Simple behavioural interventions: reducing non-attendance Provided by: NHS Bedfordshire Publication type: Quality and productivity example Sharing QIPP practice: What are Proven Quality and Productivity case studies? The QIPP collection provides users with practical case studies that address the quality and productivity challenge in health and social care. All examples submitted are evaluated by NICE. This evaluation is based on the degree to which the initiative meets the QIPP criteria: savings, quality, evidence and implementability. The first three criteria are given a score which are then combined to give an overall score. The overall score is used to identify case studies that are designated as recommended on NHS Evidence. The assessment of the degree to which this particular case study meets the criteria is represented in the summary graphic below. Proven quality and productivity examples are case studies that show evidence of implementation and can demonstrate efficiency savings and improvements in quality. Evidence summary Page 1 of 6
Details of initiative Purpose Description (including scope) Topic Other information To reduce the number of appointments wasted through patients not attending and failing to notify the organisation in advance. Missed appointments are a large source of inefficiency in the NHS: around 6 million appointments are wasted each year, at an estimated cost of 700 800 million (Martin et al. 2012). This initiative trialled a package of simple interventions, based on behavioural science, to increase patient attendance in a primary care setting. Reception staff at 2 primary care sites in NHS Bedfordshire were trained to implement 3 interventions. They were given time to reflect on the changes and ask any questions. Clinical staff were also briefed on the changes. The package of 3 interventions successfully reduced the number of appointments wasted by patients who did not attend (DNA) by 31.7% (124 appointments per month in total across the 2 sites). The interventions included: on the telephone, reception staff asking patients to repeat back verbally the day and time of the appointment they are given before completing the call in the primary care setting, providing patients with a card to write the details of their appointment themselves rather than a receptionist, nurse or doctor doing so replacing the poster highlighting the number of missed appointments with a poster that showed the much larger number of patients who do turn up on time. Reports 12 months after implementation show that a reduction in the DNA rate of about 30% has been maintained. Back office efficiency, primary care and productive care. DNAs can lead to increased waiting times and costs. With GPs preparing to commission services, the ability to engage with and persuade patients to take greater responsibility for their health and to use services appropriately will become increasingly important. Savings delivered Amount of savings delivered 124 appointments per month were no longer wasted. If the findings are replicated nationally, this would free up the equivalent in terms of productivity of 471 whole time equivalent (WTE) healthcare professionals. Based on a 50/50 mix of GPs and practice nurses, this would mean a saving of 31.8 million or Page 2 of 6
62,000 per 100,000 population. Type of saving Any costs required to achieve the savings Programme budget Supporting evidence Minimal impact on cash, but high levels of improved productivity. Can be achieved with minimal additional resources, although time needs to be allocated to training reception and clinical staff. This takes a maximum of 2 hours, comprising an initial training session of 1 hour and a refresher session 2 weeks later. This investment of time will be quickly recouped through improved productivity. Other. The following data were used to calculate the productivity savings for this example: the 2 sites provide 10,200 appointments per month between them. Of these, an average of 392 appointments DNA per month, giving a DNA rate of 3.8%. the DNA rate was reduced by 31.7% (124 appointments per month) across the 2 sites. average GP consultation is 10 minutes. average nurse consultation is 15 minutes. average NHS Bedford clinical surgery is 3 hours. a 30% reduction in DNAs across NHS Bedford is equivalent in hours saved to 3.08 WTE healthcare professionals. scaled across NHS England = 3.08 x 153 NHS Trusts = 471 healthcare professionals. These estimates are for primary care only. It is possible that these results could be replicated in secondary care. Quality outcomes delivered Impact on quality of care or population health Impact on patients, people who use services and/or population safety Impact on patients, people who use services, carers, public and/or population Outcomes may be improved because patients are less likely to forget to attend appointments and therefore more likely to get the treatment they need. Previous research has shown that missed appointments are associated with sub-optimal management of long-term conditions (Karter et al. 2004). Outcomes data have not been gathered for this initiative. Slight improvement to patient safety as changes in patients' conditions are more likely to be spotted if appointments are kept. The patient experience will improve slightly because more efficient use of available time means they can be seen more quickly. Page 3 of 6
