Report to: Board of Directors Date of Meeting: 30 th September 2015 Report Title: Outpatient Report Status: Mark relevant box with X Prepared by: Executive Sponsor (presenting): Appendices (list if applicable): For Discussion Assurance Approval Regulatory information requirement X X X Phil Browne, General Manager - Surgical Services Group Julia Spencer, Patient Service Manager Outpatients, Orthopaedics and Visiting Specialties Stacey Hunter, Director of Operations Purpose of the Report To provide background context and inform the Executive Assurance Group of the progress and plans to achieve the 6% aggregate target for the Outpatient Department Key points for discussion Planned introduction of the Call Reminder Service Next steps for further development of technology based solutions Recommendation To receive and note progress and future plans for target achievement
Trust Rates Outpatient Department - Surgical Group 1.1 Introduction In common with many trusts across England, a significant amount of activity is lost through patient s or last minute cancellations (which preclude the rebooking of the vacated slot). s have a material impact on the local healthcare system in terms of cost and waiting time, significantly adding to delays along the patient pathway. These s in effect increase demand, without an associated increase in revenue, lead to inefficient delivery of care and increase the potential for increased patient waits. Research has suggested that the reasons for non-attendance are multi-factoral, citing reasons such as: - Socio-demographic factors which include: Age and gender Distance from hospital, GP/ CCG Deprivation Patient factors: No longer need to attend Too unwell to attend Employment Previous experience Seriousness of illness Nature of illness Childcare Cost of travel prohibitive Travel difficult to organise Public transport difficult to access Additionally hospital operational and procedural factors have been suggested to impact on rates, with patients citing the following: - Difficulty in cancelling appointments Poor appointment card design Lack of notification Short notification Organisation of clinics ( late running) Booking of appointments Time or day of appointment may be inconvenient Appointment types - new or follow-up Urgency of appointment Transport / parking
Clearly any unscheduled non-attendance results in a vacant slot, downtime, which by its nature cannot be filled and results in inefficiency and lost revenue. In addition to this it causes increased waiting time, not just for that individual patient themselves, but also indirectly for other patients who may have been able to attend that slot. Whilst there are a number of simple strategies such as overbooking of clinics that have high rates, these are often blunt tools, based upon basic statistical analysis, and do not address the underlying causes. With increasing pressures both on budgets and clinical urgent pathways e.g. Cancer there is an imperative for all organisations to ensure s and last minute cancellations are kept to a minimum The main aims for reducing s are as follows: - Reduce costs Promote efficient running of clinics Reduce variation Enable more effective booking Reduce mismatch between demand and capacity Increase productivity 2.1 Progress & Performance Summary The Trust has had for some time a self-appointed, internal target of 6% for aggregate rates for Out Patient Appointments. Despite a number of initiatives to improve the rates, particularly through the Right Care Programme, the rate remains stubbornly above the 6% target. Initiatives already in place include: - Text reminder service Choose and Book Improved public transport access and connectivity Whilst the failure to achieve this target is disappointing, Airedale continues to perform favourably against other local Trusts and healthcare providers. There has been notable 21% improvement from 9.16% to 7.20% since 2007 in 1 st Appointments (31.6% improvement or follow up appointments 13.00%), with the Trust consistently ranking no.3 against our local competitors. (NB in terms of context, this is set against an overall 63% increase in new attendances and an 81% increase for follow up attendances for the same period, 2007-2015) Performance Tables (Source: NHS England Unify2 Data Collection) April June 2007
Trust Seen Rate AIREDALE NHS FOUNDATION TRUST 6,582 603 9.16% BRADFORD TEACHING HOSPITALS NHS FOUNDATION TRUST 20,153 2,175 10.79% CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST 31,388 4,439 14.14% EAST LANCASHIRE HOSPITALS NHS TRUST 29,302 3,164 10.79% HARROGATE AND DISTRICT NHS FOUNDATION TRUST 9,938 569 5.72% LANCASHIRE TEACHING HOSPITALS NHS FOUNDATION TRUST 25,693 2,981 11.60% LEEDS TEACHING HOSPITALS NHS TRUST 42,034 4,914 11.69% YORK TEACHING HOSPITAL NHS FOUNDATION TRUST 17,780 837 4.70% ALL ENGLAND TRUSTS 3,414,917 327,866 9.60% Please note there is no avaiable information for Gisburne Park or the Yorkshire Clinic for this time. April June 2014 Trust Seen Rate AIREDALE NHS FOUNDATION TRUST 10,725 786 7.30% BRADFORD TEAC HING HOSPITALS NHS FOUNDATION