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Thinking ahead about A & E (over a barbeque)

Nigel Guest


It’s June – I’m lighting the barbeque and getting excited about summer holidays….but I’m also already thinking ahead to winter! How can that be?

We’ve all seen the headlines in the press claiming to expose the ‘crisis in A & E’, and each year seems to be the worst on record. I recently read an article by the BMA which declared that ‘winter pressures are now the new norm all year’. This is a bleak picture, and absolute madness!

In late summer, I know that many NHS organisations will commence a winter planning exercise that will focus on providing enough or additional capacity, in order that ‘the system can cope’. Obviously, there is a huge financial cost to this, in addition to the difficulties of finding enough staff to safely provide the care.

However, if we consider this issue from a demand perspective rather than as a capacity problem, maybe there are alternative approaches to reducing the pressure?

We know that A & E attendances have continued to rise; in England, they have increased by a third over the last 12 years. The national target for A & E patients – that 95% should be seen within four hours of arrival – has not been met in England since 2015. A third of hospital beds are occupied by patients with one or more long-term conditions, and Delayed Transfers of Care (DTOC) continue to be a problem, particularly with older and more complex patients.

But according to a blog published by the King’s Fund in March, the volume of attendances isn’t necessarily the only driver of poor performance in A & E. Daily attendances actually tend to be higher in June and July per day than in November and December. In fact, performance is more closely linked to the types of activity seen in departments, which tend to be more complex during the winter months.

So, what is the benefit of looking at this problem through a ‘demand lens’? Well, evidence also suggests that a significant proportion of A & E attendances could be avoided, if people either helped themselves or accessed more suitable alternatives in the community.

We need to fundamentally alter our focus towards changing the behaviours of how people interact with urgent and emergency care, so that we can influence how and where demand presents in the system.  I suspect that very few people actually enjoy spending hours waiting in an A & E department, only to be sent home without requiring any treatment. Yet information from NHS Digital suggests that over 35% of attendees receive only guidance or advice from A & E.

There is a case, of course, for ensuring that performance in A & E (and wider non-elective flow in hospitals) is as operationally efficient as it can be. But is there also a case for understanding the nature of demand, engaging with people (both patients and health professionals), and shifting inappropriate demand through positive reinforcement and indirect messaging to motivate and incentivise people towards more suitable and sustainable alternatives.

IMPOWER’s approach – of using behavioural insight to gain deep understanding of a problem, before driving behaviour change – aims to reduce A & E attendances by 15%. We have a successful track record of disrupting traditional thinking in order to change the patterns of people presenting into services, including into hospital emergency portals.

If you are interested in learning more, please email me at

Written by

Nigel Guest



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