Guidance

Screening text message principles

Updated 5 April 2022

Applies to England

These principles were developed as part of the national screening inequalities strategy to support NHS screening services to make the most effective use of text message (SMS) reminders for screening appointments.

Existing evidence (such as this rapid review of cancer screening participation interventions) suggests text message reminders can:

• be highly cost effective
• play a significant role in removing barriers to screening, for instance by preventing people forgetting about an appointment, and therefore increasing uptake among people who want to be screened
• have an impact on reducing screening inequalities

Text messaging should support the established population screening principle of personal informed choice. This means that text messages should not be coercive but should provide clear and accurate information to support people to attend who wish to do so. They are to help remove practical barriers, not to change people’s minds.

Text messages are also not meant to duplicate information about screening, which is already available to the public, but should signpost people to the online versions for more information.

There is not much guidance around the practicalities of text messaging, such as their content and timing. These principles are based on an assessment of current practice and feedback from local screening services, academics and other experts. This took place through the PHE Screening blog and a national text messaging workshop, as well as an academic expert consensus (Delphi) study with Imperial College London.

This guidance aims to provide a helpful starting point for thinking about sending text message reminders for screening appointments. It is not meant to be too prescriptive and we acknowledge that text messages may be sent by different parts of the system, such as screening services or primary care. It is important to consider that messaging technology may develop in the future, for example through the use of Rich Communication Services (RCS) or app-based messaging. While the role of SMS may therefore change, many of the principles outlined here should be relevant for other message technologies.

We will keep this guidance under regular review. Please contact the screening helpdesk with:

• any comments or feedback on these principles and the recommended text message wording
• the findings from any local evaluations into the use of text messaging.

1. Message delivery

1.1. Make every effort to collect and maintain accurate records of people’s phone numbers through your local trust and GP practice IT systems. Check and, if necessary, update local records at each contact.

1.2. If possible, make sure services are integrated into the national spine system to enable telephone number verification. You may also be able to verify numbers through direct contact with patients.

1.3. People with parental or caring responsibilities may receive reminders on behalf of the family member or person they look after. You should have local processes for managing the consent around this. Using people’s full names (first name and last name) in text messages, although not recommended as standard, can help prevent confusion in certain circumstances.

1.4. If and when possible, use MEF-registered (official) SenderIDs, for example ‘[Screeningservice] sent you a message’, as opposed to ‘[+4478…] sent you a message’, and enable limited bi-directional messaging so that someone can respond directly to messages. If the sending phone number cannot be replied to, you should mention this. People also benefit from having a phone number in the body of the text that they can click on to call. Respond to requests in a timely manner.

1.5. If possible, make sure you have local processes to check it is appropriate to send a text message. For young person and adult screening, check the recipient is not deceased before sending a text. For antenatal screening, make sure you have checked that the pregnancy has not resulted in pregnancy loss. For newborn screening, ensure the baby is not deceased or very ill before sending the message.

1.6. If possible, log and monitor how many text messages are successfully delivered and opened. Follow your local processes for dealing with undelivered messages.

1.7. Use tried and tested existing systems and frameworks for message delivery wherever possible, rather than setting up new processes. Consider who is best placed to send the text messages – it could be the trust, GP, primary care network or other third party. For antenatal screening, the maternity provider should manage this.

1.8. For antenatal and newborn screening, text messaging can be helpful to signpost women and their families to online screening information.

1.9. Where possible, send reminders for upcoming screening appointments to everyone whose mobile numbers is available, and who has not opted out of receiving messages.

1.10. If possible and appropriate, you can change and tailor the content of messages to meet the needs of specific underserved or known at-risk groups. For example, an individual who has attended once previously but then missed subsequent appointments can be reminded about the importance of ongoing screening. Or an individual with language needs can be signposted to specific resources such as translations. This may help facilitate attendance among these groups.

2. Timing

2.1. We recommend not sending more than 2 text messages before a specific appointment and only one text message after the appointment if the person did not attend. If text messages are sent from multiple sources, such as from both screening and primary care, then some co-ordination and flexibility may be required.

2.2. Note that for time-dependent screening, such as in the antenatal period, it may sometimes be more appropriate to call rather than text someone if they did not attend the appointment.

2.3. We recommend sending reminder texts for timed appointments:

• close to the appointment (2 days in advance) as this is near enough that they are unlikely to forget but still gives you the opportunity to offer the appointment to someone else if the invitee responds to say they cannot make it
• 7 to 10 days before the appointment to give someone the chance to add the details to their diary, and make necessary work or childcare arrangements if they have not done so already

2.4 We recommend sending reminder texts for booking appointments or returning testing kits (when no booking has been made or kit returned) as follows:

• first message 10 to 14 days after initial invitation or kit
• second message 20 to 22 days after initial invitation or kit
• final message 28 days after invitation

2.5. If you send a text to someone who did not attend, this should be done as soon as possible after the missed appointment. Make sure the message is not accusatory and that you provide simple instructions for re-booking if appropriate.

