Clinical scenario 1

If you want to optimise the likelihood of the patient attending the appointment:

Forgetfulness is one of the major reasons for non-attendance (A1).

• Use a reminder system to improve attendance rates: all reminders improve attendance [see Chapter 4, Evidence statement (A.1): there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a (forgetful) patient to attend their appointment (evidence category Ia)].
• Use of a simple reminder will help to reduce the risk of forgetting [see Chapter 4, Evidence statement (A.1): there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a (forgetful) patient to attend their appointment (evidence category Ia), and Appendix 3, theme A.1]; however, reminders that provide additional information (such as orientation information and health information) are more effective than simple reminders [see Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)].
• The content of the reminder is important. The reminder should at least contain details of the timing and location of the appointment [see Chapter 4, Evidence statement (A.1): there is strong consistent evidence that simple reminders which provide details of timing and location of appointments are effective at helping a (forgetful) patient to attend their appointment (evidence category Ia)]. Patients have also expressed a preference for a standardised format, so they know that it is a reminder and, for clear content, using plain English (e.g. eye clinic instead of ophthalmology). (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group.)
• Use a reminder technology that is appropriate for the audience. Have an awareness of the preferences and needs of the patient, including speech, language and hearing difficulties [see Appendix 3, theme B.4, and Public Governors’ Comments (see Chapter 3, Involvement of patient steering group)].
• The effectiveness of different reminder systems is influenced by whether or not the patient receives the reminder [see Appendix 3, theme B.1, and Chapter 4, Evidence statement (B.1): there is strong consistent evidence that the reminder may not be received by the patient (evidence category Ia)]. Issues include accessibility to the reminder (homeless or travelling communities, does the patient have the available technology); structural barriers to the reminder being received, for instance not aligning the address with the window on a reminder envelope; and patient understanding of the reminder if they do receive it (mobility, hearing difficulties speech difficulties, language, etc.). Carers may need to take delivery of the reminder.
• The service should ensure that the contact details for patients are accurate and check these on a regular basis (especially telephone numbers) [see Appendix 3, theme B.1, and Chapter 4, Evidence statement (B.1): there is strong consistent evidence that the reminder may not be received by the patient (evidence category Ia)].
• Send a reminder before the appointment; however, the timing of the reminder, up to 1 week before the appointment date, does not appear to influence attendance behaviour [see Appendix 3, theme B.5, and Chapter 4, Evidence statement (B.5): there is strong consistent evidence that the timing of a reminder, between 1 and 7 days prior to the scheduled appointment, has no effect on patient attendance behaviour (evidence category Ia)].
• Do not make the appointment too far ahead of the appointment date. Reminders sent between 1 and 7 days prior to the appointment are equally as effective as each other and reminders sent up to 2 weeks before the appointment may be effective [see Appendix 3, theme B.5, and Chapter 4, Evidence statement (B.5): there is strong consistent evidence that the timing of a reminder, between 1 and 7 days prior to the scheduled appointment, has no effect on patient attendance behaviour (evidence category Ia)]. If the appointment has been scheduled several months in advance, a preliminary reminder should be sent a few weeks in advance of the appointment.
• Patients perceive that the appointment cannot be important if it is cancelled or rescheduled multiple times by the service [see Appendix 3, theme E, and Public Governors’ Comments (see Chapter 3, Involvement of patient steering group)].
• Consider the time and day of the appointment and potential obstacles to attendance. For instance, although highly variable, some studies show that the times at highest risk of non-attendance are the mornings and Wednesdays^112,162 (see Chapter 5, Timing of the appointment).
• Consider the flexibility of times for appointments for the audience, e.g. after work, to fit with transport access, such as senior citizens bus pass constraints (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).
• Provide information that increases the patient’s perception that attendance at the appointment will positively contribute to their well-being [see Appendix 3, theme A.2–6, and Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)].

