Imagine this: a patient turned up at a reception desk in a hospital carrying a stack of letters. He said: “I had all these letters about my appointment, and I don’t know when my appointment is. Could you please figure it out for me?”. This is a true story witnessed by one of our founders, Rinesh. In fact, the appointment had already been rescheduled 12 times by the hospital, over the course of some months.
The patient had got significantly confused and couldn’t figure out what was meant to be happening. They ended up missing their appointment through this bad communication, resulting in them not receiving the care they needed, and the hospital wasting its resources and time.
A few years ago, DrDoctor did some research into cancelled appointments. The numbers may have changed since then, but the situation is still largely the same. The total number of bookings made per appointment shown below includes the initial booking as well as every time the appointment is changed.
You tend to see is a distribution that looks like this:
If you work out the average against the whole cohort you see there are about two bookings made per appointment. This tells you that on average twice the effort was spent on one appointment, or half the effort was wasted, which is terrifying. This is rework; work that’s been done again and again to achieve the original output, a successful booking that someone turned up for.
You can see this all as a massive waste of time and effort or a massive opportunity of saving time and effort.
The full booking model
The traditional booking model for hospital appointments is initiated by the hospital or the doctor. A doctor says you need an appointment i.e. a control in three months’ time or an initial consultation after a referral from your GP. The appointment is then usually ‘fully booked’ by the hospital at a time chosen by them. Some hospitals try to call up patients beforehand and ask if you’re available on that day first and then book them in. But in practice this is very difficult as the average hospital not only books a thousand appointments per day, but also reschedules a thousand per day.
An enormous amount of work would go in to calling a thousand patients every day. In practice, people might not be available due to being busy at work or not having the right contact information etc. It could be as low as just 1/20 calls actually reaching someone. Understandably hospitals think there is no point attempting to call these people, let’s just book an appointment and if it doesn’t work the person will call up and tell us.
Imagine a clinic, say the Dermatology lumps and bumps clinic that runs every Thursday morning once a week with Dr Skin. The clinic has 10 appointment slots available. The hospital will often decide which patient to book to which slot based on availability, while limiting patient choice. Hospitals have a lot of demand and they need patients to be seen so that the available slots get booked up far in advance.
In reality, Dr Skin is a human being: they may have kids and lives and can get sick or go on holiday. This lumps and bumps clinic is the only clinic we have for this specific problem or as part of the patient’s continuity of care they need to be seen in this clinic. Suddenly, you have 10 patients and you need to find somewhere to put them. You can’t move them to next week because those appointments are already fully booked. You also can’t move them so many weeks into the future either because then their care has been massively delayed.
Often, cancelling one clinic means cancelling all future clinics and shuffling everyone back a week because that’s the way of minimising risk of delaying treatment. Suddenly, you have 50 patients’ appointments cancelled. You might be booked for a 6-month follow-up and the hospital cancels the clinic for some reason. Cancelling a clinic may happen a few times in that 6-month period and your appointment might be cancelled and rebooked and cancelled and rebooked and you end up having no idea what’s going on.
Hospital-led cancelling can be an absolute nightmare from a patient’s point of view as well as for everyone in the booking process. Bad patient experience can often have other knock on consequences, not just delaying care or confusing the patient but overall it can have the effect of disengaging the patient from the service altogether. When a patient is deactivated and disempowered from their own care, they might not be in the right frame of mind to have a meaningful conversation when their hospital appointment finally comes around. In this way an administrative process can have serious clinical consequences.
Partial booking model
In the partial booking model hospitals will only book appointments within a certain horizon. The horizon is usually aligned with the minimum notice you need from a doctor to book or cancel a clinic. Obviously, the horizon then keeps rolling as time progresses onwards and upwards and as new capacity becomes available and patients get booked in.
Another side process needs to be running in the partial booking model as you need a way of keeping track of all the patients that need an appointment that haven’t got one yet. In the partial booking model, you don’t actually book patients in to a clinic but place them onto another structure instead. Normally this will be an Outpatient Waiting List.
Patients cancelling appointments
Usually there are two reasons for why patients cancel hospital appointments. Either they no longer want that service, or they might not be able to make that appointment at that specific time and they would like to change that appointment to a time that suits them.
There are different reasons for why a patient might no longer want an appointment. It might be because they feel better, or they feel worse and that appointment is no longer a priority as they’ve been admitted into hospital and they can’t make it. Patients could also be cancelling because they’re moving away.
Cancelling an appointment can traditionally only happen by calling a booking centre and we already know that people often don’t like to or can’t be bothered to do that. Often the hospital has effectively booked an appointment that the patient will miss because it was too hard to cancel it.
So, what if cancelling was easier?
The DrDoctor solution enables patients to cancel their appointments easily by just clicking a couple of buttons. This means hospitals can get much better visibility of patients who want to cancel. They can then release that capacity or resources reserved for that clinic to other patients that can benefit from it. As a result, DNA rates go down and patients can experience shorter waiting times.
Sometimes hospitals are concerned that if given the option, people will keep on cancelling and rescheduling their appointments. Sometimes hospitals feel that patients shouldn’t be deciding unadvised, whether they should be turning up or not due to not being aware what’s clinically appropriate for them. In practice, making cancelling easier does not enable clinical decision making so the loss of control from hospitals is just a perception. Patients miss appointments all the time regardless of how easy cancelling them is.
Another thing we’ve noticed when looking at the data around cancellations is that around 80% of patients that do cancel, tend to do so up to 48 hours beforehand. With the DrDoctor solution, the number of cancellations does go up (which is a good thing overall- as opposed to DNA) but you also get a financial benefit from reducing patients’ waiting time and improving clinic utilisation. This is as our solution enables clinics to have a way of repurposing capacity within a period of time like 48 hours.
Usually approximately half to 2/3 of improvements in DNA rate means these people actually now turn up for their appointments and 1/3 – half will start to cancel them. The people that now cancel do so in a way that hospitals have visibility and they can offer that time to someone else even with a short notice.
In the full booking model where patients disengage from the whole booking process, DNA rates are known to be very high and cancellation rates tend to be low. Churn rates and the need to rework tends to also be very high. If you move to a partial booking model, you can choose who’s initiating the appointment and who’s choosing the appointment. Now the patient will be more likely to turn up or to cancel or reschedule.
We believe that solving these underlying problems limiting the health system is essential for the NHS and are dedicated to helping every way we can. Finding ways to fix broken parts of the system is admittedly hard to do but simple tech and gradual automation can offer benefits reaching beyond admin challenges. Needless to say, we are great advocates of the partial booking model and some of our greatest results within the NHS are due to the efficiency of hospital booking teams in our partner hospitals. We can help automate the bits of admin that can and should be streamlined (like appointment cancellation), so that people working in healthcare can focus on helping patients get better.