How can behavioural insights support families to choose the best option for their unwell child?

Children make up almost a quarter of total emergency department (ED) attendances, and in fact, their impact on current pressures is far greater. This is why the BLUEPRINTS project, funded by the Health Foundation, is looking closely at how behaviour impacts these pressures, and how we can best support families to improve child health.

A frontline challenge we are all seeing

As a doctor working in paediatrics, I often see emergency and urgent care waiting rooms full of children – with standing room only for families and carers. The Keogh review notes that a rising demand for health care is putting pressure on NHS emergency and urgent care, while the number of people attending EDs is increasing at a faster rate than population growth. Half of patients attending ED require no medical intervention, and most of these need only ‘guidance or advice' (NHS Digital 2017). A recent National Audit Office report estimates that approximately one in four emergency admissions could be avoided through effective community care and case management. There are a number of initiatives being used to encourage people to not always attend EDs, but there is often a mismatch between anticipated and actual change – perhaps because they do not embrace behavioural insights.

By taking a behavioural insight lens to this challenge, we can bring about greater efficiencies and improve patient care quality and experience.

What are families thinking when a child is unwell, and is there a role for behavioural insights?

Families are increasingly choosing to attend hospital emergency or urgent care departments with an unwell child. On a daily basis, we review children and offer important advice or education in an attempt to reassure families without clinical tests or medical treatment. A recent study estimated that non-urgent ED attendances cost nearly £100m in 2011-12, with children under 16 being the age group with the highest rate of non-urgent attendances. At my hospital, less than 10% of children that attend the ED are sick enough to require admission to hospital.

Families are understandably anxious when a young child becomes unwell, and it is our responsibility as health care professionals to provide the support and reassurance they need. Pharmacists, GPs and NHS 111 are often well-placed to provide timely, local advice which can prevent inconvenient trips to hospital EDs.

Connecting Care for Children are working with the Behavioural Insights Team – as part of the Health Foundation’s Behavioural Insights Programme – to identify which behavioural insights may be used to support parents and families not to head straight to ED when their child is sick, but choose the best option for their unwell child.

Through initial interviews and 80 hours of observations, we have identified a number of key behavioural biases that influence health care professionals and parents, including:

• Risk aversion: the tendency to avoid choices perceived as risky. Risk perceptions do not always reflect an objective weighing up of pros and cons – they are often influenced by a person’s emotional and psychological state.
• Availability bias: this refers to the tendency to make an evaluation based on examples that come readily to mind. For example, a parent may view their child's fever with particular anxiety if they have a strong memory of a family member or friend having had a fever, which turned into a more serious condition.
• Messenger effect: a common belief among some parents is that paediatricians are better equipped to treat children than other health care professionals, such as GPs or pharmacists.

So what can we do? Our next step is to design a novel intervention, and evaluate its effectiveness in North West London. Our intention is to design a low cost behaviourally-informed intervention that will:

1. provide sufficient reassurance to parents when young children have a minor illness
2. give families more confidence in identifying and managing minor and serious childhood illness
3. encourage families to choose to attend the most appropriate health services with their unwell child.

As a doctor in training, this innovative collaboration has offered me a wealth of exciting opportunities away from the clinical frontline, and has proved to be the most engaging part of my working life to date. It has allowed me to understand behaviours that influence health care staff and families’ decision-making, and has reiterated that evaluation and the generation of an evidence base for any new intervention should be an essential component of all health care policy.

Underlying every decision we make are numerous influences. We need to increase our awareness of those influences on health and work in partnership with families, carers, staff and communities (Watson et al, 2018). Only then can we improve care quality both for individuals and society generally.

Read the research team’s initial report: Why do parents bring children with minor illness to emergency and urgent care departments? Literature review and report of fieldwork in North West London

Ben Holden (@DrBenHolden) is a Clinical Research Fellow in Paediatrics and Child Public Health at Imperial College Healthcare NHS Trust. He is a member of the Connecting Care for Children team.