Clinical scenario 2

If you want to optimise the likelihood of attendance at an initial appointment:

Considerations from clinical scenario 1 plus:

• Much may depend on the person making the referral explaining the need of the referral to the patient, so that the patient understands the importance of the appointment and agrees that attending the appointment would be important for them (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).
• Consider the nature and the location of your service. How easy is it for patients to find or get to and whether the procedures that patients are undergoing invasive, worrying or anxiety provoking. Provide information that increases patient perceptions that attendance at the appointment will positively contribute to their well-being (see Appendix 3, theme A.2).
• Patients may need to overcome anxieties about going to a new (unknown) place (see Appendix 3, theme A.5). There may be issues of access/parking difficulties/patient mobility. Patients may also be anxious about specific procedures (e.g. colonoscopy, cervical screening, breast screening, etc.). Patients may benefit from the provision of materials that may influence their intention to attend (see Appendix 3, themes A.2–6, and Chapter 4, Quality of included trials). Consider what type of information would be most beneficial to provide; orientation information, such as location, parking, transport, the department may be beneficial for some clinics. Information about procedures, such as benefits of attending and consequence of not attending, may be helpful for patients by providing reassurance and motivation. How information is provided should be carefully considered, e.g. written direction vs. map, gain-framing or loss-framing of messages [see Appendix 3, themes A.2–6, and Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)].
• The provision of additional information at the first appointment may be specifically relevant and important to increase attendance [see Appendix 3, themes A.2–6, and Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)’.

Clinical scenario 3

If you want to increase the rates of attendance at screening appointments:

Considerations from clinical scenario 1 plus:

• Is the health service screening symptomatic or asymptomatic patients? If the patient is asymptomatic and the health service is calling patients in for routine screening, patients may be less motivated to attend than if the patient is symptomatic and has been referred for a screening appointment [see Chapter 5, Norms, attitudes and understandings regarding the (dis)benefits of healthcare on offer]. Provide information to highlight the importance of the appointment. Consider whether the message should be gain-framed (benefits of attending) (see Appendix 3, theme A.2) or loss-framed (consequences of non-attendance) (see Appendix 3, theme A.3, and Chapter 6, Reminder plus).
• Provide full information about the screening programme, including details of how and when the results will be reported to the patient (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).
• Provide information that increases patient perceptions that the appointment will be positive (see Appendix 3, theme A.5).
• Provide a follow-up reminder to patients who reschedule their appointment (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).

Clinical scenario 4

If you want to optimise the likelihood of attendance at follow-up appointments:

Considerations from clinical scenario 1, plus:

• First consider whether patients’ non-attendance is unintentional (e.g. forgetfulness, slept in, missed bus) or intentional (no longer wished to attend).
• You may reduce the risk of unintentional non-attendance through the use of simple reminder systems (see Clinical scenario 1).
• Patients who no longer wish to continue with their treatment may not openly choose to discuss this issue with service providers. Consider the most likely reasons why patients may decide they no longer wish to attend (see Appendix 8) and understand whether or not this is something that the health service can address.
• Ensure reminders contain appointment cancellation requests and procedures. Let patients know that the appointment can be given to someone else (see Appendix 3, theme E, and Chapters 5–7).
• Make cancellation and rebooking easy (partly through the use of appropriate reminders) (see Appendix 3, theme E; Chapter 4, Proposition E: are there any systems which effectively support the cancellation of appointments?; and Clinical scenarios 7–10).
• Patients should be told how long the outpatient appointment takes and informed of known or likely delays to the service (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).

Clinical scenario 5

If you want to optimise the likelihood of attendance of specific population groups:

Considerations from clinical scenario 1 plus:

• Consider whether or not the health service deals with populations subgroups who are traditionally at a higher risk of non-attendance [see Chapter 5, Demographic and socioeconomic characteristics, for risk factors (refugees, mental health, young men, very old people, deprived populations, homeless people)] [see Appendix 3, theme F.3; Chapter 4, Evidence statement (F.2–F.11): few studies investigate whether or not a range of distal/proxy individual attributes have a differential effect, over and above pre-existing appointment behaviour, on reminder effectiveness (in terms of attendance, cancellations or rebooking) (evidence category Va or VIIa); and Appendix 8].
• Consider the appropriateness of different technologies (e.g. SMS, phone uptake).
• Language needs to be considered and pictorial messages may be appropriate in some circumstances [see Appendix 3, theme B.2, and Chapter 4, Evidence statement (B.2): there are no studies investigating whether or not reminder factors (such as language, information provided, framing of information) influence the accessibility/comprehensibility of the reminder message for particular patient groups (evidence category VIIa)].
• For service users with severe mental health problems, it may be important to provide additional information such as orientation information or information that increases patient intention to attend, e.g. that attendance will contribute to patient well-being (see Appendix 3, themes A.2 and A.3).
• Consider issues to do with accessibility, such as child care, transport, work commitments (see Appendix 3, theme A.6 and the table reasons for not attending).
• Consider multimodal packages of reminders (these might be more interactive, personalised styles of reminders). In groups with extreme difficulties in attendance, sequential reminder intervention or patient navigation services could be considered. Such highly intensive and personalised services might, therefore, be targeted at supporting those patients with the greatest difficulties (see Chapter 5, Demographic and socioeconomic characteristics, and Chapter 6, Substance abuse/mental health/comorbidity and physical illness).

