Making a date for behaviour change

Every year the National Health Service loses a staggering £950m because of missed appointments, or DNAs (did not attends) – no-shows who fail to cancel their appointments. Twelve million GP appointments are missed at a cost of £162m and 7.1m hospital appointments at a cost of £788m. Not only do missed appointments incur financial losses in terms of underused specialists and equipment, and increased administration costs, but the patient population loses slots that are in high demand and the patients who DNA do not get the healthcare they need.

“Any reduction in DNAs will save money – which is good news for the NHS and good news for patients too.” says Peter Collins, Senior Stakeholder Strategy Manager at Pfizer Ltd, the UK division of the pharmaceutical multinational.

“We believe our CR strategy needs to focus on finding ways in which we can make a tangible difference to people’s health and to patients - we want to be the sort of partner that makes a positive, valued difference. We know missed appointments are a huge problem for the NHS and we want to support the NHS in finding a solution,” says Collins.

The company has carried out behavioural research to discover why patients behave the way they do.

“When patients miss appointments it is detrimental to both the NHS, the patients themselves and other people who are waiting for appointments,” says Collins. “Over the past 18 months, we’ve been looking into the causes of missed appointments. Working with the NHS and other healthcare organisations, our aim now is to develop and implement solutions that make a real difference to the problem.”

It is clear that current Appointment Management Systems (AMS) are incompatible with modern lifestyles, says Collins. “In this digitally connected age our lives are increasingly time pressured. We are used to exercising choice and control over our time - from when we make a hair appointment to when our groceries are delivered. At the same time growing pressure on the NHS means that fewer appointments are available, waiting times are increasing and patients’ appointments are cancelled more frequently.

Patients have told us they would like greater flexibility. “A simple measure,” he says, “may be letting patients see the available slots for their appointment and letting them choose one that best suits them. If you give people choice and control over their appointment they are more likely to commit to it as well as being more likely to show up if it is at a time which they have selected.”
However, while reasons patients miss appointments range from “too many other things to do” (1.8%) to “couldn’t get away from work” (9.2%), the most common reason is “forgot about the appointment” at 38.4%.

“Given that forgetting the appointment is the most common reason for DNAs it is perhaps extraordinary that less than 40% of patients receive reminders,” says Collins. “Many patients say that appointments being made too far ahead make them difficult to remember, so reminders are crucial.

“However, while we know that when they are used, reminders reduce outpatient DNAs significantly, we have also found that some reminders are more effective than others. The challenge is to discover the most effective wording and timing of reminders.”
Different patients are likely to respond to different types of message. The next step is to look at what message works for whom, says Collins, and to share that insight for the health services to use.

Pfizer is also looking at the value of more personalised communications. “Today’s digital communications are often tailored to our needs and interests, which makes us more likely to respond positively. Why not apply this approach to NHS appointments? If you receive a personalised communication, wouldn’t you be more likely to turn up on the day?” Collins points out.

“Our research shows that younger people would prefer a reminder the day before, or even the same day as, the appointment. Generally, the younger the patient the less notice they want.”

But while Pfizer is keen to get patients to respect the commitment they make when they book an appointment, a name and shame negative approach is not the answer, believes Collins. “It is not about blaming patients. There are lots of ways to encourage greater attendance by creating a more patient-centric approach.”

Moving forwards, Pfizer is running four pilot schemes this autumn to test practical approaches based on their findings. The first involves working with two hospitals and patient communications specialists DrDoctor to test the effect of different text reminders.
Secondly, in the north west of England, Pfizer is working with the service design agency LiveWork and a busy GP surgery with a wide demographic mix. Research will centre on the patient journey through the appointments system to see what the barriers are, and how behavioural techniques might encourage better attendance. “It might be a low cost solution such as asking the patient to write down their appointment. Or it might involve hi-tech solutions such as creating a more flexible approach to making appointments,” says Collins.

The third pilot centres on the very high levels of DNAs for outpatient appointments at hospices, such as holistic therapy sessions. “We’re focusing here on how to encourage greater attendance by capturing and reinforcing the positive impacts of both the treatment and the environment patients experience in the appointment reminders.” Says Collins “This is a part of the health care sector where there is limited research into DNAs. We are keen to share what we find about drivers of DNAs and potential resolutions with other hospices.”

The final area of concern is the number of screening appointments that are missed. “Our research showed that preventative and non-urgent appointments are more likely to be missed than other types of appointment,” says Collins. “There may also be psychological barriers because patients are afraid of the results. But screening saves lives and it is important to find effective ways to communicate the value of screening.

“We’ve known from the outset that we won’t make a difference to this issue unless we work together with the NHS and other important partners. The problem of missed appointments is not going away and the social contract between the public and the NHS will continue to be tested.

“We are not naive enough to believe we can solve this entirely,” he says. “But by digging deeper into the detail we have found that significant improvements are possible. We want to understand what practical solutions can encourage greater attendance and share what we have found. We want to create a platform for more solutions to be developed. Missed appointments are something that people feel really passionate about. So for us, this is a CR programme that is designed to create tangible benefits for the NHS and also generate real positive social impact over the long term.”

SHS247, date of preparation October 2015

This article was authored by Miranda Ingram from the Ethical Performance Best Practice editorial team. Pfizer Ltd has contributed both to the funding of this issue and also the content development of this article, however editorial control rests with the editor of Ethical Performance Best Practice.