Missed appointments (Did Not Attends or DNAs) still remain a systemic issue that leaves thousands of appointments wasted each year. 7.5 million hospital appointments were missed in 2021/2022, costing hospitals both time and resources. At a cost of approximately £120 each to the NHS, this equates to almost £1bn.
Aside from the clear financial implications, missed appointments also hold back elective recovery efforts for trusts. Reducing missed appointments is therefore essential to ensuring that patients on the waiting list can be seen more quickly.
But why do so many patients miss their hospital appointments?
Academic research on DNAs typically highlights reasons such as forgetting appointments, transportation difficulties, or family commitments. But, for a given NHS trust it’s likely that causes of missed appointments are - at least in large part - specific to that trust or even service.
Without a strong understanding of the underlying reasons behind missed appointments it is difficult for trusts to tackle them. This is why we have joined forces with a large NHS Trust to ask patients directly why they missed their appointment, so that the Trust can introduce initiatives to reduce their DNAs. In this blog post we discuss some of the reasons that came to light and how the Trust we partnered with, and other trusts, might act on them to help elective recovery efforts.
Exploring patient experience
We built a single-question survey asking patients to share the main reason for missing their appointment. The survey was sent by the Trust via our online text messaging platform, to over 9,000 patients who missed an appointment across all services over July and August. Some key insights emerged from the 3,800 responses (a response rate of 41%).
Key insight 1: The single biggest reason was 'not knowing they had an appointment'
The most interesting finding was that 23% of respondents - almost 1 in 4 - were unaware they even had an appointment scheduled. This suggests a major communication breakdown in the way the hospital is letting patients know about their appointments. Trusts clearly need faster, simpler ways to communicate with patients ahead of appointments taking place, so they are less likely to DNA.
To better ensure patients are aware of their upcoming appointments, trusts could take the following steps:
- Ensure all patients' contact details are accurate and up to date so they receive appointment information
- Employ a mix of communication methods to let patients know about their appointment. Trusts often rely on traditional letters sent via post to let patients know that they have an appointment, but this should be accompanied by other forms of communication such as text messages
Key insight 2: 10% of patients tried but struggled to cancel or reschedule their appointment
Around 10% of patients said they tried to cancel or reschedule their appointment but struggled to do so. We often hear from trusts that this is, at least in part, because patients find it hard to get through to a trust on the phone to cancel. It is important for trusts to provide an easy and reliable way for patients to cancel or rearrange their appointment. The following could make a big difference in streamlining the process:
- Implement a Patient Portal across the hospital, giving patients easy, fast ways to manage their appointments and their own care more effectively. Patients can view appointments surfaced from a trust’s PAS (Patient Administration System), and request to amend or cancel appointments through a single point of contact
- Trusts who don’t have a patient portal in place need another way to enable patients to let the service know that they can no longer make their appointment quickly and easily. This can be achieved via an online link that could be sent in reminder messages. This will remove the friction often associated with trying to get through to a busy phone line to let the trust know that they can’t make their appointment
Key insight 3: Disadvantaged groups were much more likely to forget their appointment
About 12% of patients admitted that they simply forgot about their appointment. This response was much more common among disadvantaged groups. This discrepancy might be partly attributed to the behavioural concept of 'scarcity’ whereby constant juggling of limited resources and pressing concerns that individuals from deprived backgrounds often face might create a cognitive load that limits their capacity to remember appointments, as their attention is divided among various matters.
This data suggests that at least some patients aren’t receiving appointment reminders, or if they are then perhaps these reminders aren’t being registered by patients or maybe they aren’t being sent at the right time. Trusts could implement the following ideas to improve appointment attendance amongst disadvantaged groups:
- Ensure that all patients with a mobile phone receive regular reminders of their appointments via SMS, which include key information such as the date, time and location, and consider adding additional reminders for patient groups who might be more likely to forget their appointment.
- Ensure that reminders are sent at the right time - i.e. with enough notice for patients to rearrange other plans, arrange back-up care for children or relatives, or to cancel the appointment, but also close enough to the appointment that it acts as a useful memory prompt.
- When a patient’s appointment is confirmed, offer patients the digital option to add the event to their calendar, to act as an additional prompt. This functionality already exists within Accurx, and could be a useful tool for patients.
Key Insight 4: Medical and mobility challenges were often cited, but this varied considerably by patient group
Overall, a notable 10% of patients cited medical or mobility issues that prevented them from reaching the hospital. This was much more pronounced among older patients, as demonstrated in the graph below which shows the contrast between patients aged 17-30 and patients aged 80+.
There are things that trusts can do to better support patients with medical or mobility issues:
- Provide clear information about the assistance available at the hospital, such as wheelchair services or patient transport. This can be sent within an appointment reminder message, as an attachment or link
- Ask patients to let the trust know in advance about any medical conditions or mobility issues they have so that the trust can arrange extra support. This information can be asked for in text message appointment reminders that allow patients to respond. Accurx has already developed a questionnaire to support trusts in gathering this information, which is currently being piloted at a large NHS Trust
- Where appropriate, routinely offer patients the option of a telephone or video appointment as an alternative to a face-to-face appointment for patients with medical or mobility issues.
Next steps and future projects
This project yielded invaluable insights from almost 4,000 patients. While a single solution may not exist to tackle DNAs, the Trust is in a much better position to develop targeted interventions armed with a richer understanding of why their patients miss their appointments.
We plan to continue working together with this Trust, and others, to implement some of the solutions we mention in this blog (and many more). Harnessing digital technology to better understand patients and then applying insights from behavioural science to tackle the issues can help reduce DNAs, as well as help trusts on their journey to elective recovery.
If your trust is struggling with high DNA rates and would be interested in partnering with us in a project like this, please get in touch with us at email@example.com or view our solutions for secondary care here.