Every day this month, the news has highlighted the same story: the NHS is under intense pressure. Ambulances are waiting outside hospitals, beds are full and fewer are available than in previous years. Many patients cannot be discharged because there is nowhere for them to go. At the same time, services face serious recruitment and retention challenges, making it harder for staff to care for those who need support most.

Growing demand from an ageing population, combined with reduced health and social care spending, is creating a perfect storm. Those who most need help often struggle to access services at the right time and in the right place. We saw this coming, yet the system has still reached this point.

Three Priorities for Change

In a recent blog, Chris Ham, Chief Executive of the King’s Fund, outlined three priorities for tackling these challenges. He previously predicted the situation we are now seeing. His recommended priorities include:

1. Committing to a long-term plan that secures funding and staffing.

2. Improving productivity and getting the most value out of current spending.

3. Reforming the NHS and integrating population health and care with a stronger focus on prevention.

Why Some Priorities Will Not Ease Pressure Quickly

Priorities 1 and 3 require long-term action. They are essential but will not reduce demand in the short term.

Priority 1 depends on securing more funding to deal with both current and rising demand. However, political decisions strongly influence this. Even the latest winter funding boost fell far short of what was needed and arrived only after pressures were already escalating. Change through funding alone will take time.

Priority 3 focuses on prevention, which will create significant benefits in the future. Yet prevention rarely delivers immediate reductions in demand.

Why Productivity Matters Now

This leaves priority 2. To ease pressure in the short term, the NHS must improve productivity and extract as much value as possible from existing resources. The key question is how to do this effectively.

Using Marginal Gains to Improve Performance

High performing organisations achieve major improvements by focusing on many small changes that add up to a significant impact. Instead of searching for one major intervention, they look at every possible marginal gain and combine them.

This approach is known as marginal gains theory. Sir David Brailsford, the Performance Director of Team Sky and formerly of British Olympic Cycling, helped bring this concept into public awareness. Under his leadership, a struggling cycling team transformed its performance. They achieved major Olympic success in 2012, winning 70 per cent of the gold medals on offer. They also secured Britain’s first Tour de France victory.

Brailsford’s team improved everything they could influence, from nutrition to bike ergonomics. They left nothing untested or unexplored.

Applying Marginal Gains to NHS Challenges

Long-term funding and prevention strategies will help reduce demand in the future. However, the NHS also needs short-term solutions. Marginal gains offer a practical way to reduce immediate pressure, especially in emergency departments.

One of the most impactful gains involves reducing inappropriate attendance.

Understanding Inappropriate Attendance

ICE’s behavioural insights team works with local authorities, CCGs and NHS organisations to understand why people use emergency departments when other services would be more suitable. These insights help create solutions that change behaviour.

In some areas, up to one in three attendances may be inappropriate. Citizens could often manage their condition through self-care or by visiting a different service. A reduction of even 10 per cent would make a noticeable difference to demand.

Why Citizens Default to Emergency Departments

Our research shows that citizens often face too much information and too many choices when they need help. When decision making feels overwhelming, people fall back on familiar behaviours. This is known as the ambiguity effect. It often leads to a status quo bias, where individuals repeat what they have always done.

Many people do not know what minor injury units can treat or when they are open. They do know that emergency departments are open at all hours and aim to see patients within four hours. When asked to choose between services, the emergency department feels like the safest option.

Changing How Decisions Are Made

To change this pattern, we need to change the decision-making process. Citizens respond better when they choose based on their condition or symptoms rather than selecting between services.

National campaigns such as Choose Well struggle because they still ask citizens to compare services. They encourage people who believe they are already choosing well to continue, without offering clear support to change their behaviour.

Introducing the ASAP Digital Solution

ICE created an award-winning digital tool called ASAP to support condition-based decision making. ASAP uses choice architecture and behavioural nudges to guide people towards the most appropriate option.

Users can still choose to search by service. However, the search by condition option sits above it and becomes the natural starting point. Usage data shows this nudge works. Users are three times more likely to search by condition than by service.

For each condition, ASAP provides clear information and self-care advice where appropriate. It then presents a list of local services. The order of these services guides users toward the best option. Emergency departments do not appear for conditions that do not require emergency care.

