Inappropriate use of A&E: mapping the decision journey

Client: NHS East Midlands

The challenge:

Accident and emergency (A&E) waiting times are in the headlines on a regular basis and demand on emergency services continues to grow steadily – analysis of the weekly data for 2014/15 shows ~14,500 more attendances per week than in 2013/14. Nearly 40% of patients who attend A&E are discharged without requiring treatment. A survey of 3,000 patients in twelve A&E units conducted for the College of Emergency Medicine found that 15% of patients could have been treated in the community.

What was needed:

With its A&E departments under constantly growing pressure, NHS East Midlands needed to capture insight into its patients’ behaviours and service usage, to understand patterns of inappropriate A&E use and identify opportunities for change. It also wanted better to understand people’s reasons for choosing A&E over primary care for specific conditions and treatments, to develop interventions to address this.

What we did:

Uscreates were commissioned to undertake detailed insight work with two specific target groups, both of whom display high inappropriate A&E usage:

  • Parents of children aged 0 to 4
  • 15 to 24 year olds

We captured views, opinions and mapped the decision-making, treatment and aftercare journeys of 120 people from these two target groups, along with nine health professionals, using pop-up diary rooms and video pods in universities, shopping centres, leisure and children’s centres. Using prompt cards to explore people’s stories, we undertook detailed journey mapping to identify a number of factors that triggered A&E usage when other services could be more appropriate (e.g. knowledge of symptoms, confidence to self treat, understanding of services available, ease of access, and previous experience of services). Crucially, this revealed the extent to which a past or current experience of using a service will influence future decision-making about which service to attend. Insights were explored in detail at a co-design event with 43 stakeholders, where quick win, medium term and long term solutions were jointly developed to address key inappropriate decision triggers.

The results:

This work provided NHS East Midlands with a detailed recommendation strategy, setting out key opportunities for reducing inappropriate use of its overstretched A&E services. Initiatives ranged from discharge cards to reduce repeat attendances; through to feedback loops between A&E and primary care services to promote use of alternative pathways across the system. All recommendations were clearly set out and driven by detailed understanding of patients’ decision-making processes and their awareness and knowledge gaps.