Behavioural design: a public dis-service

Using design to make people behave in UK A&E departments leaves the source of people's frustrations untouched.

A team of designers, led by PearsonLloyd and commissioned by the UK Department of Health, has managed to reduce the instances of aggressive behaviour in UK accident and emergency (A&E) wards by half. This is according to new research based on trials of newly designed A&E wards at two hospitals.

Waiting times and the resulting aggression towards staff in A&E departments are a very real cause for concern. But whether designers are best equipped to tackle such matters remains to be seen. After all, much of what is being proposed doesn’t really address the causes of ever-longer waiting times and people’s subsequent frustration. Instead, the designers appear solely concerned with placating already angry patients who expect better levels of care.

As the Telegraph reported last week, physical assaults against NHS staff are on the increase. There were nearly 60,000 assaults last year, a three per cent rise from last year’s figures. Likewise, waiting times in A&Es are getting longer. According to the Guardian, over 21million people attended A&Es in 2012/13, the highest number on record; of these patients, the number who had to wait for more than four hours to get treated has risen by three per cent.

One of the reasons for this increase in waiting times is that many GP surgeries are closed out-of-hours and a lot of walk-in centres are now being closed down. So with fewer treatment options, people are having to opt for A&Es instead.

Against this difficult background, we should welcome the attempt of designers (or anyone else for that matter) to calm down the growing number of pissed-off people having to wait for hours upon end to get treated.

So what is PearsonLloyd’s big design idea? Put simply, it is all about informing patients how A&E works, using posters, signage, and installing those digital countdown clocks that politely inform you how far back in the queue you are.

The designs trialled in two A&E departments include various posters, each explaining the clinical process, using timings and icons for each stage of treatment. PearsonLloyd has also designed a fold-out poster, featuring a process-flow diagram to explain the different treatment routes.

Now, depending on why you are in A&E, these posters could indeed be useful – they might, for example, provide a nice distraction from the agonising pain. But for all the stats showing how the signage, explanations and information have so far helped patients understand the process, this use of design seems like a cosmetic approach to a very real problem: the shrinking of treatment options.

Yes, the nicely presented stats do show that 88 per cent thought the ‘the signs clarified the process’; that staff reported ‘50 per cent less threatening body language’; and that there was ‘23 per cent less offensive language or swearing’. All of which is good news for staff and patients alike.

But even so, the fundamental question remains: have these ‘calming measures’ helped bring about improvements in A&E provision? Have waiting times been reduced? Have patients experienced a better service? The only discernable fact hidden away amid the statistical guff is that ‘patients rated their waiting experiences five per cent better post-implementation’.

So despite the clearly presented and informative explanations of how A&E works, for 95 per cent of patients, nothing has materially changed. In fact, if you are unfortunate enough to find yourself in an A&E department with something nasty, the only thing you can expect, according to the new designs, is to be firmly put in your place by being told how long you have to wait. Or to put it more brutally: it is your behaviour that is to be improved, not NHS service provision.

In effect, the designs and research identify our behaviour as the problem. And at the same time, the Department of Health, focusing on design, makes no attempt to materially improve the delivery of care.

This might just be another example of the NHS and the Design Council trying to think up new and inventive ways to solve difficult problems. There’s nothing wrong with that, so long as the ideas are a significant attempt at actually solving the problems. Seen in a different light, the problem could be much simpler. As reported in the Telegraph, in addition to longer waiting times and reduced service levels, the elephant in the room is that many A&E departments are now working with reduced numbers of staff on call.

The tendency to use designers to improve public services is on the increase; and so, too, is the focus on changing the behaviour of those on the receiving end of public services. Today, both these tendencies invariably operate hand in hand. Writing in the Guardian, Jonty Olliff-Cooper, of the Young Foundation think tank, makes this clear. He describes how government departments are increasingly set to benefit from using designers to improve how their services run. ‘Design needs to learn from other public service fields, such as behavioural economics and social finance’, he writes.

The official determination to design our behaviour should be cause for concern, even if, in this case, A&E departments are enjoying a reduction in violence against staff. After all, underneath the stats, the cause of people’s frustration – the low level of care – remains. Designers are merely allowing service providers like the NHS to shift the blame from its shoulders on to those of the public.

So, remember, the next time you have to wait in line in A&E: take a deep breath, read the signage and be prepared to wait. Wanting to let out your frustration won’t be allowed, especially now you’ve been told why the system isn’t working.

Martyn Perks is a design consultant, and a writer and speaker on design, IT and business. Visit his website here. He is also a contributor to BIG POTATOES: The London Manifesto for Innovation.

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