Dr Foster Intelligence

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A&E

Inappropriate use of A&E is a significant problem across the country. How do you persuade people to change the way they think about and use urgent care services?

The challenge is to make sure that people get the information they need to make the appropriate choice for them. Dr Foster Intelligence can help you establish the right messages and deliver them in the most innovative and effective way.

NHS Tower Hamlets

The challenge

A&E in Tower Hamlets had seen increasing demand and it was felt that many people were using the services inappropriately.

The trust knew it could manage its resources better. People were coming with relatively minor symptoms that could be best treated elsewhere by GPs or other health professionals. So it wanted to reduce the number of patients using A&E and direct them to the right service.

In 2006 the PCT commissioned Dr Foster Intelligence to help it achieve these objectives.

First phase – what we did

In order to understand the problem fully, our social marketing team began by researching the behaviours, attitudes and backgrounds of the people with the highest levels of attendance. For example, we analysed data from 200,838 individual attendance records at the Royal London’s A&E department from January 2004 to January 2006 and found that 54,866 belonged to repeat attendees. We found that the target audience was mainly of Bangladeshi origin.

To enrich the qualitative findings, we also interviewed A&E staff. They felt that there was not enough information in the Bangladeshi community about the concepts of health and illness and when it is appropriate to seek help or advice.

Focus groups with young Bangladeshi adults helped us understand their frequent use of A&E. We found that attitudes towards health and illness were being shaped by parents and grandparents. Patients of Bangladeshi origin took even minor symptoms very seriously. In Bangladesh, a stomach ache could well be life-threatening.

Their background affected expectations of how a doctor should behave, too. When Bangladeshi patients went to see their GPs they were unimpressed with the seemingly brisk examinations they received for what they thought were potentially serious problems. So instead they tended to go to A&E, where they were likely to get the more thorough examination they expected.

Local Heroes
In light of the research findings, Dr Foster Intelligence created a ‘Local Heroes’ campaign, aiming to raise awareness in the target audience of the roles that GPs, pharmacists and health guides play in keeping communities healthy.

The initiative employed a variety of interventions including a poster and leaflet campaign, direct mail activity from GP practices and a street stall in the local market, staffed by health guides and community advocates.

Engagement sessions involving local GPs were held at local religious and community venues. Representatives from these organisations were keen supporters of the campaign and helped to get the PCT’s message across. A high profile PR campaign also ensured that Local Heroes continued to feature in a variety of local publications and on the radio station Club Asia.

First phase – the outcome

Before the project, A&E attendance had been rising consistently in most of the local hospitals. An independent evaluation showed that attendances at two nearby hospitals continued the upward trend during the same period, but the number of people using A&E services in the area where the campaign was targeted dropped by 6.4%. At the same time, registrations and visits to GP surgeries rose.

Second phase – what we did

After Local Heroes, the trust continued its work to engage the local community and maintain the positive changes in A&E attendance and local health knowledge.

Education packs
In response to the lessons learned, the trust then asked us to produce an education pack to help PCT staff to deliver consistent messages to the public about urgent care. The pack, entitled ‘Get the right treatment’, was piloted in autumn 2007 and successfully rolled out early the following year.

Further research and strategy
In our previous research we had also found that children aged five and under were particularly frequent users of A&E. The PCT was keen to understand why these children were using A&E, so in early 2008 it asked us to undertake a new phase of research. This included quantitative analysis, interviews, a medical card audit, focus groups and service mapping.

Second phase – the outcome

Our research on under-fives revealed some major insights into local healthcare services, as well as parents’ attitudes towards them. In light of these we made a series of further recommendations to the PCT. The trust then employed a paediatrics project manager for six months to implement some of the suggestions. This has meant improving access to appropriate urgent care services, especially the walk-in centre.

Other work on A&E

In late 2007 NHS Barnsley commissioned Dr Foster Intelligence to design and implement a social marketing campaign to reduce inappropriate use of A&E. Although we employed a similar research process to the one for Tower Hamlets, the findings were quite different. This time we found that the target audience were men from working class backgrounds aged 20 to 45, especially those in their twenties.

Whereas Local Heroes focused significantly on community engagement, the Barnsley research showed that a new creative output would be most effective, particularly posters and direct mail. As a result, we sent letters to over 95,000 targeted homes asking residents to keep A&E for emergencies only. This was supported by a striking poster campaign. In focus groups, most members of the target audience were unaware of the out-of-hours service and preferred going to A&E. They also raised concerns about the cost of calling the 0845 numbers that the PCT used for the out-of-hours telephone service.

Certain messages were key for encouraging people to consider the out-of-hours service: patients could first get assessed on the phone, could easily make an emergency appointment and would always receive the treatment they needed. Focus groups responded best to the creative materials that contained these direct, high impact messages, which we then developed as part of the highly effective campaign.