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Behavioural Insight into Urgent and Emergency Care

Services

NHS Vanguard North East Urgent and Emergency Care Network

Final Report October 2016

Contents 1 Introduction ......................................................................................................... 1

1.1 Background .................................................................................................... 1

1.2 Scope ............................................................................................................. 2

1.3 Audience Segmentation ................................................................................. 3

1.4 Research objectives ....................................................................................... 5

1.5 Report Structure ............................................................................................. 2

2 Public Focus Groups .......................................................................................... 3

2.1 Introduction .................................................................................................... 3

2.2 View on the Definition of Urgent and Emergency .......................................... 3

2.3 Behavioural intentions: key barriers ............................................................... 6

2.4 Behavioural intentions: key choice motivators ............................................... 6

2.5 Creative vandalism ......................................................................................... 7

2.6 Channels of engagement ............................................................................... 9

2.7 Messenger ..................................................................................................... 9

2.8 Main differences by segment ....................................................................... 10

2.9 Summary ...................................................................................................... 11

3 Interviews with Stakeholders, NHS and other Professionals ....................... 12

3.1 Introduction .................................................................................................. 12

3.2 Urgent or Emergency ................................................................................... 12

3.3 Summary Findings ....................................................................................... 13

4 Rolling Focus Groups (Roving Mini-depths) and Video Booth .................... 17

4.1 Introduction .................................................................................................. 17

4.2 Patients/Public ............................................................................................. 17

4.3 Staff views .................................................................................................... 19

5 ONLINE SURVEY: QUANTITATIVE RESPONSES .......................................... 21

5.1 Responses: The Survey Sample .................................................................. 21

5.2 Detailed Responses ..................................................................................... 23

5.3 Definitions of Urgent and Emergency Care .................................................. 23

5.4 Professional Views on the Key Issues ......................................................... 26

5.5 Sharing Information across NHS Organisations .......................................... 27

5.6 Sharing Information on Waiting Times ......................................................... 29

5.7 Source of Urgent or Emergency Care .......................................................... 32

5.8 Factors in Making the Choice of Urgent/Emergency Care Setting ............... 35

5.9 Advice from the Internet ............................................................................... 39

5.10 Attitudes and Perceptions ......................................................................... 41

5.11 Reducing Urgent & Emergency Attendance ............................................. 43

5.12 The ‘Customer Experience’ in A&E ........................................................... 46

5.13 Overall Trust in Urgent and Emergency Care ........................................... 49

6 Summary and Conclusions .............................................................................. 51

6.1 Summary: The Key ‘Take Home’ Messages from the Insight ...................... 51

6.2 Conclusions: Themes for Action .................................................................. 52

6.3 Using Audience Segmentation and Behavioural Insight – A Scenario Based Example ................................................................................................................. 58

6.4 Using the Insight .......................................................................................... 59

Appendix One: Mosaic Profiles for each of the NE UECN priority segments ... 61

North East Urgent and Emergency Care Network Behavioural Insight into Urgent and Emergency Care Services

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1 Introduction Kenyons is an independent marketing, communications, and PR agency with embedded research capability, based in Liverpool. The agency was commissioned by the North East Urgent and Emergency Care Network (NE UECN) – one of 50 Vanguard areas in England - to undertake a behavioural insight study into the use of urgent and emergency care services.

1.1 Background NHS England is now working with 50 ‘vanguard’ areas across the country to develop dedicated support packages to enable and accelerate change on new models of care delivery, backed by an intensive evaluation programme so that good practice can be spread to other parts of the country.

The programme is an important part of the NHS Five Year Forward View, which sets out the health, quality of care, and funding gaps that will open up if the NHS does not change.

In July 2015, the North East Urgent and Emergency Care Network (NE UECN) was confirmed as one of eight new urgent and emergency care vanguards.

The NE UECN is described on the NHS England website as shown:

Participation by the North East Urgent Care Network (NE UCN) in the vanguard programme will benefit the whole of the North-East region.

This covers areas around Northumberland, Tees, Esk and Wear Valley, Newcastle, Northumbria, Gateshead, Tyneside, Sunderland, County Durham, Darlington, and Hartlepool – a region with a population of 2.71 million. It is made up of three major conurbations, and spreads across both urban and rural areas.

The NEUCN – which consists of all the key physical, mental health and care stakeholders and providers – already has a strong history of working collaboratively to deliver successful innovative projects to support the recommendations made in the Urgent and Emergency Care Review as well as, importantly, improving patient outcomes and experience.

This programme will enable the network to transform the regional UEC system and its services to further improve consistency and clinical standards, reduce fragmentation and deliver high quality and responsive health and social care to patients.

It will also enable them to move at pace in terms of creating and implementing one urgent and emergency care model as well as giving strategic oversight to urgent and emergency care services across the regional footprint, providing consistent and seamless care, wherever patients present, whatever the day or hour with no difference in the clinical outcomes delivered.


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NE EUCN is one of four vanguard sites in the North-East region, alongside:

§ Northumberland (primary and acute care systems); § Gateshead (enhanced health in care homes); and § Sunderland (multispecialty community providers [MCP]).

1.2 Scope The research to establish behavioural insight into the use of Urgent and Emergency care was conducted in four phases as shown in the diagram below.

§ Phase One was initial discovery of the issues through qualitative testing in focus groups and depth interviews;

§ Phase Two built on the outcomes of phase one to deliver further qualitative testing with public, patients and staff, using rolling focus groups in service setting and rapid digital ethnography;

§ Phase Three saw the key outcomes of the preceding qualitative phases tested in an online quantitative survey conducted with staff and the public; and

§ Phase Four saw the development of pilot social marketing solutions to implement the outcomes of the behavioural insight.


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1.3 Audience Segmentation

In line with sound principles of social marketing and specifically the National Social Marketing Centre (NSMC) advice to:

“…avoid a ‘one size fits all’ approach: identify audience ‘segments’, which have common characteristics, and tailor interventions appropriately…”1

NE EUCN have adopted a priority group segmentation approach based on those sections of the population most likely to attend urgent or emergency services ‘inappropriately’ constructed from analysis of admissions data and other sources. To achieve this NE UECN used the Office of National Statistic mid-year population estimates (2014) for North East of England and Experian Mosaic2 profiling data (2015) to develop the seven key segments of the North-East population3:

§ Preventers (21% of the North of England Population) § Fixers (20% of the North of England Population) § Independents (19% of the North of England Population) § Stoics (18% of the North of England Population) § Disengaged (2% of the North of England Population) § Reluctants (16% of the North of England Population) § Novices (4% of the North of England Population)

Collectively, these segments describe the behaviour of 100% of population of the North East of England. Each of these contains a larger single element Mosaic group, which are used as ‘centre segment’ around which we have based the behavioural insight research activity.

Details of the priority segments are shown in the table on the following page, with the Mosaic profile for each shown in Appendix One of this report3.

1NSMC Big Pocket Guide to Using Social Marketing for Behaviour Change http://www.thensmc.com/sites/default/files/Big_pocket_guide_2011.pdf2 Mosaic is provided by Experian giving a detailed lifestyle and behavioural segmentation of the population described as a “…cross-channel consumer classification designed to help you understand the demographics, lifestyles, preferences and behaviours of the UK adult population in extraordinary detail…”. Mosaic provides 15 major groups and 66 types from which the priority segment have been developed. 3 North East England patient segmentation, February 216, North East Commissioning Support Unit

“…There is NO SUCH THING as targeting the general public...”1


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Patient segment

Typical attitude to health

Socio-economic profile and MOSAIC classification Population Percentage ‘Centre Segment’ Mosaic

Group

Preventers “It’s better to be safe than sorry”

§ Typically, women from higher socio-economic group (SEG) and Mosaic lifestyle groups C to H.

§ 21% of North of England population are preventer

§ 26% of Preventers can be described by the mosaic group E (Suburban Stability)

Fixers “I haven’t got time

to be ill”

§ Typically, men from higher SEG and Mosaic lifestyle groups C to H

§ 20% of North of England population are fixers

§ 26% of Fixers can be described by the mosaic group E (Suburban Stability)

Independents “I like to deal with things myself if I

can”

§ Typically, women from Mosaic lifestyle groups A, B, and I to L

§ 19% of North of England population are independents

§ 30% of Preventers can be described by the mosaic group L (Transient Renters)

Stoics “I will only ask if

things get serious”

§ Typically, men from Mosaic lifestyle groups A, B, and I to L

§ 18% of North of England population are stoics

§ 30% of Stoics can be described by the mosaic group L (Transient Renters)

Disengaged

“I need help and don’t always know the right place to

turn”

§ Typically, men and women from low SEG and Mosaic lifestyle group N

§ 2% of North of England population are Disengaged

§ 100% of Disengaged can be described by the mosaic group N (Vintage Value

Reluctants

“Something’s wrong but I don’t want to cause too much

bother”

§ Typically, men and women from low SEG and Mosaic lifestyle group M and O

§ 16% of North of England population are Reluctants

§ 73% of Disengaged can be described by the mosaic group O (Municipal Challenge)

Novices “I need someone to tell me what to do”

§ Typically, young people aged 14-21 e.g. first-time mums and students

§ 4% of North of England population are Novices

§ Novices are from all mosaic lifestyle groups


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1.4 Research objectives The objectives of the behavioural insight research are to:

1. Provide high quality market research services to understand the views and

behaviours of two audiences on Urgent and Emergency care provision across the

Vanguard region, specifically:

§ Patients and the public;

§ Clinical and other NHS staff.

2. Deliver a quality solution with innovation and creativity, to enhance engagement and

provide ‘under the skin’ insights

The specific requirements from the research to understand the views and behaviours of the target audiences are:

§ Patients and the public: NE UECN want to identify what the public perceive to be the key issues around urgent

and emergency care including:

§ What the public perceive to be the difference between urgent and emergency

care

§ Gain insight into the experiences of those who have recently accessed specific

health services

§ Understand the behaviours and motivations which govern how and why people

use health services in the way they do

NE UECN also want to understand health seeking behaviours around the use and

misuse of specific care or services including:

§ Self-care (people looking after

themselves)

§ 999

§ 111

§ A&E

§ Walk-in services

§ GP

§ Pharmacy

§ Urgent and emergency mental

health

§ NHS staff and key clinical groups In line with a robust social marketing approach, behavioural insight from key clinical and

NHS staff groups will be needed. These will include:

§ A&E staff including: Consultants, nurses, triage staff and receptionists;

§ GP practice staff: GPs, practice nurses, healthcare assistants and receptionists;

§ 999 and 111 call handlers including: clinical hub control staff (providing clinical

supervision to the call handlers;

§ Paramedics, emergency care technicians, emergency care assistants;

§ Pharmacists; and

§ Health visitors.


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1.5 Report Structure Following this introduction section, the study outcomes are reported as follows:

§ Section Two: provides a discussion of the outcomes of the public focus groups

conducted as part of phase one of the research;

§ Section Three: details the outcomes of interviews with stakeholders, NHS, and

other professionals (Phase One.)

§ Section Four: details the outcomes of the rolling focus groups (mini-depth

interviews) conducted as part of phase two of the research

§ Section Five: provides a discussion of the outcomes of quantitative research

with both public and professional groups (Phase Three.)

