Better Than Cure? Public Health in the ED at #RCEM15

Better Than Cure

Is public health a problem in the UK?

Well, prior to this year’s general election, healthcare and the NHS were consistently top concern for voters. But the public are worried and confused – 5 of the top ten worries published in the Telegraph’s survey published in January 2015 related to health, aging or physical fitness. And the healthcare messages patients receive are, let’s face it, confusing – as Russell Howard explains better than I ever could.

And we know that people pay attention to the messages in the media – in fact I might have had better attendance in my session at RCEM15 if this had been the title of my talk:


Are we a healthy nation?

Well, there’s some good news: younger adults are reporting reduced drinking behaviours and reduced smoking behaviours (reduced proportions are starting smoking and increased quit rates are reported).

But there’s plenty of bad news too. Alcohol-related deaths remain the at the same rate as previously (highest in the 60-64 years age group).  The proportion of adults with a normal BMI has reduced and we are seeing increasing obesity. Although 67% of men and 55% of women in 2012 met recommendations for aerobic activity, 26% of women and 19% of men were classified as inactive.

And food-purchasing choices are poor too: overall purchases of fruit and veg decreased from 2009-2012 and spending on fats, oils, butter, sugar, soft drinks and beverages have increased.

Perhaps most relevant to the ED and most disconcerting of all is this: in 2013, data suggested that 23% of deaths in England and Wales were potentially avoidable through good healthcare or public health interventions.

And it’s not just the adults.

A recent document published by the National Children’s board revealed that there were 26,000 paediatric admissions to hospital in 2013-2014 (in the group aged 5-9) for dental intervention (an increase of 14% since 2010), and 48,000 admissions for under 5s related to injury. The report also reveals that 1 in 10 children are obese at the time they start school (although proportions have plateaued).

But hey – we’re healthcare professionals. We make good health decisions, right?

Well, let’s find out. Do any of the following statements apply to you?

alcohol veg exerciseBMI

All of these messages are familiar to us. We know what the messages are – do we follow them?

The bad news is – you are not so smart. We as human beings are not logical or smokerational. We tend to make the easiest decisions at any time. We have lots of inherent biases and many of these serve useful purposes, conserving energy and seeking out the most calorific food possible so we can store energy whenever we can, all very sensible from an evolutionary perspective – if you’re a caveman who doesn’t know where his next meal is coming from. But we aren’t cavemen. What we are is very bad at making the best decisions for ourselves in all aspects of our lives, every time, no matter how smart we are.

Can doctors change patient behaviour?

Let’s first think about how change happens. Several models of behaviour change exist in healthcare – you may have heard of the health belief model, the theory of reasoned action/planned behaviour, or the transtheoretical change model. What these models have in common is an expression of the theme that change is personal and multifactorial but that beliefs surrounding susceptibility, self-efficacy, costs and benefits all play a part.

As healthcare professionals we should see ourselves as “choice architects”, to borrow a phrase from the excellent book Nudge by Sunstein and Thaler. As behavioural economicists, they assert that evidence suggests that both adults and children can be greatly influenced by small changes in context. They describe the concept of libertarian paternalism –  people are free to choose (and to make poor decisions if they want) but we can make small changes with specific aims to make lives better, healthier, live longer.

And patients trust us: Ipsos MORI conducts an annual survey in the UK and consistently members of the public feel that doctors are more likely to tell the truth than journalists; in fact since their studies began, doctors have been the most trustworthy profession – over newsreaders, the police, the clergy, members of the public, pollsters, NHS managers and politicians.

We know that if we tell our patients to stop smoking, there’s an increased chance they’ll do it: Cochrane’s meta-analysis of 28 trials encompassing 40,000 participants found that simply offering brief smoking cessation advice interventions will increase quit rate by 1-3% (on a background quit rate of 3-5% per year).

So the world of health is confusing but we have a chance to speak the truth into it.

Behaviour change is the holy grail of public health – it’s multifactorial and it’s tricky, it’s hard to measure and it’s almost impossible to evidence causation rather than association. At the end of the day, we humans are stubborn beasts.


How can we increase our impact?

Our influence is unavoidable, like it or not – so let’s harness it.

In the ED we have particularly pertinent patient opportunities. There are some specific psychological quirks we should recognise in our patients and the first is risk proximity perception (a manifestation of the availability bias) – vivid and easily imagined causes of death often receive inflated estimates of probability, as do recently experienced events, so by coming to the ED the implications of poor healthcare decisions become more tangible. Conversely, patients’ unrealistic optimism may be “nudged” by context.

Combine this with an awareness of anchoring (which means that we interpret information in the light of what we know and adjust our thinking accordingly) and framing (the choices we make depend on the way in which problems are stated) and you can start to see the potential ways we can influence health behaviours within ED interactions.

If we frame our standard social history questions in the context of examination (making an association between our clinical findings and the apparent consequences of health behaviour decision making) rather than as part of the history, will they have more effect?

Social nudges are important too – there’s evidence to suggest that if you inform what other people are doing (positive statistics about proportions of people exercising, for example) people are more likely to be motivated to change (although if your patient is doing better than average, don’t tell them as the inverse is also true; those who believe themselves above average are more likely to increase calorie intake/reduce exercise etc).

