Chris Moulton: What is happening in A&E?


Chris Moulton

Chris Moulton, Vice President, Royal College of Emergency Medicine, and Consultant in Emergency Medicine at Royal Bolton Hospital, discusses how the A&E brand influences patients' decisions to come to A&E, and makes recommendations for reducing emergency attendances.

Chris Moulton: What is happening in A&E?

This presentation was recorded at our Urgent and emergency care conference on 27 September 2016.


Everywhere you look, if you go on the internet, you can find this. “Think” plea: people don’t go to A&E. Best recognised brand in the world, but don’t use it.  There is even websites called ‘Don’t go to A&E’ this is one of the websites in London devoted to telling people not to go to A&E.  A bit like saying Starbucks makes the nicest coffee, but we would rather you didn’t go there.  Even when I do my clinic, I do it beside one of these hospital signs.  I have asked the patients to come back to clinic, but there is a sign there saying ‘Don’t come’.  All this telling people not to come to A&E, does it work?  Monitor of course in 2015, they thought that A&E, due to all the things we are doing to divert people, we would reduce our attendances by 15%.  So were Monitor right do you think?  Well that is The King's Fund figures from their September quarterly report, emergency attendances have gone up by nearly 3%, and emergency admissions from A&E by over 4%.  So their downturn of 15% was optimistic to say the least.

And we have got a problem, because again we are trying to swim against the tide of time, and of geography, because this is attendances at EDs, all over the developed world. And if you notice here, there is the UK, so the idea that all these hypochondriacal Brits go to A&E more than anybody else isn’t true. Health watch two years ago, they said that 20% of people admitted going to A&E with conditions they knew weren’t urgent.  They did this because the other places were closed, and because they couldn’t find their way through the maze that is urgent care in our country at the moment.  The Patients Association, they said that lots of people had already contacted their GP’s surgery, and of those half nearly had been offered an appointment on the same day.  But they didn’t want to go, because the perception of people is also a very important thing.  They don’t believe they can get the healthcare they want, in urgent circumstances, out of hospitals.  But this brand continues to attract people, Saturday, Sunday or whatever.

A brand is a promise, or a guarantee, it is something that tells you you will get what you want, what you are paying for, or what you are looking for. The big German brands like BMW are obviously great examples of that. And you can even have double brands like this.  Audi are playing on the quality of German engineering.  All the elements combined together, there is Ferraris, symbols, colours, all coming together, and there is another great double brand.  The NHS is the first part of the double brand, the A&E is the second bit of the double brand.  It is open all round the clock, doesn’t cost you anything at the point of access, and now you are guaranteed, or we hope you are guaranteed to be seen somewhere near foot within four hours.

And branding experts say A&E is a super brand. It stimulates this kind of automatic response, and these automatic patterns of behaviour are very, very, very difficult to change. A&E is a 50 year old brand, it is a very long established one.  And in actual fact Kahneman who was a Nobel prize winning economist, he said ‘There is two ways of thinking’.  There was this kind of way of slow, careful, thinking, proper thinking if you like.  This is when you drive a car for the first time, you are thinking about everything you do.  And then there is your kind of automatic driving which you do when you are used to driving a car, where you just do what you have to do.  And this is the kind of thinking that we are up against.  People are making automatic decisions based on long established patterns of behaviour.

And these are what they call the brand assets. The colour, the shape, the time, the place, they all come together to make the brand. And you can use these brand assets in a positive way.  Nurofen uses them for sub branding, so you can buy all these different types of Nurofen which have got really not too much to do with the original Nurofen.  So we have had 50 years of unintentionally building this massive brand, and its brand assets, somewhere where the lights are always on.  And the branding experts, well what is their solution?  Well they say ‘Don’t fight the A&E brand, don’t spend thousands of pounds on the internet, don’t spend thousands of pounds with signs, you are fighting a losing battle here.  Extend the A&E brand, and they call this brand stretch.

So we need to give the public what they want. They want that for major emergencies, and they want that for minor emergencies, a cut down version of A&E. Let’s not call it urgent care centres, let’s not call it something else, let’s call it a different type of A&E, a sub brand of A&E, if you like a green A&E, a walk in A&E.  We have got to use the brand to give people what we want.  So if people keep walking across the grass, what can you do?  Well you can stand there, and chase them away with a baseball bat, or you can build a path.  Thank you.

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