§ Section Six: details the conclusions we can draw from the research to inform

the development of a behaviour change intervention related to

urgent and emergency care.

§ Appendix One: Profiles for each of the NE UECN priority segments.


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2 Public Focus Groups 2.1 Introduction Seven groups were recruited against the NEUECN priority segment profiles. The groups

were convened and moderated between the end of April and the start of May 2016 each

made up of between seven and ten participants:

1. Preventers (Durham 3 May)

2. Fixers (Newcastle, 5 May)

3. Independents (Darlington, 5 May)

4. Stoics (Middlesbrough, 26 April)

5. Disengaged (Stockton, 4 May)

6. Novices (South Shields, 4 May)

7. Reluctants (Gateshead, 3 May)

In total 61 members of the public living in the North East of England took part in the groups.

The groups were conducted under Market Research Society guidelines, following a semi-

directive discussion guide to ensure each group considered the same set of issues to

ensure we could explore areas of common interest to understand differences by segment.

2.2 View on the Definition of Urgent and Emergency We first asked the groups to share their views on what they thought was meant by the

terms:

• Urgent care; and

• Emergency care

Discussion took place around a ‘brown paper wall’ perception matrix, where we asked

participants to shout out conditions and whether they thought they were urgent or

emergency on the x axis.

Urgent Emergency

We then introduced a y axis (service provider or self-care) and asked them where those

conditions sat against those dimensions.

Service Provider

Urgent Emergency

Self-Care


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Examples of the outcomes of this exercise are shown below.

The groups were all initially confused by the question and could not spontaneously

distinguish between the terms urgent and emergency, in relation to medical care, feeling

both were of equal weight. However, following an explanation of the terms the groups were

then able to differentiate between urgent which they saw as:

“…conditions which have immediate life threatening danger i.e. are critical to life…”

or

“…conditions with immediate life changing consequences such as potential loss of limb…”

It is also important to note that the confusion between the words ‘urgent’ and ‘emergency’

continued throughout the discussions in some of the groups. While a common

understanding was established people continued to use the word urgent when the group

meant emergency. When asked why they used the two interchangeable the common

response was that they felt urgent was the most appropriate word for an emergency in their

everyday life.

An aggregated summary of the exercise across all groups shows the groups’ collective

clear delineation between emergency, which was seen as a call to 999, with a trip in an

ambulance to A&E. The urgent care provision was focussed around care provided by GP

surgeries, 111, out of hours, walk-in centres, and minor injuries. All groups identified

pharmacies as the most appropriate source for self-care, while emergency dentists were

only identified after prompting.

There was a clear understanding of the life threatening or life changing conditions that

constituted an emergency care need. Mental health issues – specifically suicide attempts -


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were identified as an emergency situation but none of the groups identified any services

likely to respond apart from A&E.

The clarity of focus of ‘urgent’ conditions was less clear, with people in the groups

identifying conditions such as ongoing cancer treatment as urgent care, with the expressed

certainty that “…it is urgent for people with cancer…” Perhaps further compounding the

issue around the clarity and understanding of the terms ‘Urgent Care’ and ‘Emergency

Care’ by the public in general and the priority segments specifically.

In summary, this exercise revealed a widespread confusion over the terms. All groups

convened with representatives of the priority segments found it hard to differentiate

between the two, seeing them as being mutually interchangeable until prompted with a

clear definition.

The overarching sentiment expressed by the groups was that it would be much simpler if a

standard term, Urgent, was adopted to describe all the services.


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2.3 Behavioural intentions: key barriers There was a strong (perceived?) and consistent theme in the groups of lack of access to

GP appointments, resulting in consensus that the default response to illness or injury was to

call 111, visit a Walk-In centre or to attend A&E. This was thought to be the key barrier to

‘appropriate’ attendance at urgent or emergency care.

In other words, the groups felt people don’t want to wait to see GP:

“…. they’ll just say go to A&E for x-ray…waste of time…”

2.4 Behavioural intentions: key choice motivators When we asked the groups what they thought were the key motivators to attending urgent

and emergency cares services, their response can be summed as a desire to:

§ Be healthy;

§ Stay healthy; and

§ Avoid unnecessary risks to health

The consensus amongst the groups is that people try and get information on access to care

in the easiest way which offers reassurance that the three factors shown above will be met.

This can be summed up as “speed and quality equals confidence in the service.” The

groups held the view that if the service offered speed and quality it was unlikely to prompt

escalation to another service. Setting this in the context of the groups’ perceived barriers -

cited as lack of timely access to GPs – if they felt they could get speedy access they would

use their surgery as the first port of call. However, as the groups all felt access to a GP

could not meet the ‘speedy’ criteria care was sought elsewhere as the default position.

In general participants in the groups claimed to be “…frustrated and horrified…” with stories

of misuse of urgent and emergency, given by the moderators or emerged through

discussions:

“…it’s selfish and could cause harmful repercussions for others…”

This suggested a very strong feeling for a behaviour change to be built on.

The groups also felt that providing ‘hard stats’ disseminated though social media can play a

role in changing behaviour such as:

• The cost of inappropriate behaviour: £s and lives, etc.

• Case studies – name and shame

The groups felt the aim would be getting people to think before acting and to take more

responsibility for their own action i.e.

“…to ask is it an emergency?”

“…learn to use it, don’t abuse it…”


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2.5 Creative vandalism The process of ‘creative vandalism’ is a projective technique where focus group participants

are asked to develop ‘mood boards’ for their ideal communications/ marketing campaign

We provided the groups with paper, pens, scissors, etc. as well as lots of imagery, ranging

from lifestyle magazines, to images of NHS staff and related campaigns. We then asked

them to write, draw, scribble, cut, glue, colour as much as they wanted, directing them to

think about answering as far as possible the following questions:

§ Who are you talking to?

§ What are you saying? (The message you’re using)

§ Who is saying it? (Messenger)

§ What tone is being used (i.e. strict, friendly, supportive, dictating, guilt inducing, etc.)

The groups took very different approaches as would be expected, however these broadly

fitted into two categories:

1. Focused on the content elements of a marketing campaign;

2. Focused on the overall look and feel of the approach rather than the specific

content.

Content Focused Discussions Groups that produced content focused ‘creatives’ all concentrated on what they felt where

key issues around:

§ When to attend A&E;

§ When not to attend;

§ The key issues that cause people to attend A&E that can be avoided.

Examples of the ‘content focused’ materials generated by the group is shown below and on

the following page.


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‘Look and Feel’ campaigns Groups concentrated on the look of campaigns they would like to see including:

§ People we recognise;

§ Links to TV or film ‘happenings’ – such as Game of Thrones, which at the time of the

groups had returned with a new series;

§ Clear health messages linked to recognisable people and ‘happenings’ § Clear and simple presentations – like infographics Examples of the outputs focusing on ‘look and feel’ are shown below and on the following

page.


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2.6 Channels of engagement The groups were asked to identify the way in which they would expect their ‘ideal campaign’

to be communicated to them, in other words the communications channels used. Perhaps

the most interesting ‘channel’ identified by the groups was creation of a ‘movement’ among

the community creating a trend to make it a good thing to choose well:

“Start young and change the next generation’s use and perception.”

The most popular of the other channels mentioned were:

§ Social media (Twitter, Facebook, Instagram, Snapchat, etc.)

§ Outdoor media

§ Bus adverts

§ Press

§ Posters in strategic locations (GP, A&E)

2.7 Messenger When the groups considered who, they would like to see as the person / personality

delivering the message to them, the ‘messenger’ fell broadly into three key types of people:

§ NHS professionals – doctors or nurses – because they know what they’re talking about;


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§ Celebrity associated with health and a healthy lifestyle (David Beckham, Raffa Nadal,

Khloe Kardashian, etc.);

§ Ordinary people, people like us doing the right thing.

The groups felt each of these would be equally effective.

2.8 Main differences by segment While we have so far reported by the consensus views of the groups, there were some

clear differences in opinion amongst the priority groups, which were:

§ Novices learn by experience and they tend to play it safe if they have not experienced

symptoms before. Their response tends towards going to A&E as default because this is

the safe option in their minds. Novices are also less likely to be able to recognise issues

around the impact their behaviour has on the overall urgent and emergency care

system’s performance.

§ Preventers and Fixers (more affluent people in their fifties) all base responses on their

own life experiences. However:

• Preventers are more likely to take a grandchild to A&E

• Fixers seek reference from social networks “I’d ask Aunty Hattie…”

§ Fixers are less likely to drive to an urgent or emergency care service if they suspected

the health issue they faced was serious

“…if I’m having a heart attack and I black out it’s irresponsible to drive…”

§ Preventers are the only group to report seeing the complexity of urgent and emergency

services as a failure in the system that forces ‘poor’ choice. Their view is that in

circumstance where they (and people they know) are uncertain the default is always to

go to A&E.

§ Stoics (young men) are less likely to attend with a condition and more likely to make

their own way

“…I had a problem with my heart, though it was minor, girlfriend made me go to A&E. I drove up there and it turns out I was having a heart attack, they kept me in for three

weeks…”

§ All groups felt that social media was a key ingredient in communications. However,

novices were less likely to state this need and are also most likely to take it for granted

that there will be a strong online/social media presence for any campaign or service by

default.


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2.9 Summary Findings from the groups can be summed up as follows:

§ Few groups saw dental as part of urgent/emergency care without being prompted

§ Everybody saw A&E as the safe choice, and reported being more likely to attend with

a third party (parent/friend/parent/friend/another person’s child)

§ There was a general lack of confidence in 111, the groups saw the service as being

too driven by a menu of responses coupled with or causing a lack of faith in the

credibility of call handlers:

§ …they’re not doctors or nurses…”

§ The overall default position from the groups was that A&E equals:

§ best care!

§ best facilities!

§ best staff!

§ All groups very clear that long term conditions (asthma, diabetes, COPD mentioned)

could be either urgent or emergency.

§ All groups had a clear understanding that the severity of each incident dictated if it

was an urgent or emergency situation.

§ No group spontaneously identified chemist/pharmacist as a service in urgent care,

while it was forthcoming in discussions it was always as an afterthought once all the

‘obvious’ services were identified.

§ When considering inappropriate attendance, the universal first reaction of the groups

was to “…charge/bar” the people behaving that way. However, on reflection within

the group there was a recognition that this was a very complex issue:

“…who draws the line?”

“…there may be other underlying issues”

Following the discussions, the spontaneous suggestions to adopt a policy other than

charge/bar included:

§ A “Health Education Course” like Driver Education; and

§ Skip a generation and start early in schools.


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3 Interviews with Stakeholders, NHS, and other Professionals

3.1 Introduction We conducted 41 interviews with professionals, NHS staff, clinicians, and key stakeholders,

including:

§ 111/999 call handlers;

§ A&E Consultant;

§ A&E Nurse;

§ Consultant Specialists;

§ Fire and Rescue first responder;

§ GPs;

§ Health Visitors, Community, and GP

surgery nurses;

§ Learning disability and mental health

nurses;

§ Older peoples’ consultants;

§ Paramedics;

§ Pharmacists (community and A&E

prescribing);

§ Psychiatric consultants; and

§ Receptionists.

