An inner London PCT with a high number of Bangladeshi people going to A&E ran a campaign which altered attendance behaviours

A campaign in the London borough of Tower Hamlets has contributed to a 6.4 per cent drop in the number of people attending accident and emergency.

'We decided to go beyond controlling the growth to decreasing it,' says Tower Hamlets primary care trust primary and community care commissioning director Andrew Ridley.

The Local Heroes campaign brought together stakeholders, community members and local healthcare providers.

'The three things that made the campaign a success were the dedication to improving healthcare, effective communication and excellent teamwork,' says PCT urgent care commissioning manager Carl Edmonds.

Success rested on the way the various partners worked together to meet tight deadlines and positively influence the local community to change health behaviours.

'We worked closely with our colleagues at The Royal London Hospital,' says Mr Edmonds, 'and they told us that many of the people they saw arriving were suffering from minor ailments that could be better treated in primary care.'

'We appointed Dr Foster Intelligence to design a communications campaign,' continues Mr Edmonds. 'We knew it would be tough because it would mean the PCT, GPs, Barts and the London trust, local pharmacists and community representatives all working very closely to achieve our objectives.'

Clear objectives were:

  • establish why people were going to A&E for minor ailments;

  • understand why they were using A&E services instead of other primary care services;

  • deliver a social marketing campaign that made a tangible difference without making any part of the community feel isolated or victimised.

Bears repeating

More than a quarter of the individual attendance records analysed by Dr Foster at the Royal London's A&E department from January 2004 to January 2005 were found to be from repeat attendees.

The target audience was:

  • Bangladeshi in origin, aged 20-30 and under four;

  • both men and women;

  • predominantly metro multiculture (a Mosaic group meaning tenants of public housing in inner city areas, with a high proportion belonging to minority communities);

  • bilingual (Bengali or Sylheti and English).

In interviews with researchers staff revealed they thought there was a lack of information in the Bangladeshi community about health and illness and about appropriate methods of seeking help or advice.

The focus groups found attitudes were strongly shaped by parents and grandparents. Many Bangladeshis in Tower Hamlets live in three-generation households. Young adults repeatedly attending A&E were often going with concerns about children and parents.

In Bangladesh, symptoms that may be considered minor in Britain are taken more seriously. Patients admitted not wanting to 'take a chance' by not seeing a doctor - for example, in Bangladesh a stomach ache or diarrhoea could well be life-threatening.

Typical self-diagnosis tended to centre around headaches and stomach aches too general to successfully treat at home. Previous experience of illness strongly influenced preventive measures, especially taking into account that Bangladeshi populations tend to have high rates of heart disease, diabetes and stroke.

Continued use of A&E was exacerbated by the negative reactions the community had to its experience with GPs. Expectations of how a doctor should behave were formed in the same way as attitudes to health and illness - from parents and grandparents.

In Bangladesh it is customary for doctors to perform a full health check when a patient visits and medicine is always prescribed. In England, the focus groups revealed that many people thought GP consultations consisted of talk rather than action. Comments such as 'most of the time, the GP just asks a few questions and says, oh you're all right' and 'he didn't even get his stethoscope out' were common in the focus groups.

Another problem was the availability of services. In many countries, patients can be seen without prior appointments, and doctors carry out full examinations. When families moved to the UK perceptions of primary care tended to be quite negative because of waiting times and different diagnosis styles. As one young man in a focus group said: 'We might wait a long time, but at least in A&E you are sure to be seen by a doctor and to be properly tested'.

No fear

The campaign was careful to avoid stigmatising any section of the community and instilling a fear of using A&E. Its focus was on education, with promoting primary care services a central feature.

The launch event was attended by Baroness Uddin. Club Asia radio promoted the campaign on all its shows and a publicity campaign featured the Local Heroes in several publications. Posters were distributed around the community, and local leaders at mosques and community centres promoted the campaign.

A street stall in Whitechapel proved to be one of the most successful aspects, with local healthcare staff meeting community members and working with the community leaders.

Independent evaluation found the project strongly contributed to:

  • a 6.4 per cent decline in total number of attendances at A&E at the Royal London Hospital between September and January 2005-06 and September and January 2006-07;

  • a steady increase in Pharmacy First consultations;

  • an increased number of men aged 20-29 using GPs, with two practices reporting increases of 8 and 16 per cent.

'We delivered a social marketing campaign that changed behaviour and educated not only the community, but us as well,' says Mr Ridley. 'That was very valuable for us.'