Missed Appointments in East Sussex Report
1. Context
1.1 This report provides members of the Committee with an overview on the work being done to minimise missed appointments in secondary care (hospitals) across East Sussex. The report considers in detail the measures and work being undertaken by East Sussex Healthcare NHS Trust (ESHT) to illustrate the position which is indicative and representative of secondary care providers serving the East Sussex resident population.
1.2 The importance and impact of missed appointments is equally relevant to all health and care providers and patients including primary care, community care and mental health. Missed appointments in primary care are addressed in a separate report that is being presented to the same October Committee meeting ‘Improving Access to General Practice in East Sussex – Update Report (October 2024)’. The focus on primary care missed appointments and secondary care / hospital missed appointments in these reports is in response to the committee’s expressed interest in these service areas.
2. Introduction
2.1 Across all NHS settings (primary care, outpatients, diagnostics etc) missed appointments are a daily occurrence. The consequence is wasted capacity within the system, which, at a time when health systems are under considerable pressure, it can ill afford.
2.2 Missed appointments are reported nationally by healthcare providers to support understanding of the prevalence in different areas, as well as the common demographic characteristics. The data alone does not help understand why patients miss their appointments, although it does provide insights on which mitigations can be effectively developed.
2.3 This paper aims to outline the work undertaken across Sussex to better understand why patients miss their appointments, and actions to reduce them. It will focus on missed appointments within hospital outpatient services at East Sussex Healthcare NHS Trust (ESHT), because a considerable proportion of activity is undertaken in this setting, but it recognises the causes and possible mitigations can be applied across the full range of settings.
3. Missed appointments at East Sussex Healthcare NHS Trust (ESHT)
3.1 The Model Health System shows that in July 2024, ESHT had an outpatient missed appointment rate of 5.3%, with 2,438 patients missing their outpatient appointment. This can be split by first outpatient appointment and follow-up appointment:
· First outpatient – 846 patients missed their first outpatient appointment, giving a missed appointment rate of 5.8%.
· Follow-up – 1,592 patients missed their follow-up outpatient appointment, giving a missed appointment rate of 5.1%.
3.2 The below provides a view of the national profile for missed appointments within acute outpatient settings. It shows ESHT in the lowest quartile, performing better than the peer median (6.1%) and provider median (6.9%). In contrast, the missed appointment rate, across all specialties at University Hospitals Sussex is 6.4%.
3.3 The graph below shows the missed appointment rate at ESHT has been improving since 2020. The steep increase in missed appointments in December – January 2024 can be explained within the context of industrial action and the consequential need to switch off text reminders for many services because of late clinic cancellations (the hospitals were not always aware who would be taking part prior to strike days).
3.4 While the data demonstrates that ESHT are performing well, and that their missed appointments performance is improving, there is still opportunity for further improvement. The Model Health System quantifies that if ESHT were to achieve their top peer performance of 4.8%, they would further reduce missed appointments by 335 per month across major outpatient specialties[1], however the below graph highlights that while there is an opportunity to reduce missed appointments, this opportunity is reducing, and has been reducing at a greater rate compared to peers.
3.5 Initial analysis undertaken by NHS Sussex, using 2023/24 data has shown:
· Missed appointments for patients in the most deprived quintile are significantly higher than the rest of Sussex (12.1% vs 6.7% in Mar-24).
· Missed appointments for patients from minority ethnic groups are higher compared to other groups (11.6% vs 7.4% Mar-24). Please note that there are known data quality issues with ethnicity recording, with approximately 34% of patients not having a stated, known or recorded ethnicity.
· Men aged 19-49 have a significantly higher rate of missed appointments compared to other age-gender bands: around 6.6%, followed by <19s of both genders where the rate is 2-3% higher than the average.