3.2 Urgent or Emergency There is a consensus on the definition of Emergency Care as, approximately:

“Life threatening or life changing if there is not an immediate response”

However, there are very significant variations amongst professionals on the definition of

urgent care based around:

§ Time factors;

§ Having empathy with the individual’s perception of the issue;

§ A continuum of need;

§ Functional issues.

The summary details of each are shown below:

§ Responses that defined ‘urgent’ in tems of time factors varied in degree and

included:

Needs to be addressed within a week or two People who need medical assistance but couldn’t wait until a GP is available

to see them If you can’t wait for a routine appointment to see someone

Treatment needed today but not life threatening A problem that needs dealing with urgently

Needs to be seen by a medical specialist within the day Care needed within a few hours

Urgent care is less urgent than collapse/resuscitation Hours to days (care needed)

Need care soon – e.g. within 24 hours as not life threatening


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Requires action within 12 hours Can wait a couple of hours or the next day

Not necessarily life threatening but can can’t leave because it will get worse without prompt attention

Where emergency response is not so urgent so people have to wait longer Needs an appointment on the day

§ Those respondents who discussed ‘urgent’ care focusing on empathy with the

individual’s perception of the issue, were more unified in their definition and included:

A problem that needs dealing with that’s urgent to the patient A problem that the patient feels needs dealing with urgently

A problem that people are not able to deal with – they’re medically unwell

§ Several respondents saw the definition of ‘urgent’ as a relatively complex part of a

continuum of care:

Urgent is a ‘grey’ area – minor injuries or minor illnesses Very blurred – depends on expectations – public expectations are high for

time and quality

§ Others saw the definition of ‘urgent’ care in purely functional terms:

Not necessarily hospital – urgent advice or walk-in treatment Urgent care needs are those which can be dealt with by an out of hours GP

3.3 Summary Findings Defining Urgent and Emergency is as problematical for professionals as it is for the public.

The closer the respondents are to being clinicians or other professionals working in the

Emergency Department the more likely they are to provide a “textbook” definition of both.

There are divergent views on the part ‘the public’ play in the issues faced by the system:

§ More operational roles tend to believe in the need to educate people of the

options and issues to promote better choice.

§ More strategic/senior roles take the view that the system is at issue not people’s

decision making:

“…people are making the right choice for them at the time…”

“…the system rewards the choices they make…attend inappropriately, get seen there and then, get their results, get their prescription and they’re

off…relatively quickly, why wouldn’t they come back?”

“…we should change the system to meet customer need rather changing behaviour.”


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There was also a feeling that many factors heavily influence the public’s behaviour and

expectations of urgent and emergency services, including:

§ The move from the traditional model of the ‘family Doctor’ to modern health

centres having the dual impact of:

i. Removing the ‘experience network’ in people’s neighbourhoods with care

moving to a more efficient but more ‘faceless’ centres; and

ii. For older people removing the close relationship with their GP, which often

leaves them unsure of where to turn for care;

§ In rural communities - despite changes in local provision such as the change from

a local A&E to a Minor Injuries service – people still go ‘the hospital’ because

that’s where parents, grandparents and great grandparent always went;

§ The view that inexperience of younger people leads them to turn up at A&E for

minor issues. Some went further to express this as overindulgence where parents

build an expectation of priority service in some young people that carries across

from the home into a sense of entitlement in all service areas, not just urgent and

emergency care.

It was felt that the public often viewed urgent and emergency care based on very optimistic

recollections on waiting times in the past despite the reality of very long waiting times before

the introduction of four hour waiting time targets.

“…. when I was young you were straight in and straight out…”

Despite the acknowledged pressures on service people consistently expect “more and

more.” In the view of many respondent the A&E four hour waiting targets and the impact of

Walk-In centres are to some extent victims of their own success.

Respondents provided anecdotal evidence of what they largely viewed as a sharp

differentiation in attitudes by age:

§ Younger people are immersed in an ‘always on’ culture, expecting to receive

service twenty-four/seven, often working shift patterns that did not fit in with a

nine-to-five care system. A combination of expectation and requirements means

much of the care system doesn’t respond to their needs, forcing them to use

urgent and emergency care instead.

§ Older people largely ‘don’t want to be a bother’, which is mix of recollection of the

issues faced in the past for many the NHS was formed in living memory and a

wish to ensure scarce resources for urgent and emergency care are used most

wisely.

There was also a consistent identification of specialist skills or support which are often

lacking in the urgent and emergency care system around mental health and crisis and

learning disabilities:

§ Mental Health is seen to be different and needing distinct approach within system

– emergency support needed internally and for patients


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“…we are seeing more and more people in crisis (mental health) …we will respond but know…can’t do right by them, we just put an arm around them…”

(Paramedic)

“…they (A&E) do their best and often adjust medication without knowing that had been tried with that patient before and it didn’t work simply because they

can’t access their medical history…”

(Mental health professional)

§ The needs of people with learning disabilities are largely felt to be misunderstood

in the urgent and emergency care system, compounded by what is felt to be an

issue with record sharing that often sees people put under undue stress or

receiving variations in treatment that are unlikely to work for the individual.

“…the Police have a flag on their system that this client gets agitated and will ‘flat pack’ everything and everyone if not calmed down. When they go into A&E there is no record of behavioural issues and it always escalates into a

situation, when all they need is a quiet room and a bit of time…”

(Professional talking about a client with Autism)

While the focus of this research is on behavioural insight there were many examples of

commentary on structural issues, including the benefits in co-locating inter-dependent

services providing a quicker customer experience and better communications between

professionals e.g. radiology, chest etc. for emergencies and dental, mental, and social care

in one place and for some to even include GP surgeries.

There is also a very strong observable theme around the communications messaging

among professionals including:

§ A very strong reliance on NHS language, which has ‘technocrat’ advantages

allowing concise and efficient sharing of information between professionals, with

a tendency to ‘leak’ into conversations with ‘civilians’ which generally confuse the

public:

“…we talk about it in our daily huddle…”

§ The use of service descriptions, which change based on NHS

organisational/functional changes which are not reflected in the way in services

are accessed which causes public confusion, summed up in one comment:

“…they (patients) keep asking for the walk-in centre, we don’t have one anymore, but they can walk in here and get seen…”

This confusion is carried across into the use of estates and signage in urgent and

emergency care setting – which sees increasingly complex directions to service for

the public as illustrated in the site visit photographs on the following page.


Final Report

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4 Rolling Focus Groups (Roving Mini-depths) and Video Booth

4.1 Introduction We ran a series of “rolling focus groups” in service settings, designed to be on a drop-

in/drop-out basis as a non-intrusive exercise. This was designed to allow us to gain a real-

time insight into the behavioural motivators for attendance in that setting, from ‘top of mind’

responses without any perceptual or memory lag.

We also recognised that people may not wish to share their opinions in an open setting with

other colleagues present and the groups exclude the valuable opinion and experience of

frontline staff in the service settings. To overcome this, we set up a video booth with the

capability to record personal statements in a relatively private setting.

Through these methods, we could engage opinion from 194 staff, patients and passing

members public; 32 of which were staff members with the remaining 162 patients and

members of the public. This element of the research activity was completed in four areas

across six settings:

§ Durham (A&E and paediatrics)

§ Gateshead

§ Newcastle (A&E and paediatrics)

§ South Shields

As a flexible and responsive methodology, we could adapt to the local circumstances and

the rolling focus groups developed into a series of roving mini-depth interviews. These were

very successful as a method of engaging real time opinion with both staff and patients.

However, the Video Booth met with less success, but it produced excellent results where it

did work, in the main this element was mostly used for audio recording opinion.

Set out below are the opinions reported separately for:

§ Patients/public; and

§ Staff.

4.2 Patients/Public The key issues to emerge from discussions with public and patients in the roving mini-depth

interviews were:

§ Staff in urgent and emergency care settings just don’t understand or seem able to

cope with complex issues such as learning disabilities or old people with comorbidity;

§ The choice of care location for some is driven by ‘tribalism’:

“…we live between Newcastle and Sunderland, we come here because they’re not our people, we’re Geordies not Mackems”;


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§ For many there was an underpinning sense of guilt they don’t want to be thought as

inappropriately attending even if there is genuine need;

§ There was a high incidence of GP direction to urgent or emergency care, including:

§ I’m here because the GP told me to come(anecdotal);

§ I’m here because they offer specialist services not offered by my GP – i.e.

chemical ingestion by child/ x-ray;

§ People not registered with a GP who’s only access to healthcare was urgent or

emergency care or using it as a walk-in service for issues that have been left too

long;

§ Language/cultural barriers (including international students) where people new to the

UK did not know what to expect and based their responses to an urgent or

emergency care situation based on previous experiences outside this country.

§ A lack of confidence in anything other than A&E in an emergency

“…Calling 111 is like calling O2 – they can’t fix your phone as much as they can’t fix people, it’s a machine doing the thinking…”

§ Most people in the interviews saw urgent and emergency as being the same thing

and did not see the waiting time as being an issue when they needed care: “…I just walked up, no problem, waiting isn’t an issue…”

§ There was felt to be an education need on health basics – a fever makes you cold

but you need to cool down not wrap up, with the need to start young to change

behaviour

§ The signs in this place are confusing or could tell us more

“…we don’t do this here; they do it there…”

§ The language used by the staff is confusing “…I wouldn’t know what to do next time because I never understand what they say to me anyway…”

§ It’s not the same across the country “…it seems simpler in Brighton…” Why don’t

they talk to each other?

§ A feeling that many people are motivated to attend – particularly A&E – because

they are simply worried or confused about their health

“…people feel better (safer?) for being in a waiting room…”

§ If waiting times are properly published people and they are too long they will go

elsewhere, in other words it will weed out non-urgent cases,

“…if they can go somewhere else they’re not an urgent case are they…”


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§ Several people were attending because their employers or place of study had sent

them as a ‘duty of care’; perhaps suggesting a role to work with employers to help

them make better choices.

4.3 Staff views When we spoke to staff in urgent and emergency care settings they identified the following

key issues:

§ Drunkenness is the most common cause of inappropriate attendance

§ People don’t understand how to use the service:

§ Too many people are making inappropriate presentation they need education

on what we provide, where to get care and their own responsibilities.

§ There is a 24/7 expectation of service from the NHS – in line with the way the

rest of society is moving - and A&E is the only place open all the time,

therefore, people come here irrespective of whether their need is urgent or

not.

§ An opinion that the workflow within integrated urgent and emergency services (co-

located) can makes service unsafe when there are peak demands

§ GP services are under pressure, which has the ‘knock on’ impact on urgent and

emergency services in that people who:

“…can’t get to see a GP come here (A&E) …”

The general feeling is GP access is a huge contributing factor in the volume of

people attending at A&E who could or should be seen elsewhere in the system.

§ Increasingly people in mental health crisis are attending A&E, which is often not

equipped to provide them the care they need:

“…we do our best but we are not set up to cope and often see very rapid re-presentation... (same day, same person, same issue) … because we are not able

to help them…”

§ Staff ‘on the ground’ in A&E provide a general observation the t 111 system is

extremely risk averse and sends too many people to A&E in an ambulance. Two

clear conditions qualify this:

1. It is the programming of the IT system that is risk averse not the people who

operate it; and

2. The 111 system automatically sends people to A&E, particularly with

paediatric patients, which puts pressure on the system which could be

avoided.

