Emergency departments and minor illness: some behavioural insights
Mando Watson, Mitch Blair
Archives of Disease in Childhood
The 1999 Report ‘Accident and Emergency Services for Children’ was published by a collaboration of several Royal Colleges and national organisations, and it was a major driver for accident and emergency departments (ED) to become more expertly child-focused. The paediatric emergency department (PED) provides an environment that is more suitable for young ages, shielding the child and family from the sights, sounds and smells of the adult ED, and staffed by nurses and doctors with specialist child health training.
Yet now, NHS emergency services are creaking under enormous and increasing demands placed on it by the public. In England, 40% of all ED attendances are non-urgent (60% in the case of children), where the unwell person could be self-managed at home. Accident and Emergency (A&E) attendance costs nearly £100 m in 2011–2012 with ED on average being 36% more than an equivalent general practice (GP) visit.
The waiting time target, introduced in 2004, meant that a patient would be seen, treated and sent on his/her way within 4 hours no matter how ill.
As a result, the PED became quite an attractive option for the worried parent of a child with a non-urgent ailment, who would be almost guaranteed a paediatric opinion within that time period. Maybe PED has become a victim of its own success?
So why do parents bring their children to the PED with minor illness, and what can be done to better understand the drivers and inform potential solutions so desired by policy makers?
A recent report by Holden and colleagues1 attempts to answer the questions. Holden reviews and summarises the literature and brings fresh insights on parental decision-making. Behavioural economics is being harnessed by governments across the world: for example, the Behavioural Insights Team (also known as the ‘Nudge Unit’), in partnership with the Cabinet Office at 10 Downing Street, was the world’s first government-backed institution for the application of behavioural sciences, to encourage payment of tax or organ donation.2 Holden’s report is augmented by data derived from field work in two PEDs, interpreting the latter through the lens of ‘behavioural insights’ to bring a fresh perspective to our thinking. Holden’s description of these behavioural biases should inform future developments that aim to reduce the high proportion of non-urgent repeat attenders.
Holden reminds us of the attraction of the A&E ‘brand’—easily understood by all, a place that delivers high-quality healthcare to anyone, at any time. The problem is starkly described:
- The number of PED attendances rose from 3.9 million in 2008/2009 to 5.1 million in 2014/2015.
- Ninety per cent of PED attendances do not result in the child being admitted.
- Sixty-one per cent of parents attending PED for a non-urgent problem say they would attend again for the same problem.
- Forty-two per cent of children attending PED might not have needed to if the parents had received prior education on the self-management of illness.
With this background, it is clearly a challenge to safely divert parents to other suitable resources within the wider health system. NHS 111 was designed to support such demand but nearly a quarter of parents did not fully have confidence and trust in the first call handler which may have impacted their decision to follow the advice given.
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