There’s also evidence for the use of intention questions – “do you intend to…?” Thaler and Sunstein call this the Mere-measurement effect – that simply asking if people intend to do a particular thing increases the proportion who take action to do it. This is probably why asking about smoking cessation works – reproduced by Levav and Fitzsimmons in 2006 who performed experiments using framed questions about intentions relating to health behaviours such as flossing and healthy eating. Adding questions about plans to enact these behaviours increases the effect we have when identifying poor health behaviours.

Feedback on behaviours is an important motivator to change but long-term behaviours (like smoking or inactivity) that are some of the greatest determinants of health actually very rarely receive meaningful feedback. So if we can couple a particular modifiable behaviour with a trip to the ED we can increase the perception that the two are related (just remember that feedback is about the receiver, not the giver – it’s not an excuse to tell the patient off! They have their own free will which we have to respect).

We have seen many of these effects in our clinical practice anyway – for example, conversations about antibiotics for otitis media – we tell patients that it is twice as likely that their child will develop diarrhoea than that they will have a reduction in pain but patients find this difficult because the pain is real and tangible whereas the diarrhoea associated with antibiotic use is by no means a certainty, so their perception of risk and benefit is skewed.


Why is the ED the place to do this?

As we have discovered above, the balance between perceived cost and benefit of behaviour change is skewed if costs are more tangible than benefits. ED attendances may lend themselves well to this particularly if connected to health behaviour in question (so-called present-biased preferences).

Benefit proximity and risk proximity are great influencers and if this is the case then surely the influence of a healthcare interaction must be maximal when it is unplanned – i.e. an Emergency.

We also have a mandate from both RCEM and DOH – but I want you to change your behaviour so that’s not going to help, perhaps I should phrase it like this:


Actually its not a complete lie – an article published online at EMA on 7th Sept suggested 70% of consultants and 75% of trainees in Australasia believed public health initiatives should be provided in the ED. Now we can’t have the Australasians being better than us, can we?

Where can we have the greatest influence?

The opportunities are endless.

Firstly we can think carefully about how we frame intention questions.

We can influence the patients attending our emergency departments by helping them to help themselves in understanding their own inherent biases and heuristics. For example, patients who want to lose weight will be more likely to be successful if they buy smaller plates, buy smaller quantities of things they like to eat, and don’t keep tempting food in the fridge (as we are experts at mindless choosing, especially when it comes to eating – we will eat whatever is in front of us).

We can advise all our smoking patients to stop smoking. We could even go as far as putting “smoking kills” signs in resus, which might be a bit far, but what about in the relatives rooms (along with resources for smoking cessation)? Or how about positive messaging there – share the statistic that 1 in 20 smokers successfully stops each year?


We should ask our patients about seatbelt and cycle helmet use.

We can educate parents about trampoline dangers and challenge the belief that nets make trampolines safe when that really isn’t the case – most injuries involve multiple children (or adults!) on the same trampoline at the same time. Kids who get hurt tend to be risk takers so we have an important opportunity to educate and prevent further injury.

We can help parents and patients make practical sense of healthy eating messages – like this great initiative from Leicester.

Can we have an effect beyond our four walls?

As members of the public, we can engage in campaigning for changes to take advantage of behavioural economics to improve public health. You’ll see opt-in signage on organ donation around most EDs but as members of the public we can also campaign for opt-out organ donation (harnessing the power of inertia which means that people are unlikely to go to the effort of opting out – we usually take the path of least resistance).

Your department can actively engage with local public health programmes, like I.M.P.S (which brings school age children into hospitals to educate and reduce anxiety and works with schools to deliver healthy messaging – in Oxfordshire they reach 81% of junior schools and teach 5000 children/year) and the project Phil Hyde is involved with in Southampton which brings children into departmental simulation for the dual purpose of increasing fidelity and changing health perceptions among the children themselves.

We could even support double summer time (estimates in 2010 report benefits in road traffic deaths with a reduction of 2.6-3.4 % per year and its financial implications, as well as reduction in crime, increased energy efficiency, health benefits in the context of increased outdoor activities during winter months, and increased financial benefits in tourism and leisure).

And, not wanting to get bogged down in the cycle helmet debate of the London Trauma Conference 2014, perhaps we should also campaign for safer dedicated roadways for cyclists.

One of the simplest ideas we could enact is to etch images of flies into the ED urinals, an idea mentioned in Nudge and one which started in Schiphol Airport and has reduced urinary spillage by 80%.


It’s important that you understand that you have influence, like it or not, and that you can choose to use it to positively impact public health in the ED.

And to finish: a challenge

As we realised at the beginning, we’re people too and we are part of the problem – for example we know we should wash our hands, but we continually perform audits which show we don’t do it (and this recently published study suggests we are even less likely to do it if we are busy).

Aside from making better hand washing decisions at work, we can make better health decisions for ourselves. Live better, work better, and role model good health behaviours for the next generation.

So I’ll leave you with these two questions:

  1. Do you intend to make changes to influence public health in your ED?
  2. Do you intend to make healthier decisions for yourself, starting now?

Good luck to you!


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