§ There is a general need for education for all professionals on what Urgent and

Emergency services can and cannot do. The example of infection control staff


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effecting behaviour change in staff was cited as a powerful example of a change that

could provide the potential for similar impact in urgent and emergency care by

adopting the position that:

“…it’s everyone’s job (cleaner to brain surgeon) ...”

§ Coupled with the need in staff detailed above, public education is needed to help

people identify the correct care location for them. However, most staff who

expressed and opinion on this believed it would be more effective to work with

younger people than those whose attitudes are already ‘fully formed.’

§ There is a dedication and professionalism, coupled with a duty of care, that carries

an inherent burden on staff and service:

“…once they’re here (patients in A&E) it’s very difficult to send them away…”

The view being that irrespective of the fact the patient would receive the same level

of care in another setting, particularly where their need is neither urgent nor an

emergency, once they are in the system they are deal with as if they were.

§ Many staff respondents expressed a strongly felt belief that urgent and emergency

care is often used by public either for better treatment than they’d receive elsewhere

or for a second opinion.

§ Finally, and importantly staff hold the view that ‘self-diagnosis’ sees a lot of people

attending urgent and emergency care services needlessly with minor issues:

“…Dr Google should be banned…”


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5 ONLINE SURVEY: QUANTITATIVE RESPONSES 5.1 Responses: The Survey Sample The two surveys were conducted against, broadly, the same questionnaire to allow

comparison between opinion.

Overall there were:

§ 1,176 response from the public; and

§ 613 from staff.

However, many individual responses contained little information beyond answering the first

question.

To allow for meaningful analysis we conducted a data validation to exclude those who had

completed very few questions.

After this exercise the sample4 for analysis was:

§ Public: 375 validated responses

§ Staff: 204 validated responses

A breakdown of the demographics of each is shown on the following pages.

§ All respondents either live or work in the North East of England.

Public Respondents’ Profile

Age Distribution Gender

Under 18 0.3% Male 16.0%

18-25 1.3% Female 65.3%

26-35 4.3% Missing/No Response 0.2%

36-45 8.5% Ethnicity 46-55 13.9% White British 78.40%

56-65 31.2% White Other 2.13%

66-75 18.1% Black British 0.27%

75+ 4.5% Black Other 0.27%

Missing/No Response 17.9% Asian British 0.27%

Missing/No Response 18.67%

4 Please note: this is a self-selecting sample who voluntarily elected to complete an online survey, therefore it

is not guaranteed to be representative of the general population in the North East of England


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Level of awareness of service prior to completing survey

999 96.3%

111 91.4%

Walk in Centre 94.8%

Out of Hours Centre 66.3%

Minor Injuries Clinic 64.1%

Pharmacist 90.8%

NHS Choices 54.6%

Internet Search 69.9%

A&E Department 97.5%

Staff Respondents’ Profile Age Distribution Gender

18-25 3.4% Male 14.7%

26-35 14.2% Female 61.3%

36-45 18.1% Missing/No Response 24.0%

46-55 27.9% Ethnicity

56-65 13.2% White British 78.4%

Missing/No Response 23.0% White Other 2.13%

Place of Work Black British 0.27%

NHS Organisation 92% Black Other 0.27%

Local Authority Social Services 6% Asian British 0.27%

Any voluntary organisation providing Urgent or Emergency care

2% Missing/No Response18.67%


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5.2 Detailed Responses

5.3 Definitions of Urgent and Emergency Care The responses from both professionals and members of the public to describe Emergency care, against set descriptions provided in the survey, show a high degree of confusion. No

single term being supported by more than 20% by either group.

Public Responses (Base 375)

Staff Responses (Base 204)

Care needed when a person is in immediate danger of losing their life or has been in a serious accident

20% 17%

Care needed when a person is in immediate danger of losing a limb or their sight

16% 14%

Care needed when a person has a condition that needs to be treated immediately to prevent it getting to a point where their life is in danger

19% 16%

Care needed when a person has a condition that while not immediately life threatening could become more serious if not treated within 24 hours

11% 12%

Providing life-saving measures in life-threatening situations 16% 15%

Providing care to serious and life-threatening injuries and conditions only

12% 11%

Providing care to people who feel the issues they face with their health are an emergency

5% 12%

Other 1% 3%

“Other” responses – emergency care (Categories)

Public: § Baby/child or elderly person with deteriorating health

§ All staff should act with decency

§ Disconnect between perception and purpose of Urgent Care and the reality

§ Want to know someone is there when individual most in need

§ Whatever an individual wants

• Lack of reactive mental health services for those in crisis

Staff:

• Out of hours care that patient feels can't wait for GP / needs treating quickly

• Patient can't get appointment at GP

• None life-threatening conditions that can be assessed and dealt with by nurse

practitioners

• Service closest to home when worried


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• Public difficulty in differentiating between urgent and emergency / lack of distinction

between both

• Dependent on individual interpretation / influence of family members

• Any minor ailment

• When a patient wants to be seen

• Running out of medication/ongoing diagnosed or undiagnosed pain/previous

experience which has reoccurred

• When someone can receive attention for what they feel is an urgent medical

condition either in primary care or at an urgent care centre

• My NHS - patient has a right to be seen whenever/wherever they want

We asked staff a separate question, not duplicated in the public survey “…what is your own definition of emergency care based on your professional viewpoint?”

This was an open question and we have grouped the responses into thematically based

categories as shown below. What is apparent from this is that when staff were asked to

provide their own definition of Emergency care there was closer consensus than that with

the ‘set descriptions’ with 74% of respondents agreeing Urgent care as:

“Life threatening illness or injury / immediate medical assistance required to prevent death or further deterioration”

Life threatening illness or injury/ immediate medical assistance required to prevent death or further deterioration 72%

Life and limb or sight threatening injuries 8%

Care that can't be provided by other means 7%

Serious injury or illness that requires immediate care 4%

Missing/No Response 7%

Other 1%

Staff Responses5 (Base 204)

When we asked both groups to select an appropriate description of Urgent care, again from

a set definitions provided in the survey, there was also confusion, with no single term

attracting more than 21% agreement. Indeed,14% of the public and 9.5% of staff selected a

definition better suited for Emergency care:

“Care needed when a person is in immediate danger of losing their life or has been in a serious accident"

5Asked only of staff


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Care needed when a person is in immediate danger of losing their life or has been in a serious accident

14.1% 9.5%

Care needed when a person is in immediate danger of losing a limb or their sight

12.0% 9.1%

Care needed when a person has a condition that needs to be treated immediately to prevent it getting to a point where their life is in danger

21.0% 15.7%

Care needed when a person has a condition that while not immediately life threatening could become more serious if not treated within 24 hours

20.0% 20.7%

Providing life-saving measures in life-threatening situations 13.2% 11.0%

Providing care to serious and life-threatening injuries and conditions only

9.4% 8.7%

Providing care to people who feel the issues they face with their health are an emergency

9.5% 21.3%

Other 0.8% 4.0%

“Other” responses – urgent care – when grouped into categories were:

Public:

• Baby/child or elderly person with deteriorating health

• Any person who is in distress and or pain from symptoms

• Urgent care but not life or death

• Whatever an individual wants

• None of the responses qualifies as urgent (fall under emergency)

• cuts requiring minor surgery, burns, potential infections, respiratory problems,

removal of foreign objects in ears

• Emotional and physiological support at crisis point

Staff:

• Anything patient feels is urgent

• Patients who can't get GP appointment

• Lack of patient education about what constitutes emergency

• Lack of patient education about the different services available

• providing high level transfer of patients requiring upgrade of care between hospitals.

• Conditions patients decide can't wait/can't be bothered waiting

• 999 frequently used for primary care issues - public have lost sight of primary reason

for 999

• Convenience of A&E/wanting to be seen immediately

• Lack of distinction between emergency and urgent conditions/Expectations are

boundless and the term "emergency" has been downgraded in many instances to

actually mean "routine"


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When we asked the staff group to provide their own definition of Urgent care there was a

less convincing consensus on the definition than that previously provided as a definition of

emergency care.

“Immediate care needed to prevent further deterioration/death/loss of limb if not treated” (30%)

“Care needed in next 24 hours but not immediately life-threatening” (28%)

5.4 Professional Views on the Key Issues

People go to A&E because it is open when other services are shut 86.3%

Any difficulties people experience making an appointment with their own GP 77.3%

A general need for more education on health issues, particularly emergency

care, among the general public

74.4%

Issues caused by substance misuse (drugs, alcohol, etc.) 70.4%

People just don’t understand where to go for care in an urgent situation 69.6%

An expectation that healthcare should be available 24/7 within the general public 68.1%

People go to A&E because that’s where they’ve always gone 60.4%

A reluctance to use services such as Pharmacists or 111 to assist with issues 59.6%

The names used to describe urgent care facilities confuse people 57.5%

Access to the internet causing people to become overly anxious over symptoms 57.1%

People who are not registered with a GP using urgent and emergency services

for routine care

56.6%

The number of services available to people to deal with urgent care issues is

confusing

54.9%

People being over cautious with children or grandchildren 54.0%

Elderly people requiring more care 44.8%

Younger people not knowing where to go for care 38.6%

The need to avoid risk when dealing with people who need care to ensure they

are as safe as possible

28.1%

Other 8.6%



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5.5 Sharing Information across NHS Organisations When asked if they supported the sharing of patient information to improve care in urgent

and emergency services most both staff and public supported the idea:

§ Public respondents (63%)

§ Staff respondents (66%)

We asked public respondents who said it would improve care (63%) who the information

should be shared with:

§ Own GP 24.9%

§ Local hospital 19%

§ Held centrally in a secure NHS location 18.9%

§ Local A&E department 18.8%

§ All NHS care providers 17.6%

Public respondents suggested ‘other’ sources their information should be shared with as:

§ Consultants

§ Immediate family

§ Emergency social services workers

§ NHS Care Providers anywhere in country

§ Other care providers e.g. Mental Health Services

§ Must be in best interest of patient

Of the small number of staff that did not feel this information should be shared, the reasons

included:

§ Confidence in finding the information from the patient (19.2%);

§ Lack of time (15.4%) or access (15.4%)

‘Other’ reasons suggested by this small group within the wider staff respondents included:

• Lack of confidence in colleague’s IT skills or the systems themselves

• Patient expectations being too high

Details are shown on the following pages.


