Research and analysis

A zero cost way to reduce missed hospital appointments

Published 4 January 2016

Summary

Around 1 in 10 hospital outpatient appointments are missed every year in England. Missed appointments can lead to worse patient care and waste NHS resources. Many hospitals send patients a text message reminder before their appointment. These reminders are effective and cheap, but there is no evidence about what they should contain in order to minimise missed appointments.

A randomised controlled trial tested the content of appointment reminders. The best form of words, which told the patients the specific waste to the NHS of not attending, reduced missed appointments by 23% compared to the standard message.

This is an easy innovation for the NHS to apply. Cutting missed appointments at this rate across England’s hospitals could increase NHS productivity.

Missed hospital appointments

In 2014 to 2015 around 5.6 million (9% of the total) NHS outpatient appointments were missed in England, according to Quarterly Hospital Activity Data, 2015. The missed appointment rate at some hospitals and for some clinics is much higher.

Missed appointments can lead to worse care for patients, inefficient use of staff, and increased waiting times. While it is difficult to establish the exact financial impact of missed appointments, an estimate by the National Audit Office claimed that missed first outpatient appointments cost the NHS up to £225 million in 2012 to 2013. Hospitals often put in place coping measures such as overbooking, but these can introduce their own problems.

Reminder messages

One reason patients may miss their appointment is that they forget. There is evidence that, by tackling this factor, telephone or text message reminders substantially reduce missed appointments^{[footnote 1]}. There is, however, no evidence for what the reminder message should say.

Research from a range of settings suggests that small changes to messages can have a substantial impact on how people respond^{[footnote 2]}. This research was conducted to test how different reminder messages affect missed appointment rates.

Research trial with Barts NHS Trust

A team from Imperial College, the Department of Health (DH) and the Behavioural Insights Team collaborated with Barts NHS Trust and the text message provider, iPlato. The research was instigated by Imperial College and DH and was funded by Imperial. Two randomised controlled trials were conducted from November 2013 to May 2014.

Approximately 20,000 patients at 5 clinics at Barts (who would have received the standard text message reminder) were randomly assigned 1 of a number of different reminder messages. The reminders were sent 5 days before their appointment.

The research was in 2 parts, Trial 1 and Trial 2.

Trial 1 (November to December 2013)

This compared the existing standard reminder message in use at Barts with 3 new messages designed by the research team. Examples are shown in table 1.

Table 1: Text messages used in Trial 1

Existing message	Easy call	Social norms	Specific costs
Appt at St Barts Hospital on Sep 26 at 2.30. To cancel or rearrange call the number on your appointment letter.	Appt at St Barts Hospital on Sep 26 at 2.30. To cancel or rearrange call 02077673200.	We are expecting you at St Barts Hospital on Sep 26 at 2.30. 9 out of 10 people attend. Call 02077673200 if you need to cancel or rearrange.	We are expecting you at St Barts Hospital on Sep 26 at 2.30. Not attending costs NHS £160 approx. Call 02077673200 if you need to cancel or rearrange.

Trial 2 (March to May 2014)

This compared the most effective message from Trial 1 with additional messages designed by the research team. Examples are shown in table 2.

Table 2: Text messages used in Trial 2

Specific costs	General costs	Empathy	Recording
We are expecting you at St Barts Hospital on Sep 26 at 2.30. Not attending costs NHS £160 approx. Call 02077673200 if you need to cancel or rearrange.	We are expecting you at St Barts Hospital on Sep 26 at 2.30. Not attending wastes money. Call 02077673200 if you need to cancel or rearrange.	We are expecting you at St Barts Hospital on Sep 26 at 2.30. Please be fair to others and call 02077673200 if you need to cancel or rearrange.	We are expecting you at St Barts Hospital on Sep 26 at 2.30. Please attend or call 02077673200 cancel/rearrange or we will record as a missed apt.

Results

The ‘specific costs’ message was the only message from Trial 1 to have a statistically significant effect. It reduced missed appointments from 11.1% to 8.4% (p<0.01). This is a relative reduction of 23% – a substantial improvement for the NHS.

Chart 1: Effect of messages on missed appointments in Trial 1

Trial 2 compared 3 new messages against the ‘specific costs’ message. The ‘specifics costs’ message remained the most effective (a missed appointments rate of 8.2%). It is interesting to note that a more general message about waste – the ‘general costs’ message – was less effective than the ‘specific costs’ message (p<0.05).

Chart 2: Effect of messages on missed appointments in Trial 2

Next steps

The results are of use to NHS organisations that want to reduce their missed appointment rates. This approach is cost-free (where text messages are already being sent), easy to implement, and may highlight opportunities for further research.

This paper is a summary. The full analysis has been published in a peer-reviewed journal article.

For more information, contact Jo Chandler or Annabelle Bonus from the Department of Health behavioural insights team.

1. Gurol-Urganci I, de Jongh T, Vodopivec-Jamsek V, Atun R, Car J. Mobile phone messaging reminders for attendance at healthcare appointments. Cochrane Database Syst Rev 2013;12: CD007458. ↩

2. Examples include:

   • Haynes LC, Green DP, Gallagher R, John P, Torgerson DJ. Collection of Delinquent Fines: An Adaptive Randomized Trial to Assess the Effectiveness of Alternative Text Messages. J Policy Anal Manag 2013;32: 718–730. doi:10.1002/pam.21717l

   • Hallsworth M, List J, Metcalfe R, Vlaev I. The Behavioralist As Tax Collector: Using Natural Field Experiments to Enhance Tax Compliance. NBER Working Paper 2014;20007

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