4. NHS Sussex Patient and Public Engagement – Understanding Missed Appointments
4.1 Reducing missed appointments provides an opportunity to support elective recovery both locally and nationally. To better understand the drivers for missed appointments and develop recommendations to reduce them, NHS Sussex commissioned Healthwatch Sussex (a collaboration between Healthwatch Brighton and Hove, Healthwatch East Sussex, and Healthwatch West Sussex) in 2023/24 to facilitate workshops aimed at gaining participant views on new initiatives being explored to improve the Outpatient experience, one of which was missed appointments. 31 participants took part from across Sussex, representing those who had attended an outpatient appointment and those still on the waiting list to be seen. Participants represented a diverse profile in age, ethnicity, sexuality, and health needs.
4.2 Below outlines the key findings and recommendations from the workshop:
· Patient appointment letters and information: participants felt that clear, concise information was needed, and to avoid information and letters being too wordy. Participants agreed the essential information should be highlighted at the top of the letter. Participants felt co-produced letters and patient information could help resolve some of these issues. Participants also suggested that all patient letters should include practical information about parking, public transport and how to apply for non-emergency patient transport (NEPTS, NHS England) and how to receive financial support where applicable.
· Appointment reminders: participants discussed the text alert system as being helpful to remind patients about an appointment and suggested frequent reminders, a few days in advance as well as on the day to ensure people do not forget.
· There was a recognition that people change their contact details and do not necessarily tell their doctor, so their patient record is not updated. Participants also shared experiences of missing an appointment due to their mobile signal being weak at home. Participants felt patients could be encouraged to re-confirm details including their preferred contact number. This could be reinforced by displaying the latest patient contact information held by services, on all communications with patients.
· Participants felt that a key barrier to attending all appointments was financial constraints. This could be helped by better provision of more localised services as well as regular reliable public transport to attend services outside the local area. Participants also felt that appointments should be available out-of-hours.
· Participants suggested that additional responsibilities such as caring for others (children or adults), may cause a barrier to attending appointments in person, and/or be a reason for last-minute missed appointments.
· Participants suggested other barriers to attending appointments, could be digital exclusion, age, physical mobility, or language. Participants mentioned that support could be provided by making services accessible through translators, choice between face-to-face and remote appointments, and providing physical support for patients arriving at hospital.
5. Actions Underway
5.1 ESHT are currently taking several actions to minimise and address missed appointment rates. These include:
· The Trust are currently reviewing and updating their Elective Access Policy. This will provide further clarity around missed appointments and how they are managed within the Trust.
· On occasions clinics are overbooked to accommodate urgent patients, accepting a patient may miss their appointment in the clinic.
· Because of the Healthwatch work on missed appointments, the Trust is currently undertaking a review of appointment letters to ensure they are clear and concise for patients.
· The Trust have planned deep dives into nine of the larger specialties to better understand the drivers for missed appointments. These deep dives are planned across ENT, Paediatrics, Maxillo Facial, Diabetes, Endocrinology, Cardiology, Gynae, Ophthalmology and Neurology. Part of this work will also focus on better understanding missed appointments from an economic/social lens. These deep dives will inform specialty level action plans.
· The Trust are reviewing different patient engagement tools that will allow more sophisticated and flexible communication with patients regarding their appointments, including tailored/variable messaging, and a facility for patients to notify the Trust if they no longer need an appointment.
· Work is planned to focus on demand and capacity planning at a specialty level. This is a priority due to the impact that ad hoc clinics have on missed appointment rates – this is due to them being set-up at short notice and patients not being given reasonable notice.
6. Summary and Next Steps
6.1 An opportunity exists to further reduce the number of missed appointments. However, this opportunity is relatively small given the current performance. ESHT are consistently maintaining upper quartile performance regarding missed appointments. Other providers serving East Sussex may present more of an opportunity.
6.2 It can be seen that the feedback and recommendations that came from the workshops commissioned by NHS Sussex is being taken by providers as demonstrated by the examples provided by ESHT.
6.3 The local health and care system will continue to monitor and look for opportunities to further reduce missed appointments for the key reason to ensure best possible outcomes for patients, and to make best use of healthcare capacity and resources.