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I feel very strongly that information should NOT be shared

9.6% 15% NO

3.9% 11% NO

I feel strongly that information should NOT be shared

5.6% 6.9%

I do not feel strongly either way 13.6% 21.6%

I feel strongly that information should be shared

34.9% 63% YES

45.1% 66% YES

I feel very strongly that information should be shared

28.5% 21.1%

Don't know 6.7% 1.5%

Missing/No Response 0% 3.9%

Who should be allowed to share your personal information? (Total = 63% ‘Yes’)

Your GP 24.9%

Your local hospital 19.0%

Held centrally in a secure NHS location 18.9%

Your local A&E department 18.8%

All NHS care providers 17.6%

Other 0.8%

Public Responses (Base 375 x 63% = 236)

‘Other’ responses:

§ Consultants

§ Immediate family

§ Emergency social services workers

§ NHS Care Providers anywhere in country

§ Other care providers e.g. Mental Health Services

§ Must be in best interest of patient

Why do you feel that sharing information across all NHS organisations won't improve the

care offered to individuals? (Total = 11% ‘No’)


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I can find out all I need to know by talking to the patient 19.2%

I do not have time to access this information in an emergency care situation 15.4%

I do not have time to access this information in an urgent care situation 15.4%

I do not think this information will help me do my job 15.4%

This information is obtained by other members of the team to a level that allows

me to do my job 7.7%

Other 26.9%

Staff Responses (Base 204 x 11% = 23)

Staff ‘other’ responses

§ Patient information sharing systems reliant on often unreliable technology, or used

by staff who are not IT literate

§ Public information is available but patients do not read or act upon it

§ Patient expectations too high

§ Take staff longer to find and read through full patient records - delays

§ No amount of information replaces a face to face meeting with a health professional

§ Different computer systems used by health organisations

§ People will still use services inappropriately

5.6 Sharing Information on Waiting Times When we asked if displaying waiting time information in public areas in urgent and

emergency care settings would influence patient choice of destination there was a roughly

equal balance between those who believed it would and those who believed it wouldn’t with

the public being less convinced:

§ Wouldn’t: Public 45.6%, Staff 38.2%

§ Would: Public 35.8%, Staff 36.6%


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Public Responses Staff Responses

Knowing local waiting times would have no influence over

my choice whatsoever

31.2%

I strongly believe publishing

average waiting times WILL NOT be effective in managing

demand

14.7%

Knowing local waiting times

would have little influence over my choice.

14.4%

I believe publishing average

waiting times WILL NOT be

effective in managing demand

23.5%


would have no influence either

way on my choice.

15.2%

I neither believe or disbelieve

publishing average waiting

times will be effective in

managing demand

18.1%


would have some influence over my choice.

17.9%

I believe publishing average

waiting times WILL BE effective in managing demand

9.8%


would have a very strong

influence over my choice

17.3%

I strongly believe publishing

average waiting times WILL BE effective in managing demand

27%

Don't know 2.7% Don't know 5.4%

Missing/No Response 1.3% Missing/No Response 1.5%

(Base 375) (Base 204)

Members of the public who felt the provision of information would influence attendance

behaviour did so because it would – amongst other things “…allow individual to choose

alternative/less busy service/avoid delays in treatment…” as shown below.

Allow individual to choose alternative/less busy service/avoid delays in treatment 28.5%

Would not influence choice 21.9%

Encourage rethink service use/encourage evaluation of severity / help decide 7.5%

Good reputation/trust/being seen at local hospital more important 2.1%

Limited choices of hospitals/ too far away alternatives 1.9%

Happy to travel further if less waiting/better service available 1.9%

Nearest service 1.9%

Not sure 0.3%




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Staff respondents felt that it would not influence attendance behaviour because – amongst

other things:

§ The public ignore all information anyway so this will have no impact

§ Other factors influence choice (limitations with the ability to travel, limited choice of

services)

x People ignore them / not interested / feel they have a right to be seen /

know will be seen if wait / prepared to wait

25%

x Other reasons influence choice i.e. travel, limited choice of services 7.4%

x Do not want to wait/deter from waiting 6.4%

x Don't think it would be effective (no explanation) 5.4%

ü Think twice about attending/think about attending another service/make

informed choice

21.1%

ü Go to other service i.e. another A&E, or ring 999 3.4%

ü Helps to understand pressures 2.5%

ü Feel it would be effective (no explanation) 2.5%

± Other 14.2%



However, when we asked the public respondents if the reasons for their wait where explained nearly 67% felt that this would be helpful or very helpful.

Not helpful at all 2.9%

Not helpful 2.7%

Neither unhelpful or helpful 9.3%

Slightly helpful 17.9%

Very helpful 64.8%

Don't know 1.9%




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5.7 Source of Urgent or Emergency Care When asked where they would consider the most appropriate for urgent care needs, public

respondents felt their top three choices - if they had an urgent issue with their own health -

to be:

§ Walk-in Centre (19.5%);

§ Their own GP (18.1%);

§ Out of Hours (13.7%)

Similarly, staff considered their top three services that patients should consider using if they

had an urgent issue with their own health to be:

§ Walk-in centre (17%);

§ Their own GP (16%);

§ Out of Hours (14.9%)

As shown in the table below.

PUBLIC STAFF

Walk-in centre 19.5% 17.0%

Own GP 18.1% 16.6%

Out of hours’ centre 13.7% 14.9%

111 12.5% 14.3%

A&E department 9.3% 5.4%

Minor injuries clinic 8.5% 11.3%

Pharmacist 7.9% 10.0%

Internet search 3.9% 1.2%

NHS choices 3.6% 5.4%

999 2.5% 3.0%

Other 0.6% 0.7%

(Base 375) (Base 204)

‘Other’ responses can be grouped into the following categories:

Public respondents:

§ Providing an appointment is available

§ Difficulty in accessing GP

§ Need assistance to assess how serious condition is

§ COPD special contact number

§ Urgent Care Centre

§ If medical help required, go to wherever help could be accessed


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§ Community Matron or District Nurse service

§ 111 used to see whether A&E necessary

Staff respondents:

§ Dependent on definition of urgent care/emergency care

§ Dependent on urgency of condition

§ Occupational health service

§ Dependent on time of day (i.e. GP open/closed)

§ Whatever service can help the patient

§ Friends and family

§ 999/A&E if life threatening

§ Self help

We asked a specific question - solely of public respondents - to gauge differences in

attitudes towards destinations for urgent care based upon the needs of others. Using the

same question as before, but for a friend or relative, the top three choices remained the

same.

Would you consider using the following if you had an urgent issue with the

health of a friend or relative?

Walk-in centre 19.8%

Own GP 15.0%

Out of hours’ centre 14.3%

111 13.5%

A&E department 10.6%

Minor injuries clinic 9.5%

Pharmacist 7.0%

NHS choices 3.8%

999 3.3%

Internet search 3.0%

Other 0.3%


‘Other’ responses from the public around urgent care for others included:

§ No access to Walk in Centre or Out of Hours centre without phoning 111;

§ Contact GP of the friend/relative rather than mine (unless they were staying with

me);

§ Urgent Care Centre;

§ 111 would advise best way forward.


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We asked a specific question purely of staff respondents to explore their attitudes towards

the destinations for urgent care they felt most appropriate for patients. In response to the

question “…Can you tell us briefly why you think patients should consider these choices…”

staff felt the reasons patients should use the urgent care services they identified were to:

§ Reduce pressures on A&E;

§ A&E should always be the last option and these services are more appropriate for

urgent health needs.

As shown in the table below.

To stop people with minor ailments coming to A&E/reduce waiting times and pressures on A&E

17.2%

A&E should be last resort/other options available for non-urgent care 14.7%

More appropriate options allow patient to be treated effectively and in a timely manner

13.2%

Patients will be able to be referred appropriately by the service 7.8%

A&E - just for emergencies 5.9%

Depends on severity of condition 4.9%

Other 16.2%




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When the public were asked the most likely destination they would attend for an

emergency care need (for themselves) the top three were:

§ A&E

§ 999

§ Walk-in Centre

A&E department 29.2%

999 27.9%

Walk-in centre 10.3%

111 9.0%

Own GP 8.6%

Out of Hours centre 6.5%

Minor injuries clinic 3.5%

Pharmacist 2.5%

NHS choices 1.5%

Internet search 0.5%

Other 0.3%


5.8 Factors in Making the Choice of Urgent/Emergency Care Setting When asked, which factors influenced the decision of care setting:

§ The most popular was due to a life-threatening condition although staff ranked

this of slightly higher importance than the public

§ Staff also tended to rate service factors of lower importance than the public,

particularly the impact of “always having a senior member of staff present” (public

63.2%, staff 15.1% rank this the number one factor)

Detailed responses are shown in the table on the following page.

North East Urgent and Emergency Care Network

Behavioural Insight into Urgent and Emergency Care Services

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Public (Ranking) Staff (Ranking) Staff V Public 1 2 3 1 2 3

Having to attend as condition is life threatening 70.4% 9.9% 16.9% 76.9% 9.6% 9.6%

Attending a service where you/they know there is always a senior member of

clinical staff (i.e. a consultant/specialist) present 63.2% 16.5% 19.5% 15.1% 45.3% 35.8%

Being close to where I/they live 45.3% 25% 29.7% 43.3% 30.0% 21.7%

High Quality Clinical Staff 31.1% 48.1% 19.8% - - - N/A

Knowing I/they can go there, get seen, get their results there and then and get

the treatment needed. 29.9% 22.1% 44.2% 36.2% 27.5% 33.3%

Access to the resources of a hospital 29.3% 30.4% 40.2% 26.9% 19.2% 46.2%

Access to the best facilities 26.9% 33.3% 38.7% 26.9% 19.2% 46.2%

Being open when other medical facilities are closed 20.0% 36.7% 41.7% 24.2% 35.5% 35.5%

Knowing I/they will always get seen 17.8% 37.8% 40% 40.3% 25.4% 32.8%

It’s the only place that is open 24 hours a day seven days a week 16.7% 40.7% 38.9% 16.4% 46.3% 32.8%

If I don’t attend my health will be compromised 12.9% 48.4% 33.9% - - - N/A

It’s where we’ve/they’ve always gone in an emergency 9.4% 31.3% 53.1% 19.4% 22.2% 47.2%

Access to X-ray 9.1% 45.5% 27.3% - - - N/A

Not registered at a GP 0% 33.3% 66.7% - - - N/A

Other 33.3% 33.3% 33.3% 33.3% 33.3% 33.3% N/A


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When asked about receiving/giving positive advice on the best location for future care following treatment:

§ 81% of the public were happy to receive this § 54% of staff felt able to provide this type of advice.

The full responses were as shown in the tables below.

How would you feel if at the end of the treatment you were advised in a positive manner where else you could go/could have gone for treatment in future?

OK/pleased/helpful 81.1%

Depends on condition / facilities / distance / opening times 5.6%

Depends on how the information is delivered to me 3.8%

Not pleased/patronised 3.1%

Not sure 2.4%

It’s my own decision on where to go for care 1%

Other 2.8%


Do you feel able to advise patients, in a positive manner, where else they could attend if this issue occurred in the future at the end of your involvement or their treatment to?

Yes 54.4%

No 10.8%

Don’t Know 6.9%



In terms of ranking various conditions as requiring emergency care:

§ Staff tended to rank conditions as less urgent than the public; § The main exception being children and older people with temperatures and

serious asthma attacks.

The detailed responses are shown in the table on the following page.