TRUST 24,332 3,543 14% CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST 30,815 2,422 8.00% EAST LANCASHIRE HOSPITALS NHS TRUST 33,091 3,263 9.86% GISBURNE PARK HOSPITAL 1,345 340 25.20% HARROGATE AND DISTRICT NHS FOUNDATION TRUST 14,265 634 4.30% LANCASHIRE TEAC HING HOSPITALS NHS FOUNDATION TRUST 36,355 3,293 9.05% LEEDS TEAC HING HOSPITALS NHS TRUST 61,003 7,552 12.30% THE YORKSHIRE CLINIC 3,764 280 7.40% YORK TEAC HING HOSPITAL NHS FOUNDATION TRUST 31,195 2,221 7.10% ALL ENGLAND TRUSTS 4,505,395 424,100 9.41% April June 2015 Trust Seen Rate AIREDALE NHS FOUNDATION TRUST 10,739 780 7.20% BRADFORD TEAC HING HOSPITALS NHS FOUNDATION TRUST 25,228 3,416 13.54% CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST 28,935 2,578 8.90% EAST LANCASHIRE HOSPITALS NHS TRUST 32,145 2,281 9.45% GISBURNE PARK HOSPITAL NOT AVAIABLE HARROGATE AND DISTRICT NHS FOUNDATION TRUST 14,732 652 4.42% LANCASHIRE TEAC HING HOSPITALS NHS FOUNDATION TRUST 35,573 3,355 9.43% LEEDS TEAC HING HOSPITALS NHS TRUST 64,123 7,138 11.13% THE YORKSHIRE CLINIC 3,876 285 7.35% YORK TEAC HING HOSPITAL NHS FOUNDATION TRUST 32,145 2,281 7.10% ALL ENGLAND TRUSTS 4,585,169 423,142 9.22% In addition to previous initiatives, and as part of the Right Care Programme, the Trust is reviewing: Letter communications standardise and simplify Patient car parking increase number of spaces and reviewing charges Trust signage and wayfinding Discussion with other local providers who are performing consistently better than us suggest these initiatives will have a small but positive impact on s owing to improved patient experience. Perhaps of greatest significance will be the introduction of the call reminder service, which despite a number of technical delays will now go live on 5 th October 2015. The evidence supporting the
suggested improvements is contradictory. Whilst some studies suggest that such interventions are of limited use, first hand feedback of a number of Trusts that have introduced the same system have elicited significant reductions in their individual rates hence our decision to invest in this. 3.0 The Future The go-live for the call reminder service is planned for the 5 th October 2015. It is anticipated that this will, if benefits are realised in line with the reported benefits from other trusts such as Sheffield Teaching Hospitals NHS Foundation Trust and Ipswich Hospital NHS Trust, and the review undertaken by Healthcare Improvement Scotland in 2012, result in the achievement of the 6% target. At implementation/deployment of the call reminder service, each of the specialities/services will be set an individual target in terms of expected improvement in their percentage. This will be designed to reflect differences in patient populations and therefore some of the socio economic and patient factors whilst overall achieving an aggregate Trust wide performance of 6%.; Progress against individual trajectories will be monitored and tracked via the monthly OPD Programme Board as well as at the relevant Divisional Assurance Group ( DAG )performance reviews. This will be triangulated with financial performance in order that delivery against the CIP can be measured and managed. The gains already outlined in this paper will deliver a significant contribution to the achievement of the Right Care OPD Financial Targets as well as improve the experience for staff and patients. However, as previously referenced there is conflicting experience regarding the efficacy of a call reminder with the type of generic messaging currently proposed. Anecdotal evidence suggests that rather than a generic message a personalised version may be more effective in terms of influencing individual behaviour. Whilst such personalised reminders have been affectionately termed nudging this simple term should not detract from the potential such reminders have for altering patient behaviour. There is anecdotal evidence that suggests rates are unaffected but that the derived benefits from reduced cancellations should not be disregarded in terms of positive contribution towards increased efficiency in OPD departments. (see attached case study) As part of the Right Care Programme the OPD Programme Board will explore the evidence and the options available to the Trust to utilise available technology to adapt and personalise messages including the opportunity to increasingly use social media accounts to interact and communicate with patients. This will include exploring the feasibility of development of apps allowing facilities such as the electronic management of appointment booking, cancellation and re booking of appointments, along with ensuring technologies such as E-consults and Telemedicine become standard offers to patients as well as face to face consultations. This work is part of the scope of the Outpatient Transformation programme for the next 2 years. 4.0 Summary It is expected that by the end of Qtr.4 2015/16 the OPD aggregate target for s of 6% will be achieved following a successful implementation of the call reminder service, with associated
