Pathway to Equity: working with young people to reduce hospital appointment non-attendance

Non-attendance at hospital appointments – also known as ​‘did not attend’ (DNA) – is a pressing global health care challenge. In the UK, 7.6% of outpatient appointments in 2021–22 were missed, or 650,000 appointments each month. These absences increase clinician workload, delay diagnoses, worsen outcomes (particularly for those with chronic conditions) and strain already stretched systems. 

Young people aged 16–24 years are particularly at risk. This transitional age is marked by complex developmental, psychological and social changes. Yet, research and intervention efforts have largely focused on adults or specific conditions, leaving a knowledge gap around broader causes of youth non-attendance.

To address this, the Pathway to Equity project was launched at University College London Hospitals (UCLH), supported by the Q Lab. In phase one, the team applied a systems-thinking approach to understand how individual behaviours intersect with structural and cultural systems. The project used the iceberg model – examining events, patterns, structures and mental models – and combined quantitative data from electronic health records with qualitative insights from interviews, surveys and engagement events. A co-design committee, including nine young people and eight health care professionals, guided the process.

Data analysis revealed a 16–17% DNA rate among young people at UCLH, costing over £1.1m annually. Qualitative insights (from 21 interviews and a school survey of 130 students) highlighted the key barriers to attendance. Predictors included deprivation, distance to hospital and engagement with the digital patient portal. 

These findings underscored the need for both logistical and systemic solutions such as improved scheduling and transport as well as better communication, inclusive design and partnerships across the health, education and community sectors. Importantly, involving young people directly in shaping the project improved trust, engagement and perceived equity.

The team created a project video for phase one.

At a UCLH engagement event in July 2024, young people service users, school students and clinicians co-identified priority interventions. Following this event, three interventions were piloted:

1. Peer support scheme (downstream intervention) 
A peer support coordinator proactively reached out to over 500 young people flagged by a new DNA predictor model. Calls offered appointment reminders, barrier identification (school, cost, transport) and the opportunity to reschedule. This led to the launch of a dedicated Peer Support Telephone Clinic, enabling non-clinical conversations about challenges and access to tailored support.

The project team, the peer support coordinator and young people interns also created the HangO.U.T. space – a digital peer community – to foster informal, supportive interactions, promote dialogue with clinicians, reduce isolation and improve engagement.

2. Youth health space (upstream intervention)
In partnership with year 12 and year 13 school students, Public Health Haringey, and Healthwatch Haringey, Pathway to Equity is piloting a youth-led health space within a local school. This hub offers onsite health care consultations to reduce school absences, health education and wellbeing support and real-world leadership opportunities for year 12 and year 13 students through structured work experience, guided by professionals.

3. Youth Healthcare Bridge
Youth Healthcare Bridge aims to create an inclusive and empowering digital storytelling hub where young people’s voices actively shape health care resources. The goal is to ensure information is relevant, accessible and equitable. Through sharing real-life experiences, young people can inform, inspire and connect with one another. This fosters a vibrant space for knowledge exchange, peer-to-peer support and pathways to equitable access to health care as well as education and career opportunities.

Youth engagement
Sustaining participation in co-design spaces was difficult, particularly in digital forums. Many young people found health care settings adult dominated or inaccessible. To overcome this, the project team used relationship-building via consistent outreach, student-led workshops and creative feedback channels.

Cross-sector collaboration
Aligning multiple organisations with varied priorities proved complex. The team found that regular joint meetings and shared outcome frameworks helped develop collective ownership.

Digital barriers
Some young people lacked access to devices or confidence in digital tools. The school-based health space doubled as a tech access point and digital literacy hub.

Sustainability
Maintaining momentum, funding and institutional support remains challenging. However, integrating interventions into existing school and public health frameworks and using student work experience helped build sustainability into the model.

• Improved attendance: between September 2024 and February 2025, 69% of contacted young people attended or rescheduled appointments – compared with 36% of those not reached.
• DNA reduction: monthly DNA rates dropped by 33%, with a record low of 5.2% in April 2025 – the lowest in 6 years (national average 8%, UCLH average for adolescents and young adults 11.2%). Consistent peer support cover can result in 66% reductions.
• Financial savings: a total estimated cost savings from reduced DNAs equalling £76,000 annually.
• Cultural shifts: UCLH staff report better understanding of young people’s lived experiences and more relationship-focused care. The model is gaining interest beyond UCLH, with four other NHS trusts expressing interest in replication.
• Quality work experience for students from underserved communities: 28 students contributed to this project as part of their work experience. It provided them with a valuable opportunity to learn, grow and develop essential skills. Time used as part of this project was counted toward quality work experience.

The project highlighted the importance of relational care, youth voice and slowing down to understand root causes. 

Growth requires discomfort
Innovation thrives beyond traditional roles and settings. Peer work with young people demands flexibility, humility and courage to shift norms.

Listen before acting
Trust-building and deep listening – especially with marginalised or disengaged groups – are essential to designing meaningful interventions.

Relational work is transformative
Peer support isn’t supplementary; it is foundational. It rehumanises care, builds confidence and fosters belonging.

Looking ahead: vision and requirements
With further investment and evaluation, Pathway to Equity offers a scalable, inclusive model that centres young people in the design and delivery of health care to build a more equitable, preventative system from the ground up.

To scale impact and embed equity into outpatient care, Pathway to Equity’s next steps include:

• embedding peer roles in formal care pathways
• deepening school partnerships to support students navigating health and identity
• expanding work experience to build skills, representation and system understanding.

The Pathway to Equity project demonstrates that with co-production, peer support and systemic understanding, health care can be reimagined around the real lives of young people. It challenges traditional models and shows that relational, preventative and inclusive approaches are not only possible but vital for a future where health equity is more than a goal – it is the foundation.