North East Urgent and Emergency Care Network

Behavioural Insight into Urgent and Emergency Care Services

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Public (Ranking) Staff (Ranking) Staff V Public 1 2 3 1 2 3

Having to attend as condition is life threatening 70.4% 9.9% 16.9% 76.9% 9.6% 9.6%

Attending a service where you/they know there is always a senior member of

clinical staff (i.e. a consultant/specialist) present 63.2% 16.5% 19.5% 15.1% 45.3% 35.8%

Being close to where I/they live 45.3% 25% 29.7% 43.3% 30.0% 21.7%

High Quality Clinical Staff 31.1% 48.1% 19.8% - - - N/A

Knowing I/they can go there, get seen, get their results there and then and get the

treatment needed. 29.9% 22.1% 44.2% 36.2% 27.5% 33.3%

Access to the resources of a hospital 29.3% 30.4% 40.2% 26.9% 19.2% 46.2%

Access to the best facilities 26.9% 33.3% 38.7% 26.9% 19.2% 46.2%

Being open when other medical facilities are closed 20.0% 36.7% 41.7% 24.2% 35.5% 35.5%

Knowing I/they will always get seen 17.8% 37.8% 40% 40.3% 25.4% 32.8%

It’s the only place that is open 24 hours a day seven days a week 16.7% 40.7% 38.9% 16.4% 46.3% 32.8%

If I don’t attend my health will be compromised 12.9% 48.4% 33.9% - - - N/A

It’s where we’ve/they’ve always gone in an emergency 9.4% 31.3% 53.1% 19.4% 22.2% 47.2%

Access to X-ray 9.1% 45.5% 27.3% - - - N/A

Not registered at a GP 0% 33.3% 66.7% - - - N/A

Other 33.3% 33.3% 33.3% 33.3% 33.3% 33.3% N/A

Perceptions of factors influencing choice of care settings (public compared with professional opinion)


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5.9 Advice from the Internet

When considering medical advice from the internet:

§ Around 35% of the public used the internet as a source of medical information as opposed to the 22% staff thought patients they saw had used it.

Do you make an initial check for information on the Internet when you are faced with a medical condition that you feel is either urgent or an emergency?

Do you find patients have made an initial check for information on the Internet when faced with a medical condition they feel is either urgent or an emergency before using services?

Yes 34.7% Yes 22.1%

No 55.7% No 28.9%

Not applicable to me 2.8% Not Applicable to Me 16.7%

Not sure 6.8% Not Sure 15.7%

Public Responses (Base 375) Missing/No Response 16.7%

Staff Responses (Base 204) In terms of perceptions of the usefulness of this information:

§ 65% of the public found this useful or very useful § 36% of staff felt this advice was of no use (12% found it useful)

How useful do you find making an initial check for information on the Internet when you are faced with a medical condition that you feel is either urgent or an emergency?

How helpful do you find it when patients have made an initial check for information about their condition on the Internet?

No use whatsoever 5.4% No use whatsoever 15.2%

Not useful 6.3% Not find it useful 21.1%

Neither useful or not 3.6% Neither useful or not 30.4%

Somewhat useful 61.6% Somewhat useful 10.3%

Very useful 23.2% Very useful 1.5%

Public Responses (Base 375) Missing/No Response 21.6%



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When asked (staff and the public) which sites they used:

§ Staff felt it was mostly ‘general google search’ (77%) with only a small percentage (16%) believe patients use NHS Choices.

§ However, most public respondents (72%) who stated they sought advice from the internet used NHS Choices as their source of advice, although many (66%) did use general Google searches.

Where do you look for information on the internet?

In your experience where do patients most commonly look when seeking information on the Internet?

NHS Choices website 71.7% General Google search 76.7%

General Google search 66.5% NHS Choices website 16.3%

WEB MD 23.9% WEB MD 5.0%

Mumsnet 3.5% Other 2.0%

Other 2.0% Staff Responses (Base 204)


‘Other’ responses (public):

§ Patient.co.uk § My NHS and other helpful

medical sites § red cross app

’Other’ responses (staff):

§ Wikipedia § Mumsnet


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5.10 Attitudes and Perceptions

When asked if they believed arriving at an urgent or emergency care setting in an ambulance meant faster service:

§ 22% of the public felt it did compared with the staff view that 63% of patients believed this

§ Most staff (57%) also felt that patients became angry or frustrated when they realised arriving in an ambulance does not ensure quicker service

Do you think that arriving at A&E in an ambulance means that you will get seen quicker than people that bring themselves in or are brought in by friends or relatives?

Do you find that patients believe that arriving at A&E in an ambulance means that you will get seen quicker than people that bring themselves in or are brought in by friends or relatives?

Yes 21.8% Yes 63.2%

No 64.8% No 2.9%

Not sure 13.4% Not sure 3.4%

Public Responses (Base 375) Do not experience this in the service I work in 12.7%



We then asked staff only the question:

“If patients expect to be seen quicker when they arrive by ambulance but find out that they are in exactly the same queue for service as people who walk in, what do you find their

reaction to be?”

The majority (57%) of staff stated that patients became angry or frustrated on realisation that despite arriving in an ambulance they were assessed on the same scale of urgency as people who had ‘walked in’. Responses in detail are shown below.

They are angry/frustrated that they are not 57%

They are fine because an ambulance is the only way they could attend 20.5%

They accept it with good grace and wait their turn 9.5%

They are embarrassed at wasting ambulance time 3.5%

Other 9.5%



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‘Other’ responses to the question included:

§ Dependent on patient/patient need § Some accept with good grace § Do not believe you § Relatives tend to get more irate § They feel it is their right to be seen quicker as they arrived by ambulance § Often don't understand why 111 sent an ambulance in first place § Happy as they don't have to pay for parking but expect to have a lift home

When asked if people always exaggerated their symptoms or conditions in urgent or emergency care settings this was felt to be relatively low:

§ Always exaggerate (Public 3.8% and Staff 2.9%)

How useful do you find making an initial check for information on the Internet when you are faced with a medical condition that you feel is either urgent or an emergency?

How helpful do you find it when patients have made an initial check for information about their condition on the Internet?

Sometimes 57.1% Sometimes 49.5%

Occasionally 31.3% Occasionally 23.5%

Rarely 5.6 % Always 2.9%

Always 3.8% Rarely 2.9%

Never 2.2% Missing/No Response 21.1%

Public Responses (Base 375) Staff Responses (Base 204)

However, the views of people who “sometimes or occasionally exaggerate” was much higher:

§ Public 88% § Staff 73%


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5.11 Reducing Urgent & Emergency Attendance

When asked how to reduce the number of people attending A&E:

• The public and staff believe provision of education and information is the most important

• 18% of staff and 30% of the public believe that people should be fined for ‘inappropriate’ attendance

Public Responses

Staff Responses

Give people information / educate them 97.5% 35.5%

Send them on a health education course 44.8% 18.5%

Say no and do not provide them with treatment 30.6% 17.0%

Fine people 29.7% 15.3%

Make them wait longer to receive treatment next time they attend 8.5% 4.2%

Stop them using services in the future 6.0% 3.9%

Other 12.9% 5.7%

(Base 375) (Base 204)

‘Other’ Responses (Public) ‘Other’ Responses (Staff)

§ Public education as to what constitutes an emergency, different services available and what conditions treated in each

§ Telephone triage service § Immediately redirect people to

alternative services / offer reassurance to use other services

§ Refuse treatment to those on drugs/under influence of alcohol (unless life threatening)

§ Fines for those abusing system / repeat offenders

§ Nuisance attendees to be requested to appear before a local healthcare committee

§ Easier access to GP

§ Greater access to walk-in centres § Not all services on one site § Inform frequent attenders about how

to access other services § Explain what patient should do next

time / using resources that are needed for persons seriously ill

§ Charge GPs and other medical services that direct patients to A&E rather than treating them

§ Charge for services that are non-urgent / patients that are abusive / repeat time wasters / those under influence of alcohol or drugs

§ Local telephone triage § Separate genuine emergencies in

statistical data


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§ Investigate repeat offenders and their reasons for attendance/ assess for mental health conditions

§ Improved level of staffing in walk in centres (i.e. prescribing staff)

§ Develop an app § Offer alternative support for repeat

offenders § Alternative services located on same

site/area § Charge for conditions that are not

urgent § Important to acknowledge that people

react differently when in pain § More local walk in facilities § Better education as to how people

should treat different conditions § Inform people as to how much their

treatment costs § Education in schools

§ Immediate triage on entering service - help patient to get GP appointment

§ Fines might prevent people from attending when it is a genuine emergency

§ Health education for individuals/ care homes / repeat offenders - easy to follow flow charts, and in schools

§ Encourage people to call for advice first

§ Make it clear how much patient treatment cost / provide itemised bill of treatment

§ Treatment plans for frequent attenders § Case meetings for clients abusing

service § Flag on records for persistently using

wrong services § A better GP service § Provide people with poor

understanding (LD, MH) with better explanations about where else to go

§ GP's to direct patients with long term conditions where to go out of surgery hours

Factors which would make public respondents think before deciding to attend A&E or call 999 the top three were:

1. Knowing the impact on others (88%) 2. Knowing of other services to meet my needs (87%) 3. A&E is for serious and life threatening conditions only (87%)

The least likely factor to influence the public’s decision to attend A&E or call 999 is the cost to the NHS (49.3%).

Details of the responses are shown in the table on the following page.


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* Asked only of public respondents Would make me

think before attending

Would have no impact on me

thinking before attending

Knowing the impact on others – e.g. if I use an Ambulance for something minor a neighbour with a heart attack may not get to Hospital as quickly 88.4% 11.6%

There are other services available to meet my needs 87.3% 12.7%

“A&E is for serious and life-threatening injuries and conditions only.” 87.2% 12.8%

If I attend with something minor it makes the waiting time for everyone else even longer 85.2% 14.8%

If I and too many other people with minor conditions attend at once there is a chance that the A&E department will need to close its doors because it is at full capacity 85% 15%

I am using services that others have more pressing need of 84.2% 15.8%

I am increasing the workload of already busy professionals 75% 25%

Each time a treatment area is used it must be scrubbed down even if I only have a minor condition, making it temporarily unavailable for others 73.4% 26.6%

Knowing how much it will cost the NHS every time I visit 49.3% 50.7%



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5.12 The ‘Customer Experience’ in A&E Staff generally rate service issues experienced in Emergency Departments as being of less importance than the public:

§ Being seen quickly (Public 70.3%, Staff 59.4%) § Highest quality service (Public 51.2%, Staff 42.25%) § Being treated as an individual (Public 25.8%, Staff 15.2%)

Areas where staff rate the importance higher than the public are:

§ Receiving treatment quickly with minimum delay (Public 36.4%, Staff 44.3%) § Knowing why I am waiting so long (Public 3.2%, Staff 8.3%) § Feeling I have the correct answer (Public 11.5%, Staff 25%)

The details of the responses are shown in the table on the following page.


