Using Segmentation analysis to drive behaviour change around A&E access

1. Using Segmentation analysis to drive behaviour change around A&E access Thursday 9th June 2011 Mandy Clair, Public Health Intelligence Analyst

2. Content • Background and context • Segmentation “revision” • Method • Analysis • Campaign Approach • Impact

3. Background • Attendance at Walsall Manor hospital A&E unit by local residents cost around £6.5m a year. • Over 50% are self referrals AND are discharged with no action on onward referral for care. • A perception that these attendances are not necessarily warranted or can be dealt with more appropriately and at lower cost in the community. Working towards • A local campaign to address symptoms recognition and signposting appropriate services could reduce A&E traffic and costs that could be utilised elsewhere.

4. Methods/Approach • Data on A&E attendances from Walsall resident who are registered patients in Walsall were extracted from HCS for 1 year period (total records= per ‘000s). • Analysed using a market segmentation data set called ACORN and software (INSITE) • Segmentations were grouped at geographical and practice-based levels to allow for different approaches to market the awareness campaigns. • The above informed a 3-pronged marketing approach: • General Population Information • GP Based Awareness • South Asian Population

6. Segmentation ‘Revision’ What is market segmentation?(and what is our market?) “The process of splitting customers, or potential customers, in a market into different groups, or segments, within which customers share a similar level of interest in the same or comparable set of needs satisfied by a distinct marketing proposition.” OR “The process of dividing a total market into subgroups of consumers, or potential consumers, who are similar in some way.” OR “A way of analyzing a market by specific characteristics in order to create a target market.”

7. What is market segmentation?(and what is our market?) Fundamentally it’s a process by which we can gain a deeper insight and understanding of the characteristics and behaviours of our consumers (patients/service users), particularly as to how they utilise and interact with services and respond to different information and media messages.

8. What is market segmentation?(and what is our market?) Our “market” can be: • geographical areas e.g. GP Practices, Communities • patient cohorts e.g. Obese children, AE patients • an entire population e.g. Walsall borough • users of a service e.g. smoking cessation • those at potential risk of adverse health outcomes e.g. risk stratified CVD ….and anyone else who we would wish to target with information or services

9. Some potential uses for market segmentation • Inform social marketing & Health Promotion • Inform media campaigns / public engagement • Inform service development • Demand management • Increase general understanding of our population

10. How do we segment our markets?Classification: ACORN Around 400 variables go into the postcode classification including census, credit, consumer, survey and other proprietary data. Hierarchical approach: • Categories (n=5) • Groups (n=17) • Types (n=56) Each with their own description and definition Denoted as code e.g. 5.N.47 which is described as “Low income families on terraced estates”

11. How do we segment our markets?Classification: ACORNhttp://www.caci.co.uk/acorn2009/CACI.htm

12. Analysis A&E Admissions • Analysis highlighted several ACORN groups within Walsall that were using A&E unrepresentatively compared to the underlying population, and several practices with markedly higher use from their practices.

13. A&E Admissions by Postcode Walsall Grouped by ACORN categories

14. ACORN Profile: Walsall

15. Acorn Profile: A&E

16. Segmentation of A&E • From the analysis we found that Patients who self referred and discharged with no action to A&E from the Groups are “Asian communities”, “High-rise Hardship”, “Burdened Singles” and “Struggling Families”. • Further segmentation analysis was done and pen portraits were produced. For each of these key categories, and also for high usage practices.

17. General Practice : Practice X • ACORN: • ACORN is a population segmentation dataset that contains information on 400+ variables. Every postcode in the country is grouped according to their shared characteristics into 5 categories (broken down into 17 sub-groups and 56 sub-types). • Each category, group and type are named and brief descriptions of that specific population are provided in the ACORN user guide: http://www.caci.co.uk/acorn2009/CACI.htm • By applying these classifications to the A & E dataset and comparing to the underlying population profile we can determine which segments of the practice population are likely to use A & E services and be retained in acute health services as a result. • Accident & Emergency usage: • Practice Population : 4290 registered Patients • There were over 2000 A&E attendances from patients who are registered at the practice in 2009/10, of which 85% were self referral. Over 1100 of the attendance who self referred were discharged who did not require follow up treatment, left before being treated or refused treatment. 70% of these type of attendance were from the 3 ACORN groups:- • 3H Secure Families • 4K Asian Communities • 5N Struggling Families • The total cost of self referrals made by patients in this practice in 09/10 was approx £145,000. Of those attendances resulting in no follow-up, cost from the 3 groups above was approximately £63,000.