2.6. It is helpful to use confirmation texts immediately after a booking has been made or after a completed screening test kit has been received.

3. Wording

3.1. Messages should be clear and well-formatted, with essential, factual, non-coercive information. Use concise, non-technical language. Use line breaks to make the message easier to read.

3.2. Consider the target audience. Bear in mind that English might not be someone’s first language and that they might have other communication challenges, such as a learning disability, sight or hearing impairment. If and when possible, make language translations of text messages available, for example via a weblink.

3.3. Keep messages as short as possible. Research suggests a maximum of 320 characters (2 standard text messages) is ideal but this is not always practical.

3.4. Include the date, time and location of the appointment, as well as any additional information or special instructions as appropriate, a contact phone number (if different to the number the text message is sent from) and a link to the relevant online national information in phone-friendly HTML format. Never link to PDF documents as these cannot be easily read on phones.

3.5. Include a link to the online screening information but do not try to explain what screening is, or its benefits, within the text. This information is already provided in the invitation and repeating it is not necessary.

3.6. Make it easy for someone to reschedule an appointment. If and when possible, allow someone to rebook both by telephone and another method, such as text or weblink.

3.7. Write out the day of the week and the month in dates. For example, ‘Monday 23 March’. Including the day of the week makes it easier for someone to remember and add to their diary.

3.8. Evidence suggests that GP endorsements can encourage people to take screening more seriously. Where appropriate, use a GP endorsement in reminder messages. If you’re able to and the practice consents, include the recipient’s GP practice. For instance, ‘Your GP practice, Ashville Surgery, endorses bowel cancer screening’. This does not apply to antenatal screening.

3.9. Evidence is unclear as to whether it is always useful to personalise text message to include the recipient’s name. However, it may be helpful to do so in some cases if systems allow and depending on local circumstances.

3.10. Evidence is currently unclear whether including a statement on the cost to the NHS of missed screening appointments is an appropriate way to encourage attendance. We therefore do not suggest using wording of this sort until more research is done in this area.

4. Information governance (IG)

4.1. Follow your local policies on updating someone’s contact and mobile phone details and be aware that some local systems may also update the national spine record.

4.2. Follow your local policies on consent and IG around using text messages for screening and ensure you have a messaging policy on your trust or GP practice website which you can point people to. Each screening service is responsible for compliance with local IG, consent and data protection processes.

4.3. Try to ensure you have as few barriers to engagement as possible. PHE advice was that specific consent from members of the public to be sent text messages is not required but you will need to follow local policy on this. NHSX has confirmed that appointment reminders are not considered to be direct marketing and therefore do not require the consent of the individual before sending.

4.4. Make sure that someone can opt out of receiving text messages if they want to. This does not necessarily need to be a one-step process – and ‘one-click’ opt out options should be avoided to prevent accidental opting-out – but requests should be actioned quickly.

4.5. Inform people in advance that they may receive text message reminders. Standard text is being developed to inform people via national NHS screening leaflets and invitation letters. For antenatal and newborn screening, we suggest women are informed at their booking appointment and by adding this text to the booking appointment letter/invitation or website with self-referral information.

4.6. Any message you identify as having been sent to the wrong recipient should be handled as a reportable IG breach and local governance processes should be followed.

4.7 It is important to maintain consistency regarding contact details of screening services on websites, invitation letters and SMS messages so people can recognise these as legitimate.

4.8 To comply with optimal SMS length, it may be useful to use shortened URL links. These should be from approved NHS or government sources (as opposed to third parties). Access to these services should be made available to third parties acting on behalf of the screening service when undertaking message delivery.

5. Evaluation

5.1. Aim to carry out annual research to check user satisfaction. Add a question about text messaging to any patient surveys you carry out. This might include using GP practice annual user surveys or seeking feedback via GP practice patient representative groups.

5.2. You should also measure the impact on attendance and DNA rates. Consider undertaking a baseline audit so the impact of text message reminders can be measured.

5.3. Share the results with local or regional screening programme boards and agree actions where necessary.

6. Research

6.1. Services should be aware of the research trials being undertaken in that screening programme, as this may have an impact on current and future practice.

6.2 Research methods will ultimately be determined through collaboration between researchers and screening services and may include large randomised controlled trials, or other methods including online A/B testing. Public and patient involvement should form an important component of these trials and may involve inviting screening service representatives to participate.

6.3 Researchers should be encouraged to report the outcomes of research to relevant screening services, especially on the effect on health inequalities.

6.4. National screening research priorities should be agreed and made available to help guide researchers and areas of potential interest to services.