News reports over the last few days have talked of an ‘A&E crisis’ with MPs saying staffing issues and rising attendances were among the main causes of the problems. They state that just 17% of hospitals had the recommended level of consultant cover, while difficulties with discharging patients and a lack of beds at times meant the flow of patients through the system has been disrupted.
Addressing staff issues in acute hospitals or creating more out of hours services to provide more local care at home would be powerful solutions but the costs and arguments over GP contracts could mean either approach might take a long time to resolve before ‘winter pressures’ happen in a few months.
Perhaps a behavioural approach to addressing A&E attendances could be less expensive and implemented more quickly. It may not be a full solution to such a big issue on its own, but along with addressing the other issues above, it might add to the tool-kit for acute providers and GPs
Clearly where paramedics, a GP or a nurse makes a referral that is a clinical judgement. That is not the problem; it is exactly what an A&E is there for. However often the decision to take an elderly person to A&E will be taken by able-bodied adults who are low users of health services and have low knowledge of the condition. They may for example not be used to the symptoms of a diabetic episode or another chronic disease that A&E’s were not really designed for. Naturally people are seeking reassurance and a trip to A&E is perfectly rational in those trying circumstances. However often the visit is unnecessary. The NHS needs additional ‘reassurance’ mechanisms and these able-bodied family members are the key target who need to be engaged with on this issue.
What could be done to address behaviour in this area?
- Close family relatives of regular A&E attendees could be segmented and engaged with after a visit to hospital. These people not the patients are key determinants of such a visit that may not be clinically determined
- They could be given a number at the hospital on top of the NHS Direct and 111 numbers they will have. This at the very least alerts the hospital to a potential admission. Fundamentally a reassuring conversation may help a person who is contacting the other numbers to get a further opinion.
- Feedback should be given to the family member immediately after an unnecessary visit in order for them to learn lessons from it. Lack of feedback often means someone might well bring their relative to the hospital again.
- Online family networks could be developed so family members could learn more from others in similar situations so they gain a greater understanding before taking a decision to go to A&E
- GP’s could also develop a better relationship with family members on long-term patients who go to A&E’s, so they again feel better informed
Clearly there are some forms of behaviour change, sometimes applied in less sensitive areas, such as incentives or forms of naming and shaming that would go against the ethics of the NHS that could not be applied here. However a behavioural approach is worth looking at with pilots and randomised control trials conducted to see what worked. The point being this is much more likely to be done quickly rather than wait for relatively slow moves on staff reconfiguration or GP contracts to change