Addressing health inequalities to reduce missed appointments

A team in Bristol, North Somerset and South Gloucestershire (BNSSG) are working to address health inequalities to reduce missed appointments. Data showed that the ​‘Did Not Attend’ (DNA) rates for cardiology patients in BNSSG were 36% higher for black and Asian patients and 48% higher for those living in the most deprived areas. Health and improvement teams from North Bristol NHS Trust and University Hospitals Bristol and Weston came together to secure Q Exchange funding to explore the issue. 

Patients from deprived areas and minority ethnic backgrounds are more likely to miss their appointments and have poorer health outcomes. Missed appointments are an issue for every health trust, often impacting the most disadvantaged and underserved communities. DNAs lead to worse care for patients, inefficient use of staff and increased waiting times. 

With a desire to better understand the causes of DNAs, the BNSSG Elective Recovery Inequalities Integrated Care System Steering Group, hosted by the integrated care board, have been working with cardiology teams in North Bristol NHS Trust and University Hospitals Bristol and Weston. 

Dr Seema Srivastava said there was strong link between heart health and inequalities, highlighting the need to boost attendance to improve cardiovascular health. 

North Bristol NHS Trust Project Manager Khadija Begum and the project team brought together a range of stakeholders across the region to address health inequalities with patients and community partners. The team spoke with clinicians, administration staff and community groups. They also gathered feedback from around 200 patients who had missed appointments. These patients were invited to join focus groups to discuss issues and solutions in further depth.

The insight gathered from these conversations showed there are four key barriers to people attending their appointments:

Communication 
Some people did not receive their appointment letters on time. For others, the letters were too complex or used language they did not understand. 

Trust 
Some people had a distrust of the NHS, particularly when dealing with people and teams they were unfamiliar with. 

Transport 
For some, just getting to and from appointments was expensive or difficult. Even if they wished to attend, they were logistically unable to. 

Flexibility 
Some people were unable to attend their appointments due to other commitments.

With support from Q, the project team was able to recruit an administrator to support patients most likely to miss appointments. The administrator called patients before their appointments, encouraging them to attend and supporting them around any challenges. They aimed to listen, understand and build trust for improved communication. 

Patients who spoke to the administrator missed approximately half the number of appointments compared with those not contacted. This highlighted the need for improved communications and alternative approaches for those unable to engage with health care by the conventional methods. 

The team turned insights from the administrator’s conversations and the appreciative inquiry into scalable improvements. These improvements included support for a business case to purchase additional wheelchairs and training materials to help administrative staff understand and champion health equity. Videos were also created to help patients understand and prepare for appointments. The project started with cardiology, but patients in other specialties have benefited too. Q is enabling the team to reach out and liaise with other trusts doing similar work to share learning. 

The team shared the following advice from their experience: 

Be data driven – The data will tell you where you need to go and who you need to work with. 

Be a good listener – Patients are more likely to engage if they feel someone is listening to their concerns. 

Be prepared to test and trial interventions to see what works – What works for some groups of people may not work for others.

Make a strong case for change – It’s important teams understand why a change is needed or beneficial, especially in a highly pressurised environment.

Patient perceptions drive action (or inaction) – Patients need to understand the treatment they are receiving and why.

Innovate out loud – Share what you’re working on and use resources from the community.