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Why behaviours?

• We start with demand….

• ….but in complex, people-related public services, behaviour almost always follows

• We have used a behavioural lens to investigate two big questions:

1. Are behaviours (patients and professionals) part of the explanation for rising, avoidable acute demand for older people?

2. Can we use behavioural approaches to design and deliver better, more successful integrated care?

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‘The present system is under such strain because patients call 999 or go to A&E because they don’t know what else to do. Keogh has designed proposals to tackle that problem from the clinical side; but perhaps the greater challenge is to direct patients to the correct service in the first place.’ 

David Blackburn. The Spectator online 13/11/13

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‘The development of integration may even be destructive….since professionals as well as managers tend to defend their territories when these are believed to be threatened’Ahgren and Axelsson: ‘A decade of integration and collaboration: the development of integrated care in Sweden:’ February 2011

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Values Modes

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Understanding the values which underpin motivations provide a model by which behaviours and choices can be predicted and influenced.

This system identifies and describes a spectrum of values and corresponding behaviours.

This approach recognises that those behaviours drive service demand and puts people (versus process and ICT) at the forefront of public policy decisions.

Values Modes Segmentation – a quick explanation

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Overview of behaviours and characteristics by segments

“Settlers” “Prospectors” “Pioneers”Characteristics Traditional. Like ‘top-down’ messages. Naturally conservative and risk

averse. Driven by unmet need for safety,

identity, belonging. Wary of change – nostalgic about

past. Low sense of ability to effect

change.

Behaviour ‘Follow the crowd’. Least empathy of the groups. More likely to get family (often

extended family) to help out with some tasks.

Can be inflamed by threats. Pessimistic about future.

Characteristics Guided by external influences (e.g.

people, money, status, power). Status oriented – do things

because they are cool/ fashionable/ clever.

Draws esteem from others.

Behaviour Smarter dressed. “Don’t want to look stupid”. “All about me- how does it affect

me?” Unlikely to come up with ideas. “Keeping up with the Jones’”

Characteristics Guided by their own sense of ‘right’

& ‘wrong’. This is deeply emotional and informs rational decisions.

Strong ‘Self-efficacy’. Less worried about others’

perceptions of them. More creative. Most empathetic.

Behaviour More likely to volunteer. ‘If the rules don’t let me do it,

change the rules’. Issues that concern them are

local / within control. Come up with ideas / solutions.

Value Modes Model copyright Cultural Dynamics

No segment is ‘better’ or more desirable than another. The characteristics and behaviours are all legitimate, as are the underlying values which drive them

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0

10

20

30

40

50

60

1972 1976 1980 1984 1988 1992 1996 2000 2004 2010

YEAR

PE

RC

EN

TAG

E

Note: Data pre-1988 is from TNS Monitor

Settler

Prospector

Pioneer

Over the past 40 years in the UK there has been a significant shift

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Survey research headlinesTrust, confidence, relationships

• 54% of older people don’t have confidence they can access the right health and care services when they need them

• An older person’s children are the second highest influence (next to GPs) in determining health care choices – but these influences vary widely by values segment

• Settlers have higher levels of trust in the health and care system than Prospectors and Pioneers

• 56% of GPs believe their relationship with social care is poor or very poor

• Only 25% of GPs trust the quality of social care provision in their area

• 47% of GPs feel they are a better assessor of need for residential care than social services

• 50% of GPs trust hospital discharge teams to make decisions in the best interests of their patients

• 91% of GPs would value a better relationship with social services

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Settlers and health/care services - characterisation

• Likely to be the biggest population for older people as age/frailty increases (although this is not yet fully tested/understood and somewhat challenged by the Sandwell pilot)

• Less likely to be strongly proactive about preventing ill-health unless an established norm in home, family and community setting

• Can be suffering in silence – acquiescing to what has been given• Pre-disposed to acceptance – can say they are satisfied, perhaps not feeling they have the

authority to challenge• Potentially angry after the event if treated badly. Often characterised by an ‘us and them’

paradigm and a feeling of being wronged

OVERVIEW

• A very high risk for urgent care – most likely to experience a crisis after suffering in silence

• Likely to ‘accept’ staying in hospital for longer than needed

• Likely to ‘accept’ a residential option if recommended

• Unlikely to be comfortable with novel features of integrated care

• May not take as much ‘control’ of their care as the NHS/Councils would like

• Professionals will continually need to scratch under the surface

URGENT/ACUTE INTEGRATION

“..no-one came and asked me”

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Pioneers and health/care services - characterisation

• A high sense of need, purpose• Intrinsically optimistic in many adverse circumstances• Empowered, confident people who want to lead full and active lives• An enormous social capital opportunity if engaged in the right way• Will not necessarily look at issues in the narrow confines of service professionals• Will react very strongly/powerfully if they are not engaged well (early and in the widest possible

terms)

OVERVIEW

• Likely to be a lower risk for urgent services (will actively seek the appropriate alternatives)

• They will be keen adopters of novel approaches

• They will be active, providing support, signposting for others

• What they think is important might not be the same as for health and care professionals

URGENT/ACUTE INTEGRATION

“..they are not doing anything to ensure a longer life is healthier”

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Prospectors and health/care services - characterisation

• Will be concerned about how any health and care offer affects them personally – this is not selfish as such – but reflects a way of trying to understand an offer

• They regard the health and care system as a maze – you need special knowledge and some sort of edge to get what you need – this group is most likely to ‘game’ the system (in legitimate ways)

• Will want to know their rights in a given situation – and how they (and others) can get the best deal

• They can be cynical about motives – as iMPOWER have found in many other public services they will think (right or wrong) that there may be a kind of financial ‘con’ in operation

OVERVIEW

• Likely to be a very high risk for urgent care attendances (although less so for lengths of stay once admitted)

• Currently they may rationally have figured out A&E is a good way to be seen

• If the offer is credible, liable to be the strongest early adopters for integrated care

• But they will need to be absolutely sure it is going to work before they give their full trust

URGENT/ACUTE INTEGRATION

“..you have to be a nuisance”

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Conclusion - there isn’t an app for this…

…but there is an evidence based way of drawing insight from population segments, trialling and rolling out change

Go to www.impower.co.uk for a copy of the report