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Taken against public’s first choice Public (Base 375) Staff (Base 204) Staff V

Public* 1 2 3 1 2 3

Being seen quickly 70.3% 13.2% 13.2 59.4% 23.20% 14.50%

Feeling that the service I/ they get is of the highest quality 51.2% 28.6% 19.0 42.5% 30.00% 25.00%

Receiving any treatment quickly with minimum delays 36.4% 23.3% 37.2% 44.3% 28.3% 47.8%

Being treated as an individual 25.8% 28.8% 36.4% 15.2% 28.3% 47.8%

Feeling I am getting the most appropriate care 23.7% 40.7% 32.8% - - - N/A

Feeling that I/they can understand their condition 22.9% 42.9% 22.9% 15.8% 36.8% 36.8%

Having all that is happening to me/them explained clearly and in simple terms 21.9% 43.8% 31.9% 26.3% 42.0% 26.3%

Knowing why I am waiting so long 3.2% 9.7% 71.0% 8.3% 25% 50%

Knowing the different options that are available to me/ them 9.1% 15.2% 66.7% 6.3% 6.30% 68.8%

Feeling that I have received the correct answer 11.5% 23.1% 53.8% 25% 50% 4.2%

Perceptions of the most important ‘experience’ factors when visiting A&E as a patient (Public compared with professional opinion)


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When asked if they would value a suitably qualified member of staff redirecting (signposting) people to another more suitable service:

§ 47% of patients would find this helpful § 64% of staff would also welcome this approach

Public Staff

Extremely unhelpful 4.4% 10.3% Unhelpful 10.4% 1.0% Neither unhelpful nor helpful 38.3% 3.4% Helpful 34.2% 27.9% Extremely helpful 12.7% 36.3% Public Responses (Base 375) Staff Responses (Base 204)

When asked if they thought having a member of staff who circulated in the waiting area who could give information on likely waiting times and other issues would be a useful addition, this was thought to be useful or very useful by:

§ 73% of the public; and § 71% of staff

Public Staff

Not at all useful 2.5% 1.9%

Not useful 7.3% 11.3%

Neither useful or not useful 17.1% 15.6%

Useful 47.9% 43.8%

Very useful 25.1% 27.5%

Public Responses (Base 375) Staff Responses (Base 204)

When asked If a published guide (print or online) to urgent and emergency care would be useful 86% of staff said they would find it useful.

Asked only of Staff

Not at all useful 1% No Use 3% Not useful 2%

Neither Useful nor Not Useful 8%

Useful 50% Useful 86% Very Useful 36%



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5.13 Overall Trust in Urgent and Emergency Care

Public respondents who had used urgent or emergency services within the last twelve months found services to be generally good or very good.

Very Poor Poor

Neither Poor nor

Good Good Very

Good N/A6

Your own GP 1.9% 6.1% 7.2% 25.5% 38.4% 20.9%

999 4.2% 3.3% 3.3% 6.6% 24.9% 57.7%

111 7.9% 7% 6% 13% 18.1% 47.9%

Walk in centre 3.1% 2.7% 7.1% 13.7% 26.5% 46.9%

Out of hours’ centre 2% 2.6% 2.6% 9.7% 14.8% 68.4%

Minor injuries clinic 2.2% 1.6% 3.2% 6.5% 11.3% 75.3%

Pharmacist 0.9% 2.3% 6.8% 26.8% 28.2% 35%

NHS Choices 0.5% 2.6% 4.7% 9.9% 18.8% 63.4%

An internet search 1.5% 3.1% 17% 18% 16.5% 43.8%

Accident and Emergency Department 4.5% 3.7% 5.4% 13.6% 34.3% 38.4%


6Urgent or emergency care not used in the last 12 months


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However, when asked the extent to which they trusted the same services:

• A&E, 999 and people’s own GP are felt to be the most trustworthy;

• The 111 service and internet searches where felt to be significantly the least trustworthy.

Very Low Trust

Low Trust

Neither High nor Low Trust

High Trust

Very High Trust

Accident and Emergency Department 2.6% 2.2% 6.6% 88.6% 58.3%

999 3% 2.2% 10.4% 39% 45.4%

Your own GP 3.4% 6.2% 19.2% 37.5% 33.7%

Minor injuries clinic 2.5% 7% 28% 43% 19.5%

Walk in centre 2% 8.1% 27.6% 43.1% 19.1%

Pharmacist 3.5% 13.1% 29.6% 36.9% 16.9%

Out of hours’ centre 3.6% 7.7% 32.8% 39% 16.9%

NHS Choices 5.8% 14% 39.5% 27.9% 12.8%

111 13% 17.5% 32.5% 26% 11%

An internet search 20.8% 19.8% 39.6% 14.5% 5.3%



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6 Summary and Conclusions

6.1 Summary: The Key ‘Take Home’ Messages from the Insight

The combined insight findings from the initial qualitative and follow up quantitative insight study reveal:

§ A&E is the option for most people because it is viewed as the safe option in what most people tell us is a confusing and complex range of service nomenclature around urgent and emergency care.

§ All the priority segments are seeking the safest option for them or the people they care for to “…be healthy, stay healthy…and…avoid unnecessary risks to health…”

§ Staff are nearly as confused over the definitions of urgent and emergency care – which adds to the overall complexity for patients and the public.

§ Many of the challenges are structural, requiring investment beyond the scope of this study – such as harmonising service names across the region, as the simplest example. However, there appears to be a need for the UECN to consider these as a separate exercise to reinforce the impact of any behaviour change intervention.

The key challenges for any behaviour change intervention designed to reduce the number of people attending accident and emergency to only those in the most need is reacting to the findings:

§ The priority audience segments all seek reassurance and advice but strongly reject the idea of being lectured to “…if they tried to force me to go somewhere I would go to A&E just because I don’t like being told what to do…”

§ There is a strong driver for anyone in the priority groups to treat third party care responsibilities as more pressing (i.e. grandchild, friend’s child, elderly relative, etc.) and to take them to A&E simply because it’s the option they have most confidence in. This includes relatively minor injuries (cuts, grazes) or conditions (cough, slightly raised temperature, etc.)

§ Providing reassurance and a strong message to reinforce the safety of other options, including the role of the community pharmacy in dealing with the default responses described in the preceding bullet.

These insights provide a direction of travel for any behaviour change marcomms campaign/campaigns focused on:

§ Providing a message to reinforce the safety of other options in the urgent and emergency suite of options – such as the fact the community pharmacist is a highly-qualified person who can give advice.

§ Providing a clarity of focus of the role of individual services – again reinforcing the safety of each option, and avoiding any messages of ‘don’t use’ – which are both


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counterproductive and carry inherent risk of misdirecting without a clinical base to make that recommendation.

§ Provide a message delivered by ‘people like us’ reinforcing the safety (“…ask aunt Nelly…”) important for most priority segments who require either advice or reassurance on the safest option for care.

The campaign should avoid:

§ Reliance on NHS language or attempting to define the difference between an urgent and an emergency;

§ Reliance on a negative message proposition – such as “…don’t use A&E…” no matter how well it is justified the audience told us strongly that they are more likely to do the opposite.

6.2 Conclusions: Themes for Action

The insight gathering allowed us to collect a broad range of opinion as ‘themes’ which were taken to a coproduction workshop held in Durham on the 21st of July, with members of the NHS UECN NHS Vanguard communications network and wider stakeholders. These themes were presented and formed the core of workshop discussions and subsequently tested through phase three’s quantitative research.

This results in the presentation of a series of themes for action based on the behavioural insight, which is tied together by an overarching theme around identifying the exchange benefits in any proposed intervention. In this context, we adopt the definition of ‘exchange’ as

‘the exchange of resources or values between two or more parties with the expectation of some benefits’

Alongside this overarching issue, we identified eight key themes for action – either as part of a behaviour change intervention or as wider structural issues. These themes were

1. Data sharing and tracking; 2. Fairness and justice; 3. Too much choice, too many names; 4. Education through communication; 5. Quick advice; 6. Missing specialist skills; 7. More community focus; 8. Acceptance of risk.

Each of which is discussed in turn on the following pages.


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Overarching Theme: The Exchange Principle (What’s in it For Me?)

An overarching issue to emerge from the discussions was identification of the ‘exchange’ in behavioural transactions, essentially identifying “What’s in it for me?”

For the public and patients, the system currently rewards behaviour that is viewed by many as representing ‘inappropriate’ attendances with a quick, responsive, high quality and gold standard service that is:

§ Consultant led; § Provides rapid access to services such as bloods/X-ray/CT Scan, etc. with the full

resources of the hospital behind them; § The A&E brand a universally understood and iconic service name amongst a very

‘muddy’ branding landscape (urgent/emergency) and the only the only ‘primary care’ NHS service open 24 hours a day, seven days a week and 52 weeks a year.

But there are also exchange factors for NHS and associated professionals, including:

§ Reduction of ‘inappropriate’ attendances by the public at urgent and emergency care settings;

§ Reductions in the number of ‘inappropriate’ calls to 999 § More ‘appropriate’ calls to 111; § Increased use of community pharmacy to reduce attendances at urgent and

emergency care settings.

Theme 1: Data Sharing and Tracking

A common theme in discussion to date has been the use of data and the need to share to improve patient care, support wiser choices, give better outcomes, speed up the system and reduce challenging behaviour. This includes:

§ Understanding our customer, which along with clinical/behaviour benefits will inform future communications and marketing.

§ Being able to track the regular users and to flag possible over attendance to allow behaviour change interventions.

§ Being able to access all elements of a patient’s medical history to understand what’s been tried and the impact of any treatment in an urgent/emergency care may have on any long-term condition management.

§ Having behavioural flags to highlight any issues or conditions that may prompt challenging behaviour by patients and ready access to suggested coping strategies.

§ Using a private sector retailer model to understand the attendance behaviour and the usage of estates/signage to nudge behaviour. For example, one site within the supermarket X chain of stores selling in an area which contains predominantly people form the C2DE socioeconomic group will sell a different range of goods to a supermarket in the same group selling to ABC1.


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§ For the public, there is the potential benefit of reducing the number of times “…I have to repeat my information over-and-over again…”

Theme 2: Fairness and Justice

Conversations to date with the public, patients and staff suggest that there is a commonly held belief that there are people who do not use the system wisely, and there was an automatic reaction to call for some form of sanctions to prevent this. Discussion centred around:

§ Should consideration be given to introduction of a fair usage policy, in the same way unlimited broadband or other services do, which must be considered case-by-case, dependent on personal circumstance and need?

§ If the system where ever to change the fundamental principle of care free at the point of delivery what would the penalties be for not being a fair user, but who makes the decision on what is fair?

§ Should we introduce a charge for people who attend but don’t need treatment?

§ Should we introduce three strikes and you’re out policy for consistent misuse? § Should we offer a fine which is reduced if paid within 30 days?

§ In addition, there is a widespread and strongly held feeling among the public that we need to tackle the unfairness of selfish usage of service, for example through publicly naming and shaming.

§ How much should the ‘system’ accept responsibility for preventing ‘good’ choice of care through the complexity? Is part of being fair recognising that there is a need to make choice for customers as easy as possible to ensure they get the right care at the right time?

Theme 3: Too much choice, too many names

The evidence collected suggests that there is widespread confusion over the naming and function of urgent and emergency care services, including:

§ The use of different names for the same service in differing areas is confusing everyone, public and staff included.

§ The reliance on NHS language to inform the public is confusing, highlighted by the following observations, which were commonly cited by NHS staff during our research:

§ “Why do the general population have to adapt to ‘our’ way of doing things?” § “John Lewis (or any other major retailer) wouldn’t shout at customers if they

took goods to the wrong till, they’d work out how to change the layout to make it easier for the customer.”