experience Supporting evidence Karter et al (2004) Evidence of effectiveness Evidence base for case study Evidence of deliverables from implementation Where implemented Degree to which the actual benefits matched assumptions If initiative has been replicated how frequently/widely has it been replicated Supporting evidence Although this is a novel combination of interventions to reduce DNA rates in a primary care setting, the initiative is based on published research that demonstrates the effectiveness of written commitments (Cioffi and Garner 1996) and positive social normative messages (Schultz et al. 2007) on changing behaviour. The initiative was implemented at NHS Bedford, with published, systematic reporting of results (Martin et al. 2012). It was also featured in the Cabinet office behavioural insights team annual update (2011). Wheatfield Surgery NHS Bedfordshire. Toddington Medical Centre NHS Bedfordshire. Before implementation it was not known how effective the measures would be, but the observed 31.7% reduction in nonattendance was very positive. The initiatives have been disseminated to 3 newly formed clinical commissioning groups across London representing over 140 practices, although results have not yet been provided. Martin et al. (2012). See contacts and resources. Details of implementation Implementation details Receptionists at 2 primary care sites were trained to implement small changes to the process of booking appointments for patients, depending whether they were booked over the phone or in person. The training sessions included reception staff supported by the partners and the practice manager. The training focused on the rationale for the interventions and the practicalities of applying them. Training was held 2 weeks before starting the interventions, which allowed staff a period of time to reflect, ask questions and raise any concerns. The changes included: asking patients booking appointments by telephone to repeat back verbally the day and time of the appointment they are given Page 4 of 6
providing patients booking appointments in the primary care setting with a card to write the details of their appointment themselves rather than a receptionist, nurse or doctor doing so (previous research has shown that a written commitment to undertake an action results in a lower rate of failure to undertake the action; Cioffi and Garner 1996) replacing the poster highlighting the number of wasted appointments with a poster that showed the much larger number of patients who do turn up on time (this was inspired by previous research demonstrating that highlighting positive or negative behaviours normalised them and increased that type of behaviour; Schultz et al. 2007). A variation on the appointment card intervention above would be to get patients to record the appointment on their smartphone (if available), although this has not been tested. Ongoing implementation in the study centres and subsequent roll out has been managed primarily by the practice managers after a short training session. Time taken to implement Ease of implementation Level of support and commitment Barriers to implementation Risks 0 6 months including planning and training. Changes affect both administrative and clinical staff within a primary care organisation. The initiative received a mixed reaction from reception staff who had to alter their normal practice and needed to be convinced of the benefits. This was overcome with training. Reception staff may need to be convinced during training of the benefits of the changes through highlighting the problems of DNA rates and the benefits of a more efficient service. There may be a perception that missed appointments provide an opportunity to catch up on other work, and that reducing missed appointments could reduce the time available for these tasks. To overcome this barrier it is worth explaining two key points: missed appointments are unpredictable, so it is more efficient to schedule dedicated time for other work a DNA patient is rarely a clinical issue resolved. The patient is likely to turn up somewhere else in the system, often at a more costly point of service (for example A&E) and potentially with a worsened condition. These factors can lead to an increase in the cost of care and make it harder to plan workloads effectively, so it is better to reduce the DNA rate and reallocate the time appropriately. There is a risk that a significant reduction in DNA rates could cause problems if appointments are currently over booked to Page 5 of 6
compensate for DNAs. If this is the case, fewer appointments will need to be booked to ensure that a 30% reduction in DNA rates can be accommodated. Supporting evidence Martin et al. (2012). Further evidence Dependencies Training for staff to implement the new measures. Training takes around 1 hour and ideally should be led jointly by a clinician and a member of the administrative team to improve buy-in from those groups. A refresher 2 weeks later is also recommended, before implementation, to allow time for reflection and questions. A slide set to facilitate training is available on request (please see Contacts and resources). Contacts and resources Contacts and resources If you require any further information (including the slide set to facilitate training for this initiative), please email: qipp@nice.org.uk and we will forward your enquiry and contact details to the provider of this case study. Please quote QIPP reference 12/0008 in your email. Cabinet office behavioural insights team (2011) Behavioural insights team annual update 2010 11. Cioffi D, Garner R (1996) On doing the decision: effects of active versus passive commitment and self-perception. Personality and Social Psychology Bulletin 22: 133 44 Karter AJ, Parker MM, Moffet HH, Ahmed AT (2004) Missed appointments and poor glycemic control: an opportunity to identify high-risk diabetic patients. Medical Care 42: 110 15 Martin SJ, Bassi S, Dunbar-Rees R (2012) Commitments, norms and custard creams a social influence approach to reducing did not attends (DNAs). Journal of the Royal Society of Medicine 105: 101 4 Schultz PW, Nolan J, Cialdini RB, Goldstein NJ, Griskevicius V (2007) The constructive, destructive, and reconstructive power of social norms. Psychological Science 18: 429 34 ID: 12/0008 Published: 29 January 2013 Last updated: 29 January 2013 Page 6 of 6