Monthly Archives: March 2015

The myth of the rational patient

(and the rational doctor).

There is no disputing the fact that the pressure on the open doors of the NHS – primary care, urgent and emergency care – is unmanageable. One recurring cry from GPs and A&E staff is that they are seeing ‘the wrong people’ – that one patient takes up a GP appointment with a ‘trivial problem’ while another fails to get an appointment and becomes an emergency, or at least accesses unscheduled care, as a result. In addition, A&E waiting times are at least in part being affected by the need to triage and see patients who don’t need the specialist services of an emergency department (though this is not the main problem).

Recent NHS England campaigns illustrate the difficulty of trying to modify health-care seeking behaviour that has risk-judgement at its core.

On the one hand we have campaigns such as Choose Well (or as I call it – Don’t bother the busy Doctor), clearly aimed at over-consulters. The various configurations of these posters and websites attempt to categorise services by symptom, but ‘tummy ache’ could be period pain or pancreatitis – and most advise you to consult your GP if your symptoms don’t go away, without specifying how long the course is likely to be. For a cough, 3 weeks is normal, but I doubt most GPs would want a patient with a severe headache to wait more than a couple of days.

On the other hand we have the “Minor Illnesses can get worse quickly in the Over 60s” campaign, which seems to target under-consulting, but has a deep incoherence. The smaller print on the posters directs people to consult their pharmacist, but most of the products that a pharmacist can supply for minor illnesses target symptoms, not causes, and cough mixtures and paracetamol will not halt your infection – though simple self-care such as keeping warm and hydrated might give your own immune system a better chance. Presumably the pharmacist’s role in preventing escalation here is mostly as triage, but in a ring-at-8am-and-cross-your-fingers same day appointment system, directing someone who might deteriorate quickly to try the pharmacy first is only likely to delay the useful consultation with a GP who can give steroids, antibiotics and so on. If it doesn’t delay consultation then that is because the GP is willing to tag emergency patients on to their later sessions when the patient presents at 3pm because the pharmacist has told them they need a consultation today.

The biggest weakness of both campaigns is that they’re trying to nudge behaviour that is too complex to be nudged by such simple messages.

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