ASAP was developed and implemented in Gloucester. In the 12 months that followed the launch of ASAP, emergency department attendances at Gloucestershire Hospitals NHS Foundation Trust reduced by 7.2% for the target audience of ASAP (0-50 year olds), a result that may be considered even more impressive based on the fact that the year prior to launch had seen an 11% increase for this cohort. Further, attendance at minor incident units – the service G-CGG wanted demand moved to – increased by 7%, suggesting that demand had been successfully shifted across the system.

Beyond the Digital Solution

Digital tools can deliver marginal gains that add up to major impact. However, the ASAP digital solution was only one element in its overall success.

A Strategic Communications and Engagement Approach

A targeted communications and engagement strategy played a central role. Supportive message frames and strong visuals encouraged citizens to use ASAP independently. We also worked closely with leaders and stakeholders to align services and improve signposting, including sharing digital banners across partner websites.

These activities raised awareness of available services and supported the workforce to change how they talked with citizens. Together, these elements helped create an aligned ecosystem that made local services easier to navigate.

Creating an Aligned Ecosystem

Success came from leadership, culture, communications, engagement and behavioural solutions working together. Each provided marginal gains that collectively delivered a significant impact.

Preparing for NHS 111 Online

In 2018, NHS Digital is expected to launch NHS 111 online as part of its urgent and emergency care strategy. To discuss how behavioural insights can reduce demand in emergency departments and support your preparation for NHS 111 online, please contact the ICE team on 0151 647 4700.

The Growing Pressure on the NHS

Every day this month, headlines have highlighted an NHS under strain. Ambulances are waiting outside hospitals, beds are full, and there are fewer than in previous years. Discharge options are limited, and recruitment and retention challenges persist across the workforce.

An ageing population and reduced spending in health and social care are creating a perfect storm. People who most need support are often unable to access it when and where they need it. This situation has long been predicted, yet action has not kept pace with demand.

Key Priorities for Tackling the Challenges

In a recent blog, Chris Ham, Chief Executive of the King’s Fund, identified three priorities for addressing these pressures:

1. Commit to a long-term plan for funding and staffing.

2. Improve productivity and extract maximum value from current spending.

3. Reform and integrate population health and care with a stronger focus on prevention.

Priorities 1 and 3 require long-term investment and will not significantly reduce demand in the short term. Funding decisions are influenced by political factors, and prevention takes time to deliver measurable change.

Focusing on Productivity

This leaves priority 2: improving productivity. High-performing organisations often achieve major performance improvements by identifying and combining many small, incremental gains rather than relying on one major change.

This marginal gains approach, brought to prominence by Sir David Brailsford in British cycling, focuses on optimising every detail, from nutrition to equipment ergonomics. Small changes, when combined, drive significant impact.

Applying Marginal Gains to NHS Demand

To reduce demand in the short term, we need to identify the marginal gains that, when combined, can ease pressures on emergency departments. The first step is reducing inappropriate attendances.

Understanding Behavioural Drivers of ED Attendance

ICE’s behavioural insights team has worked with local authorities, CCGs and NHS organisations to understand why people attend emergency departments inappropriately and to design behavioural solutions that address these drivers.

In some areas, up to one in three attendances may be inappropriate, with self-care or alternative services offering better support. Even a 10% reduction would make a meaningful difference.

Navigating Too Much Choice

Citizens often face too much information and too many options when deciding where to go for help. When choices feel unclear or risky, people default to familiar behaviours. This is driven by the ambiguity effect and often results in a status quo bias.

For example, most citizens do not know what minor injury units can treat or when they are open. However, they know that emergency departments will see them at any time of day, typically within four hours. When forced to choose between services, ED frequently feels like the safest option.

Changing the Decision-Making Process

To shift behaviour, we need to change how decisions are framed. Rather than asking people to compare services, we should support them to make condition or symptom-based decisions.

National campaigns such as Choose Well struggle because they still present service vs service choices. They ask people who believe they are already choosing well to choose well and do not provide the guidance needed to change behaviour effectively.

The ASAP Digital Solution

ICE developed an award-winning digital tool, ASAP, which uses choice architecture and behavioural nudges to support condition-based decision making.

The option to search by service remains available, but search by condition is given prominence, acting as the default. Usage data shows this nudge works, with users three times more likely to search by condition than by service.

For each condition, users receive clear information, including self-care guidance and a list of appropriate local services. The services are ordered to encourage use of preferred pathways, and emergency departments are excluded when not clinically appropriate.

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