunt of GP shortfall
Why they are in A&ESpecific quotes relating to GPs I needed to see a doctor today and the first My GP was very appointment he had was thorough, then next week she said I needed to go to A&E The GP is no good. He never finds a solution I don’t like The GP just wants you out of hospitals but my their office. They start writing GP said he a prescription before you’ve couldn’t see me even finished explaining for 3 days
State of MindPatients 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 needHealth Victim (c70% of sample) Health Manager (c30% of sample)More likely to have self-referred Confident, informed, for convenience / reassurance proactive, better educated, / a belief in hospitals (vs. GPs). impatient, busy.
The A&E balance for the Health Manager “I can sort this A&E likely to out myself” resolve the 4 hours waiting time problem (should be at work) Benefits Shame / sense of weakness DOWNSIDEs Avoid A&E unless situation is dire
The A&E balance for the Health Victim Free service “Life is a struggle... Now look what happened to me...” Being a good parent / daughter 4 hours wait time Feel relaxed / safe, “at (but I have home”, cared for, welcome plenty of time) A&E will solve the DOWNSIDEs problem Benefits Go to A&E
Patient types comparison (caution: tendencies only, based on small sample)It’s the process, we Health Healthtreat everyone thesame Aspect Self manager Manager Health victim Victim Language and Proactive, solution Passive, problem Behaviour profile focused, know what focused, want to be to do 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
“Structuring choice sometimes means helpingpeople to learn they can make better choices ontheir own” Thaler & Sunstein, Nudge Part 3: Applying the research results
RecommendationsAIM: Increase co-responsibility“This is a public service and we are all part of the public”. More co-creation / co-responsibility. Choose your queueBehaviour will only change if the Health Victim’s practical andemotional needs are met in new ways. This will require:1. Practical changes to redress the imbalance that currently pushes them towards A&E2. “Nudge” changes to increase their sense of ownership
RecommendationsAIM: 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 pressingEG2: it is much easier to choose the right knob toturn on the red hotplate on the right hand hob
RecommendationsAIM: 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 recommendations1. Increase salient costsClarify consequences of their actions to patients byshowing information in the waiting room. Jack and Jill both Last year our got injured. ambulances received Jack went to the GP 1,325 calls and and got help which attended 742 people. cost our country £75. Not all of them really Jill went to A&E and needed an got the same help ambulance. but it cost our So for Bob it was too country £265. late. Thanks Jack. Sorry Bob.
Nudge recommendations2. Understand mappings, increase co-responsibility Use social norms to emphasise the “right” behaviour DID YOU KNOW? 90% of the population did 10% came Only 3% not come to A&E at all at least needed to last year once Ask our advice on using A&E well
Nudge recommendations3. Understand mappings Use status quo bias by expecting patients to see a GP in A&E CAN YOU HELP? SUPPORT: Coaching • Avoid unnecessary visit, session if visit was not necessary (good save £145 parent?) • Avoid unnecessary SELF HELP: Touch ambulance, save £575 screen app FACE SAVING: Easy to It’s your A&E. leave without seeing somebody So save it for a rainy day.
Nudge recommendations4. Use first choice biasAlways offer options in NHS preferred order If they had one queue for emergencies PICK THE CHAIR and one for YOU NEED other things, 1. Pink chair if you feel a GP can most people probably help you would stand in the right 2. Grey chair if you are in too much queue. pain 3. Red chair if you feel you need help urgently Severe Urgent & I can wait pain critical
Practical recommendations5. Give feedback I don’t hear so well They couldn’t and I worry I’ll miss pronounce my name my name and I waited an extra 2 hours unnecessarilyIntroduce LED display with nextpatient’s name and room ratherthan staff calling out name
Practical recommendations5. Give feedback I don’t mind the wait so much as the I’ve been dying for anxiety of not the loo for an hour knowing how long or now but I daren’t if I’ve been forgotten leave the roomIntroduce deli styleticketing system sense of how manypeople are before you
Applying the resultsCommunications that change mindsThe Language and Behaviour profile of the Health Victims is importantto bear in mind when creating communications for them. In particularthey 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 We have many ways we can deal with any health situation. help you here at the hospital or Ask us for guidance at your GP, online or on the First fill in this form then... phone The problem is too many Our goal is for every patient to people come here when they get the best treatment don’t need to Our aim is to have an excellent Don’t get stuck in the wrong package of health options queue. Fill in the form correctly. 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
Who we observed and spoke to 77 patients were classified by demographics Age profile 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
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 ofco-responsibility Less than 5% of those It’s a lovely building. observed were engaged It’s nice here in an activity (reading, writing, crossword) 55% of adults were staring You just sit here and into space wait. You don’t have 35% were a choice talking/interacting with the people they had It’s good they have come with the children’s TV. We 5% were watching TV don’t mind waiting NB: In the children’s waiting room there was It’s worth waiting more activity (kids because you believe they can help you playing)
Patient QuotesTHE GP ALTERNATIVEEQUIPMENT• 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 hereAPPOINTMENT 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 QuotesOTHER ALTERNATIVES TO A&EWalk 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 hoursNHS 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 QuotesBEHAVIOUR CHANGECONDITIONS 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 QuotesA&E SERVICE RELATED COMMENTSBUILDING• 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 placePARKING• 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 QuotesA&E SERVICE IMPROVEMENT SUGGESTIONSNAME 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 VICTIMS GP ISSUESNOT 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 NEEDSGOOD 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 MANAGERSINCONVENIENT 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