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§ On site signage, should direct people to the point of service in a clear and easily understood manner and consistently does not do this. Which in turn suggest the ese of NHS estates assets at the point of service delivery to remove confusion and provide clarity for patients and the public. Perhaps achieved most simply by asking patients to conduct a signage audit, including an assessment of the messages they receive while conducting this review. Which further points to the existence of “choice tyranny” at urgent and emergency care sites whereby more than three choices ‘frazzle’ the brain.

Theme 4: Education through communication

In our consultation with the public, patients and staff it appears that all parties are, to a greater or lesser extent, making broad assumptions about service availability and the root causes of the issues. From our non-specialist viewpoint and investigations, it seems that many of these are, at best, ‘urban myths’, and suggests that a positive approach could be to address these apparent misconceptions directly, through:

§ Communication of behaviour change messages through myth busters for both the public and NHS (and partner organisation) staff.

§ Stating commonly perceived “truths” and then the reality of the situation as a series of bold and arresting statements, which might include:

§ Myth – people (public) arriving in an ambulance get treated quicker: § Reality – people are treated in order of their medical need so there is

no advantage in arriving in an ambulance

§ Myth – we (staff) only deal with drunken people: § Reality – alcohol related incidents only account for x% of cases, they

stick in the mind because they’re high impact events

§ Myth – the public all use ‘Dr Google’ and not reputable or reliable internet resources such as NHS

§ Reality - 72% of the public use the NHS choices website for advice

As an effective idea to provide a behavioural nudge to all parties by challenging assumptions and shifting perceptions:

§ Staff should use the opportunity of contact to educate people on the options available to them in the future at the point of service – and feel empowered to do so:

§ For instance, during or after treatment – adopting the principles of Make Every Contact Count (MECC)

§ Use of NHS estates assets at the point of service delivery to educate the public on making the right choice at the right time in the right place.

§ Using digital channels to best effect.


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Theme 5: Quick Advice

The insight reveals the pressure felt by patients and the public while waiting in an urgent or emergency care setting due to lack of/ready access to information to explain what is happening. Spontaneously generated suggestions from our consultations include:

§ The introduction of a navigator/guide function in the waiting area (separate to the receptionists), which could be a:

§ non-specialist, kind and reassuring person roaming around the waiting room; or

§ A phone line which can be picked up in the waiting area to get quick non-specialist/non-clinical updates (i.e. waiting times); or

§ A combination of the two approaches based on the reality of the setting and issues of personal safety for staff as a one-stop-shop approach.

§ Display of real-time waiting times supported by suitably anonymised details of the reason for the delays, such as

“…we are currently dealing with x life threatening cases which take priority, we will get to you as soon as we can…”

§ Building trust in the system by offering quick clinical advice from a one-stop-shop approach.

Theme 6: Missing Specialist Skills

Both professionals and members of the public have spoken of the frustration or service issues they face felt in part to be a result of missing specialist skills and knowledge in urgent or emergency care settings. This includes a need to be supported by access to skills/advice on specific issues such as:

§ Mental health, support for dealing with people in crisis. We have heard anecdotal evidence of rapid re-presentations because the assurance provided at the point of delivery is enough for a temporary change in mood but the person can very quickly return to crisis at home

§ Learning disabilities, specialist advice on reducing the impact of the urgent/emergency setting for people who are, for instance, very sensitive to over stimulation, leading to challenging behaviour in noisy/crowded waiting rooms

§ Elderly with comorbidities or end of life issues

§ Dealing with people with dependency on drugs and/or alcohol

§ One-stop-shop (professional support) with access to all relevant specialist services

§ Access to specialist consultant expertise for all parts of the system (clinical)


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Theme 7: More community focus

The focus of discussion was often not about what can be changed in urgent and emergency care settings but around the impact of ‘up stream’ interventions in changing attendance behaviours, including:

§ Developing a schools’ education programme to inform future ‘novices’ of wise choices for care, which may have the added benefit of peer education for parent/carers

§ A drive to promote the use of community pharmacy/self-care (NHS minor ailments scheme)

§ A structured programme of discharge/after care education for all who attend an urgent or emergency care service for treatment

§ Enhanced links to social care around discharge and end of life issues

Theme 8: Acceptance of Risk

There is a perception that the urgent and emergency care is inherently risk averse, which in turn tends to drive the public towards A&E as the safest option. This suggests a need for inspection of structural issues related to:

§ System driven responses which are programmed to be risk averse are increasing the number of people attending urgent or emergency care. This includes, among others, 111, care homes and junior staff in A&E.

§ Concerns over criminal liability from junior staff over their decisions which results in an over cautious approach i.e.:

§ Seen in the over use of facilities such as full bloods, scan, and x-ray (which suggests that people get a gold-plated service which in turn reinforces the likelihood of using this service again); or

§ Nurses’ reluctance to make decisions in some circumstances.

§ A tendency to blame and/or mistrust of other parts of the ‘system.’ Which in turn suggests a need for training and recognition of other professional competences enhance the system? (Example: prescribing pharmacists.)

§ An observable/anecdotally reporter increase in willingness to ‘take a risk’ increasing with seniority and experience. Which leads to the following questions for consideration:

§ How is this experience shared, how can this confidence (expertise) be shared around the system?

§ Is this likely to reduce the escalation of care to A&E as the default option?


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6.3 Using Audience Segmentation and Behavioural Insight – A Scenario

Based Example

Having developed these themes for action the simple scenario based matrix below demonstrates how this insight can be applied. Taking the case of promotion of self-care as an alternative to attending an urgent or emergency care service the same message can be used if it includes a variation to recognise the subtlety of the targeted segments. In this case the emphasis is upon using a community pharmacist as a trusted source of advice and care.

Scenario Priority

Segment Call to Action (CTA) Based on Insight Findings

Promotion of Self-Care (Three sub groups for subtle variations on messaging)

Novices

Message: “Ask Aunty Nelly” or in this case “Ask your neighbourhood pharmacist”

§ Younger people – before you assume it’s something serious (you or your child) ask a friend/relative, it’s not always a brain tumour/meningitis (Dr Google), the local pharmacy can and will help

Independents

§ Fixers rely on peer advice. § Independents and Stoics are very heavily influenced

by advice from friends/partners. Message: I deal with it myself until it becomes an issue – don’t do that - “Ask your neighbourhood pharmacist”

§ The pharmacist is quick, local, and available – ask and they’ll give you the advice you need (subtext – it may be serious and they are qualified to tell you where to get help if it is)

Stoics

Fixers

Disengaged

§ Reluctants – wait until it’s too late and it becomes an urgent/emergency situation that could have been prevented by early advice/self-care

§ Disengaged – know they need help but are unsure of where to go

§ Fixers – “grand-maternal” instincts generally kick in and most likely to take child or others in their charge to GP or A&E

Message – not sure or worried “Ask your neighbourhood pharmacist”

§ The pharmacist is quick, local, and available –

ask and they’ll give you the advice you need (subtext – they want to help, they’re very qualified, it’s their job and it will save others time further down the line)

Reluctants

Preventers


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6.4 Using the Insight

Kenyons are actively developing a pilot social marketing intervention based on the Behavioural Insight research findings. These findings help inform a series of approaches to support the North East Urgent and Emergency Care Vanguard’s work:

§ A three-stage approach to the provision of innovative social marketing solutions to improve the delivery and uptake of the right care, at the right time and the right place in the North East.

§ In development: a campaign in response to the locally defined need for the Winter

2016/7, incorporating some of the findings, as an innovative model of responsive marketing and communication around Urgent and Emergency Care.

Suggested milestones

Understanding flow

An exercise to better understand the likely demand for Urgent and Emergency Care Services across the North East in Autumn/Winter 2016 is underway by NECS Clinical Intelligence team. This will:

1. Assess previous demand across five years and developing a projection model, including types of demand, medical conditions, hotspots, and dates where demand exceeded provision capacity,

2. Develop a system of incorporating real-time factors which may affect demand for urgent and Emergency Care, e.g. integrating Met Office weather data to predict likely demand at short notice, and

3. Provide real time monitoring data from NHS (tbc what’s available)

SHORT TERM (1-4 MONTHS)

MEDIUM TERM (4-12 MONTHS)

LONGER TERM (12 MONTHS – 2 YEARS)

Quick Wins: what can we do/what do we need… now Phase 1 Marketing and communications campaign piloting and roll out for the Winter 2016/17 period

Strategic Actions - set in place to build and progress from Phase 2 Marketing campaigns, strategic buy-in and building system requirements for longer-term change – from Spring 2017

The ‘big hairy audacious

goals’ - harder to achieve but demonstrate real innovation Ongoing campaign delivery Further campaign and intervention mix for sustained behaviour change


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Development of a suite of Marketing tools and actions

Reflecting on the insights gained, alongside knowledge of social marketing campaigns and the health MarComms (Marketing and Communications) environment:

• A flexible responsive system of messaging in line with local peaks and dips of historic A&E use, weather conditions and ideally current usage.

• The flow modelling will assimilate trend data inform a predictor model which will inform messaging to provide a suite of possible creative and messaging solutions that can respond to a changing marketing need, facilitating swift, targeted, and on-message campaign activities to support local messages around Urgent and Emergency Care in the North East

• A partnership between NECS and Kenyons will develop the mechanism to marry projections with marketing delivery.

Outline Creative approach

The approach will use a character/family of characters as a mouthpiece for the NHS to deliver a suite of messages in a timely targeted way – to support appropriate use at times of demand.

The creative provides instant striking appeal to provide real cut through; in a digital world, this instant communication quality has huge benefits.

The tone can balance NHS authority though challenging topics can be covered in a direct style because the character softens the theme.

Humour can be deployed in expressions or copy where appropriate to enhance appeal.

Headlines and call to actions are being developed in line with flow modelling


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Appendix One: Mosaic Profiles for each of the NE UECN priority segments7

Preventers Fixers

• Typically, women from higher socio-economic group

• 26% of Preventers can be described by the mosaic group – E -Suburban Stability

• 21% of North of England population are preventer

• Typically, men from higher socio-economic group

• 26% of Fixers can be described by the mosaic group – E -Suburban Stability

• 20% of North of England population are preventers

Independents Stoics

• Typically, women from mosaic life style socio-economic group

• 30% of Preventers can be described by the mosaic group – L Transient Renters

• 19% of North of England population are independents

• Typically, men from mosaic life style socio-economic group

• 30% of Fixers can be described by the mosaic group – L Transient Renters

• 18% of North of England population are stoics

Disengaged Reluctants

• Typically, men and women from low socio-economic group

• 100% of Disengaged can be described by the mosaic group – N Vintage Value

• 2% of North of England population are Disengaged

• Typically, men and women from low socio-economic group

• 73% of Disengaged can be described by the mosaic group – O Municipal Challenge

• 16% of North of England population are Reluctants

Novices

• Typically, young people across whole spectrum of socio economic groups

• 4% of North of England population are Novices

• For the purposes of this research young people have been defined as persons aged between 18 and 25.

7Source:NorthEastEnglandpatientsegmentation,February2016.AnalysisreportbyNorthEastEnglandSupport(NECS)


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Mosaic Profiles for each NE UECN Priority Segment


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Documents

Behavioural Insight into NE Urgent and Emergency Care Services …uecnetwork.co.uk/wp-content/uploads/2017/09/Behavioural... · 2017-09-11 · 3.1 Introduction ... The programme is