18. General Practice : Practice Y • ACORN: • ACORN is a population segmentation dataset that contains information on 400+ variables. Every postcode in the country is grouped according to their shared characteristics into 5 categories (broken down into 17 sub-groups and 56 sub-types). • Each category, group and type are named and brief descriptions of that specific population are provided in the ACORN user guide: http://www.caci.co.uk/acorn2009/CACI.htm • By applying these classifications to the A & E dataset and comparing to the underlying population profile we can determine which segments of the practice population are likely to use A & E services and be retained in acute health services as a result. • Accident & Emergency usage: • Practice Population : 8367 registered Patients • There were over 3000 A&E attendances from patients who are registered at the practice in 2009/10, of which 80% were self referral. Over 1600 of the attendance who self referred were discharged who did not require follow up treatment, left before being treated or refused treatment. Three quarters of these attendances were from the 3 ACORN groups:- • 3H Secure Families • 4K Asian Communities • 5N Struggling Families • The total cost of self referrals from patients in this practice in 09/10 was around £210,000. Of those attendances resulting in no follow-up, cost from the 3 groups above was approximately £100,000.

19. ACORN Group H Secure Families Insight: Houses are typically mortgaged semis with two or three bedrooms. Traditionally these neighbourhoods experience low unemployment, but the numbers claiming jobseeker’s allowance increased during the recession, and although still below average, unemployment is increasing. Residents are more likely to consider these to be close communities where people share the same values. These are felt to be safe areas and people tend to think it fairly unlikely they will themselves be a victim of crime. Neighbourhood Description: These are home-owning families living comfortably in stable areas in suburban and semi-rural locations. They mainly live in three-bedroom semi detached homes. Families might include young children, teenagers or even young adults who have not yet left home. The school children tend to get slightly better-than-average exam results. Within this group, there are also some neighbourhoods with high numbers of comfortably-off Asian families. People are employed in a range of occupations, including middle management and clerical roles. There are also reasonable numbers of shop workers and skilled manual workers. Incomes are at least of average levels and many earn well above the national average, most people in this group have some small savings and would consider themselves financially prudent. The more affluent will have good company cars and will have built up somewhat greater levels of savings and investments. Spending on alcohol and tobacco is below average. These are the stable suburban families that make up much of middle Britain. Population Characteristics Population: 17.3% of Walsall registered population Proportion of ACORN group: 9.9% of Walsall GP Population Newspaper: Daily Mail & Daily Express Housing: Semi Detached 3-4 bedrooms Employment: Middle management and clerical roles Shop Workers and Skilled Manual Worker, Low Unemployment Income: £20,000-£40,000. Education: GCSE’s Or A Levels Equivalent Dependants: 2-3 children Superstore: Asda, Morrisons Interests & Hobbies : Socialising, Holidays, Cinemas Transport: 1-2 cars, foot/bike/other means

20. Acorn Group K Asian Communities Insight: Many people are still employed in traditional, blue-collar occupations. Others have become employed in service and retail jobs as the employment landscape has changed. These areas of low-priced housing have some of the highest concentrations of first-time buyers, and a high proportion might have self-certified their incomes. Unemployment levels are much higher than average, also these areas have some of the highest numbers claiming jobseeker’s allowance. Their religion is very important to them and religion-related activities provide much of their social contact. They are unlikely to go on holiday often, but when they do, long-haul trips, perhaps to visit family, are popular. Neighbourhood Description: These are poor urban areas where poorly paid young people and a relatively high concentration of Asian families are key characteristics. These young families live in the terraced streets with a lots of children and there are the highest levels of children under the age of five. There may also be a number of students and first-time buyers living in the low-cost housing in these areas. Overall, qualification levels tend to be low and unemployment levels are high. The number claiming jobseeker’s allowance is double the national average but rising more slowly during the recession than in any other group. People typically work in routine manual roles or in the retail sector, and typically work more overtime than average. However most women tend to be at home bringing up their young families. The combination of high unemployment, many children and the low incomes of those in work, means that over a third of the total income of these streets comes in the form of benefits such as jobseeker’s allowance, child benefit, housing benefit and tax credits. They spend more than any other group on home multimedia entertainment. Less ability to afford broadband connections, and possibly generational differences, may be the reasons for frequent use of internet cafés. Population Characteristics Population: 6.5% of Walsall registered population Proportion of ACORN group: 23.6% of Walsall GP Population Newspaper: Daily Mirror, News of the World Housing: Terraced Housing Employment: Never worked & long-term unemployed Manual Skills Communication: Postal Mail or Door to Door Visits. Transport: 0-1 cars, foot/bike/other means Income: £0-£30,000. Education: No Qualifications Dependants: 4-5+ children Superstore: Asda, Sainsbury’s Expenditure: Food and Alcoholic beverages and tobacco Interests & Hobbies : Cinema, Cookery and DIY

