No show-a-no-no

Last year, mssed appointments in the NHS went from 5.7 million to 6.8 million, based on data from a sample of 50% of acute NHS trusts, so says today’s Times newspaper. The good news is that missed appointment rates were down from 12.2% to 10.9%. Given that overall numbers are up, that means appointments actually increased by far more.

An MP, Grant Shapps, estimated the cost at £614 million. By maths, that makes the average missed call cost around £90. That’s less than numbers I used to hear bandied around when I worked in government when I often saw quotes of up to £250. I suspect £90 came about because £100 looked too round so, following the old dodge of a number with pennies after it looking less suspicious to the Inland Revenue, we have £90-odd.

I got interested in this area in late 2001 when I broke my ankle out in the Welsh hills. Visiting St Thomas’ fracture clinic I watched the duty nurse putting post-it notes on the wall with figures scribbled on them. The numbers seemed random but were in the range 30-50. When I asked what they were for I was told that it was the number of missed appointments over the previous few days. I was stunned. After all, when you’ve broken something (the usual reason you’ll be in a fracture clinic) you’re unlikely to forget the fact and, if you’re like I was, you’ll be keen to get the plaster off so that you can get back to normal. You’ll also be keen not to visit the x-ray department again where they make you hop down the corridor on crutches, up two flights of stairs, round the corner and then back again, clutching your x-ray films between your teeth. But, nonetheless, people don’t show up for appointments.

There are a few questions here:

1) What is the no show rate for hairdressers, restaurants and personal trainer sessions? Are they higher or lower? Does paying for a service make you more or less likely to show? I know, from empirical data, that the percentage of no shows for reserved seats on trains is higher than 10.9%, based on the number of seats that stay empty on my weekly trips to the north of England, despite having tags attached to the seats. There’s no consequence for missing a train except maybe having to fight for a seat on the next one.
2) Is the no show a consequence of forgetting the appointment or of being unable to figure out how to change it? Or having figured out how to change it, not being able to because the phone in the surgery/hospital isn’t answered?
3) Is the no show unplanned until right at the last minute so that there isn’t time (or isn’t felt to be time) to call and let the hospital know, even if it’s only a few minutes notice?
4) Is there really a cost to no shows? I’ve never seen people sitting around doing nothing, unless they’re patients, in a hospital. There’s a queue of people and the doctors or nurses see them one after the other. They seem to keep seeing them until there are no more and then go off and do other things. It’s unlikely that they would loaf around if no one shows up at a specific time – and, most likely, they’ll be running late from the previous appointments (unless you’re first in) so will catch up a little with a no show.
5) If you sort out no shows and get a 100% attendance, do you need more staff to handle them?
6) If you get 100% attendance and need more staff, will other costs go up. For instance, more people will follow a course of treatment through to the end and need more appointments, rather than dropping out of the system and “self healing”?
7) Is there an “economic level of no show”? That is, is there a rate at which slack in the system is a good thing because it makes a little room for emergencies, unexpected absences of medical staff or where staff are able to spend “just enough” time with patients?

Ages ago, maybe 2002 or 2003, we did a short pilot with some hospitals in Norfolk. We sent text reminders to patients the day before an appointment. We did this for some clinics and not others, hoping to get indications of an improvement in turnout for appointments. There turned out to be lots of practical problems: people didn’t know their mobile phone number and couldn’t turn it on in the hospital to check what it was (it being against the rules to use a phone inside) was one of the more memorable. But they were all cracked through and data emerged that showed a simple reminder improved things.

Our plan was to go from reminders to interactive services that would allow a response saying “I’m not going to make it, but can I have another slot tomorrow” or something like that. Events overtook us and the NPfIT came along with its promised National Booking Service (eBooking I think it’s called). That is now in and running although press reports are usually negative on the basis that not all trusts have hooked into it yet so relatively few appointments are booked. But it will get there one way or another I hope.

Text reminders will then be available to all as, I suspect, will be easy ways to respond and request changes. And that should solve some of the problem. It might now, however, solve the rest of the problems – if the root is around lack of consequence of no show.

Waving large – £614 million large – numbers about won’t help much though, especially if they’re not backed up or turn out not to be true. Maybe cleaning up no shows will cost us money, Maybe we want more no shows?