financial targets for 2016/17 being met going forwards. However, in line with recent evidence the OPD Right Care Board will continue to investigate more technological based solutions to patient attendance, including nudging through more personalised patient contact. The Project Board will work closely with in particular the Digital Care Programme to develop and invest in affordable technologies to further enhance the patient experience of OPD appointments, through face to face and/or virtual attendance; progress will continue to be reported through the Right Care Portfolio Board. Case Study A holiday reading list of Edward Rose, including Freakonomics and Nudge left him wondering how behavioural economics could be better applied in the NHS. As a result a small experiment was undertaken, by Ed, in the services managed at an NHS acute hospital. Gone were the generic reminders with their abrupt sentences and dubious grammar. In came five messages based on behavioural theory. Message Type Loss-framed (personal) Loss-framed (collectivist) Gain-framed (personal) Conformity Heuristic Authority Scarcity and Liking Heuristics Message text <dd> at <hh>. Please text back CANCEL if your appointment is no longer needed or text REBOOK if you want to reschedule. If you miss your appointment without informing us, you may be discharged back to your GP <dd> at <hh>. Each unused appointment costs the NHS < cost of missed appointment>, and means other patients have to wait longer to be seen. Please text back CANCEL if your appointment is no longer needed or text REBOOK if you want to reschedule <dd> at <hh>. By attending your appointments you may improve your health, and can also ask any questions you have to your doctor. Please text back CANCEL if your appointment is no longer needed or text REBOOK if you want to reschedule. <dd> at <hh>. Last week 95% of patients at <hospital name> attended their appointment or cancelled in advance. Please do the same - text back CANCEL if your appt is no longer needed or text REBOOK if you want to reschedule I just wanted to remind you that you have an appointment in one of our clinics at <clinic> on
<mmm> <dd> at <hh>. We are looking forward to seeing you. Please text back CANCEL if your appointment is no longer needed or text REBOOK if you want to reschedule as we are usually fully booked. Dr <doctor s name> MRCP MS (Neurology Clinical Director) The results were unexpected. None of the messages made a dent in rates. But digging into the data, it became clear that one had produced an unintended effect. For the message playing on authority, liking and scarcity, there was a statistically significant reduction in cancellations of over a third (p<0.001). This was mirrored by a corresponding rise in attendances. In other words, the type of people who tended to cancel when receiving a generic message were instead attending when they received a tailored message. So what to make of these results? Well to me they suggest that once basic text reminders have been applied, rates are actually very difficult to shift no matter how many sophisticated behavioural theories you employ. Many clinics will simply have a residual rate of 8% or so. Given this we should simply do what the restaurant and airline industries have been doing for decades predict the likely drop-out rate per clinic and over-book so we don t waste resources. But when it comes to cancellations, it looks like we can influence behaviour. The literature suggests many patients cancel simply because of other commitments, but by virtue of the fact they cancel we can assume they are quite conscientious. For this group, receiving a personal text from a highly-qualified consultant, reading that this consultant is looking forward to seeing you, and remembering just how scarce these appointments are may be enough to influence a readjustment of priorities. Whilst this would be of little value in many settings, the advantages for screening programmes or certain high-risk clinics could be significant. The experiment involved almost 9,000 patients, but this doesn t mean the results should be interpreted as proof of one method working everywhere. Tiny shifts in the type of person you re trying to influence, the words you use, the communication method you employ all of this can bring big changes in results. In recent years similar experiments have been run at other acute trusts and the results have always differed depending on the messages and hospital. But what the experiment should show you is that you don t have to be told what to do. You ll know your own clinics the patients that attend them, the types of conditions they might have, and the reasons they might not attend. So don t wait around for someone to tell you what works best. Read up on the evidence, talk to colleagues, and try experimenting. Don t wait for permission. When you re done, spread the news so other people can give it a try. Some experiments will show that an intervention works. Some will show one doesn t. But if we all tried out even just one idea, we would all learn a huge deal about how to make the NHS that bit better.