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Too much choice, not enough support - making marginal gains in order to reduce demand on emergency departments

February 8, 2018 16:21

Every day this month I’ve read a news story that tells me the NHS is in crisis - ambulances are lining up outside hospitals, beds are full and there’s less of them than in previous years, there’s nowhere to discharge the individuals in those beds to and there are significant issues with both recruitment and retention of qualified staff to care for those who need it. Increasing demand on services from an ageing population and a net reduction in health and social care spending is causing a perfect storm wherein those individuals who are most in need are unable to access services where they need them, when they need them. If only we knew this was coming then we could have done something about it, right?!

In a recent blog, Chris Ham, the Chief Executive of the King’s Fund – who did predict this scenario a number of years ago - proposed 3 key priorities for tackling these challenges: 1) committing to a long-term plan that provides funding and staffing, 2) improving productivity and extracting as much value out of available spending as possible and 3) reforming the NHS and integrating population health and care to provide greater emphasis on prevention.

In short, priorities 1 and 3 involve taking a long-term perspective that will be unlikely to significantly reduce demand in the short-term. Priority 1 requires finding more money to tackle current and increasing demand. However, with politicians celebrating the money they have made available to help the NHS with pressures this winter - despite providing less than half of what was needed after the crisis this winter had already begun (hardly a proactive long-term strategy) – this priority will be heavily influenced by the political landscape and will take time to have an impact if and when funding changes. Priority 3 involves a focus on prevention that will undoubtedly have an impact in the long-term, but will also see minimal short-term changes in demand. This leaves us with priority 2 - so how do we improve productivity and extract as much value out of what’s available as possible?

In order to deliver major performance improvement, high performing organisations will often consider all of the marginal gains that they may make that will aggregate to a significant improvement – rather than trying to find that one thing that provides significant improvement alone. This approach is known as marginal gains theory, which was brought to public consciousness by Sir David Brailsford – Performance Director of Team Sky and previously of British Olympic Cycling – when taking an ailing cycling team to major Olympic medal hauls (winning 70% of the gold medals on offer in 2012!) and providing Britain with our first Tour de France winner. By optimising everything from nutrition to the ergonomics of the bicycle seat, Brailsford and his team left no stone unturned. If long-term funding and a focus on prevention are the big things that will reduce demand in the long-term, then to reduce demand in the short-term we must ask what marginal gains can be made that - when clumped together - will be able to tackle some of the challenges in demand faced by the NHS and in particular emergency departments.

Our first marginal gains must start by reducing inappropriate attendance at emergency departments. The behavioural insights team at ICE have worked with local authorities, CCGs and NHS organisations to explore the behavioural challenges that lead to inappropriate attendances at emergency departments and to create behavioural solutions to solve them. In many places, we have identified that up to 1 in 3 (>30%) attendances at emergency departments may be deemed inappropriate, with self-care or a visit to another service being a more appropriate behaviour. Imagine the difference having even a 10% reduction in inappropriate visits could make! The insight our team have conducted with citizens has clearly demonstrated that citizens are presented with too much information and too much choice when they need to decide where to go for treatment/support. When faced with a lot of choices, we are unable to fully understand all of the available options and when we have incomplete information, new choices or novel behaviours feel too risky, so we will just do what we’ve always done. This is known as an ambiguity effect and will often lead to a status quo bias wherein we default to our habitual behaviours. For example, most citizens would be unable to tell you what they can visit a minor injury unit for or even when they are open, but they know that if they go to an emergency department at any time during the day or night, they will be seen by an expert within 4 hours (the target the NHS has set itself). When we ask citizens to make this service vs. service decision, the emergency department will always win.

To change this behaviour, we need to change the decision making process. We need to move citizens away from a service vs. service decision, and we need to support the individual to make a condition/symptom based decision. National campaigns such as “Choose Well” do not work because they continue to make citizens choose between services. They ask citizens who believe they are choosing well to choose well and do not provide information or communications that supports them to change this decision - the message frames typically just ask them to stop and think and take responsibility.

ICE have developed an award winning digital solution called ASAP that uses choice architecture to support citizens to make a condition-based decision by utilising behavioural nudges. Within ASAP, a citizen’s choice to search by service is not removed, but a search by condition icon is placed above the search by service icon, making it the default choice and nudging users to search by condition first. ASAP usage data demonstrates the effectiveness of this nudge, with users 3 times more likely to search by condition than by service. For each condition, users are given information regarding the condition (including how to self-care for certain conditions) and are then presented with a list of local services to choose from. The presentation of services is ordered based on which service we want users to use, and an emergency department is not included in the list for conditions that we do not want users to present with at an emergency department.