21. Acorn Group M Blue-Collar Roots Insight: These people look at the world through ‘Big Headlines’, they read the Red top newspapers. They live in deprived communities and life for them is not easy. Of the many concerns on a day to day basis they are unlikely to perceive their health status as a serious problem. Incomes are moderate rather than low. Levels of educational qualifications are generally low. Car ownership is below the national average and many people travel to work on foot or cycle. Hobbies and pursuits tend to be less physically active which, coupled with high expenditure on alcohol, tobacco & fast foods lead to poor health. Neighbourhood Description: These are communities where most employment is in traditional blue-collar occupations. Families and retired people predominate with some young singles and single parents. Most property is two or three bedroom terraced housing. Many are being bought on a mortgage although renting from private landlords, local authorities and housing associations is common in some areas. Levels of educational qualifications tend to be low. Most employment is in factory and other manual occupations. There are many shop workers as well. Incomes range from moderate to low and unemployment is higher than the national average, as is long term illness. There are pockets of deprivation in this group. Car ownership is below the national average, and cars tend to be lower value and often bought second hand. Some of the better off areas within this group have modest levels of savings and investments, but many find it hard to save regularly from modest incomes. There are some households with high levels of debt. The tabloid press is favoured reading and other interests include camping, angling, bingo and horseracing, as well as watching cable TV and going to the pub. These people have a modest lifestyle but most are able to get by. Population Characteristics Population: 4.6% of Walsall registered population Proportion of ACORN group: 6.9% of Walsall GP Population Education: GCSE Level Housing: Housing over shop, Terraced Income: £10,000-£20,000 Dependants: Singles/single parents Communication: Postal Mail ,Door to Door Visits or SMS Transport: 0-1 cars, bike & foot Superstore: Morrison's (<£50/week) Finance: Loans or refused credit Newspaper: Daily Star/Daily Mirror/The Sun Hobbies: Computer Games, Rugby On-Line: Less than Average Occupation: Routine (index 135) Males F/T, Females F/T or P/T

22. Struggling Families ACORN Group N Insight: These people look at the world through ‘Big Headlines’, they read the Red top newspapers. They live in deprived communities and life for them is not easy. Of the many concerns on a day to day basis they are unlikely to perceive their health status as a serious problem. Hobbies and pursuits tend to be less physically active which, coupled with high expenditure on alcohol, tobacco & fast foods lead to poor health. Neighbourhood Description: Some people may be in poor health. General health problems, for example with climbing stairs, or walking any distance, may approach the levels found in areas with older populations. There are many smokers. Incomes are low and unemployment high. Jobs reflect the general lack of educational qualifications and are in factories, shops and other manual occupations. A combination of large families, illness, single parents, high unemployment and low incomes means that a significant proportion of the total income comes from benefits such as jobseeker’s allowance, child benefit, housing benefit and carer’s allowances. There are fewer cars than most other areas. Money is tight and shopping tends to focus on cheaper stores and catalogues. Visiting the pub, betting, football pools, bingo and the Lottery are the principal leisure activities. Population Characteristics Population: 34.7% of Walsall registered population Proportion of ACORN group: 27.0% of Walsall GP Population Newspaper: Daily Star & The Sun Housing: Terraced, Semi-detached Council rented accommodation Employment: Looking for Work & Long term ill Mainly Routine Occupations. Communication: Telephone or Postal Mail or Door to Door Visits. Transport: 0-1 cars, foot/bike/other means Income: £0-£20,000. Education: No Qualifications Dependants: 2-3 children Superstore: Asda, Lidl, Aldi Expenditure: Alcoholic beverages and tobacco Interests & Hobbies : Bingo and Gambling

23. Marketing Approach: • Advert costs kept low - £25K approx for winter campaign • Targeted GPs/GP packs • Information on their patient usage of A&E • Their Population segmentation profile • Positive response received from GPs • New way of working • Areas of increased communication included the Asian population. • Radio advertising • DVD in Urdu and Punjabi • Leaflets to over 10,000 homes.

28. Issues raised through GP Work: • Practice Managers were surprised that some of their patients were self presenting at A&E. Genuine issues or data coding issues?? • Lengthy debate took place. The meeting was advised that once a patient attended A&E, their GP was/was not notified of the visit. It was agreed to look at the PCT issuing a routine report of A&E presenters to GP practices. • The GP group agreed that this seemed an effective way of raising awareness to Walsall residents and it had been well received with their patients.

29. IMPACT • Too Early to tell • The project is not yet progressed to allow formal evaluation against outcomes • (Of Target groups and GPs) we are yet to analyse usage of information post campaign compared to equivalent historic period. • Feedback through GP awareness exercise indicates a much greater understanding of their “population”, “behaviour” and importantly how that impacts financially on the commissioner of A&E services in the future.

30. Thank you Questions? Mandeep.clair@walsall.nhs.uk Acknowledgements:- Jane Hayman, Public Health Dept, Communications Dept.