Understanding patient behaviour in A&E and recommending nudges to shift that behaviour

1. “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
A&E Behaviour and Attitudes
Patient Research at North Middlesex Hospital, Mar 2010
Catherine Shovlin, Director, customerinterpreter.com
cmshovlin@gmail.com

2. 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

3. Objectives
 Understand patient attitudes and
behaviour when choosing to use the
Accident and Emergency service
 Explore what it would take to change
this behaviour

4. 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

5. Part 1:
Summary of the research results

6. 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

7. Key conclusions
Patient 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

8. 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”

9. Part 2:
Detailed research results

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

11. Why they are in A&E
Specific 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

12. 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) 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.

13. 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

14. 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

15. Patient types comparison
(caution: tendencies only, based on small sample)
It’s the process, we
Health Health
treat everyone the
same 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

16. “Structuring choice sometimes means helping
people to learn they can make better choices on
their own” Thaler & Sunstein, Nudge
Part 3:
Applying the research results

17. 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

18. 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

19. 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

20. Nudge recommendations
1. Increase salient costs
Clarify consequences of their actions to patients by
showing 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.

21. Nudge recommendations
2. 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

22. Nudge recommendations
3. 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.

23. Nudge recommendations
4. Use first choice bias
Always 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

24. Practical recommendations
5. 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 unnecessarily
Introduce LED display with next
patient’s name and room rather
than staff calling out name

25. Practical recommendations
5. 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 room
Introduce deli style
ticketing system
 sense of how many
people are before you

26. Applying the results
Communications that change minds
The 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  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

27. 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

28. Appendix:
Additional data and verbatims

29. 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

30. 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?

31. The waiting: passive and no sign of
co-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)

32. 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

33. 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

34. 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

35. 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.

36. 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

37. Patient Quotes -HEALTH VICTIMS
GP 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.

38. Patient Quotes -HEALTH VICTIMS
EMOTIONAL 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.

39. Patient Quotes - HEALTH MANAGERS
GP 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.

40. 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