ASAP was developed and implemented in Gloucester. In the 12 months that followed the launch of ASAP, emergency department attendances at Gloucestershire Hospitals NHS Foundation Trust reduced by 7.2% for the target audience of ASAP (0-50 year olds), a result that may be considered even more impressive based on the fact that the year prior to launch had seen an 11% increase for this cohort. Further, attendance at minor incident units – the service G-CGG wanted demand moved to - increased by 7%, suggesting that demand had been successfully shifted across the system.

Whilst digital solutions can provide marginal gains that actually result in big impacts, the ASAP digital solution itself was in fact only one factor in its success. An effective communications and engagement strategy was developed that utilised supportive message frames and visuals that ensured citizens accessed ASAP independently. We also worked closely with leaders and stakeholders to align services and improve signposting, with digital banners shared across websites. The communications and engagement activities also raised awareness of available services and ensured the workforce was changing its conversation with citizens. These are key factors in creating an ecosystem wherein the system is aligned, connecting and making it easier for citizens to navigate it. It is this ecosystem of leadership, culture, communications, engagement and behavioural solutions that can provide multiple marginal gains that provide a big impact.

During 2018, the NHS is expected to launch NHS 111 online. NHS 111 online is being developed by NHS Digital within programme 5 of their urgent and emergency care strategy to transform health and care through technology. To talk to us about how you can use behavioural insights to reduce demand in emergency departments and to prepare for the implementation of NHS 111 online, please contact the ICE team on 0151 647 4700

Changing behaviours to A&E access - a proven approach

February 15, 2017 15:25

At 2016's CIPR PRide Awards, Advice ASAP - co-created with NHS Gloucestershire CCG - was presented with the Gold Award in the Public Sector Campaign category. The PRide Awards recognise deliverable results for clients and employers.

"With clear objectives and a well thought out strategy, this campaign delivered tangible results and significantly changed behaviour amongst its target audience. The judges were highly impressed by this outstanding entry. A clear winner." - CIPR PRide Awards Judges

At an average cost of £114* per A&E attendance, the reduction of 13,447 attendances means Gloucestershire CCG achieved more than £1.5m in savings, which was redirected to other services such as primary care and community minor injury units. 

*Department of Health reference costs Nov 2013

Do our citizens know where to turn?

5 January 2015 saw both Gloucestershire Royal and Cheltenham General Hospitals declare ‘major incidents’ due to high demand in their emergency departments, with 30% of people attending with non-urgent ailments. Advice ASAP was co-created with Gloucestershire CCG to combat the number of inappropriate attendances at emergency departments.

Insight was used to identify the ‘why’ – why were people who could be treated more appropriately by other health services visiting emergency departments? Parents of children aged 0 to 5, 10 to 18 and adults aged 17 to 39 were identified as the key target audiences.

With these audiences presenting with minor conditions that could be more appropriately treated in the community health access centre and community minor injury and illness units, we needed to produce a solution that would help inform citizens about where best to turn.

Development of ASAP:

The innovative app and website allows citizens to identify the most relevant health services to treat their conditions, locate the services closest to them (using geolocation functionality such as maps), and to view opening and waiting times.

Videos are used as a visual aid to advise on the roles of different services – raising education and awareness of where and when to attend, depending on the condition.


Within the first week of the campaign, the NHS Gloucestershire health community witnessed an 8% reduction in emergency department attendances and a corresponding 8% increase in attendances at the county’s community minor injury and illness units.


“Our ASAP partnership project with ICE Creates has been hugely beneficial and has resulted in a striking, sustainable campaign and intuitive campaign tools co-produced with clinicians and local people.

Through genuine and meaningful insight gathered from our population and reflecting changing times and the ‘key message culture,’ ICE identified that highlighting the clear routes into assured advice on what to do if you are ill or injured was the right path to take.

As well as signposting to face-to- face and telephone advice options, ASAP offers a groundbreaking app and website that guides people through health conditions and symptoms, care advice and provides the user with specific (and appropriate) service details.

This was a challenging project, but ICE provided friendly and professional project management support throughout, highly creative campaign concepts and visuals and were patient and understanding in our shared approach to developing wireframes and the wider digital assets.

Early signs from evaluation have shown that where people have seen or have acted on the ASAP messages, there have been clear signs of intended or actual behaviour change that can only benefit the local NHS and individual patients as we look to build on the first phases of the campaign.”

Anthony Dallimore, Associate Director, Communications – NHS Gloucestershire

You can view the Advice ASAP website here:

To request a full case study or to discuss how we can co-create solutions bespoke to the needs of your citizens, contact Paul Williams on 0845 5193 423 or at