Clinical scenario 6

If you want minimise the number of unfilled, non-attendances on any 1 day (i.e. minimise unused capacity):

• Optimise the likelihood of attendance by sending a reminder (see Clinical scenario 1).
• Understand likely barriers to attendance in the health service (see Appendix 8).
• Make it easy for people to attend/reduce barriers to attendance (see Clinical scenario 1).
• Make it easy for patients to cancel and/or reschedule (see Clinical scenarios 9 and 10).
• Install notices in clinic waiting areas to inform patients about delays.
• Consider whether or not overbooking clinics is right for the health service; however, also consider the possible disadvantages of in-clinic waiting times, which can be off-putting for patients and could lead to increased non-attendance rates [see Chapter 6, Current and future developments (Innovations)].

Clinical scenario 7

If it is a high priority that patients cancel then it is important that health-care services, make it as easy as possible for patients to cancel:

• Health-care services and staff should consider taking a non-judgemental approach to cancellation and recognise that cancellations (and rescheduling) of appointments is a desirable outcome. This recognises that patients are people with busy lives, various commitments and shifting priorities that need to be juggled around health care. It recognises that patients can sometimes be too embarrassed/fearful to phone and say that they cannot attend (see Appendix 3, themes A.1, A.7 and D.3).
• Reminders need to be sent well in advance, but not more than 7 days in advance. Patients should be asked to cancel an unwanted appointment and reminders should contain a request regarding cancellation. The language and framing of the reminder should be checked to ensure that it is not alienating (see Appendix 3, theme E). This will allow the service to reallocate the appointment to a different patient.
• Some reminder systems that are more interactive, such as personal telephone calls, have the advantage that cancellations (and rescheduling) can occur concurrently [see Appendix 3, theme E, and Chapter 4, Evidence statement (A.2–A.6): there is weak consistent evidence that ‘reminder plus’ are more effective than simple reminders at helping a patient to attend their appointment (evidence category IIIa)]. This may particularly helpful in health services with very high non-attendance rates.
• Patients should know the mechanism for cancelling an unwanted appointment. Reminders should make it clear what the cancellation procedures are and thereby offer several possible options. Wider advertisement of cancellation procedures should also be considered, for instance by including information on cancellation procedures in standardised patient information, as part of routine appointment-making processes (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).
• Patients should be informed that using the mechanism will be quick and easy and this should be made clear in the reminder [see Appendix 3, themes E.1 and E.4, and Chapter 4, Evidence statement (E.1 and E.4): there is indicative evidence to suggest that whether or not a patient cancels and rebooks will be influenced by patient perceptions of how easy it is to rebook (evidence category Va)].
• Unhelpful or difficult cancellation mechanisms will lead to patient frustration, lack of engagement with the cancellation mechanisms and poor levels of cancellation [see Appendix 3, themes E.2 and E.5, and Chapter 4, Evidence statement (E.2 and E.5): strong consistent evidence indicates that system factors related to appointment systems will hamper patient intentions to cancel/rebook (evidence level Ib)].
• Health services should have quick and easy cancellation procedures in place, such as dedicated phone lines (with answerphones, if required), SMS reply in order cancel, e-mail facilities, etc., which means that patients can make a brief contact any time, day or night, in order to cancel. It may be helpful to offer a variety of ways to support cancellation by patients, which could all be automated, so that patients can cancel at any time that is convenient to them [see Appendix 3, themes E.1 and E.4, Chapter 4, Evidence statement (E.1 and E.4): there is indicative evidence to suggest that whether or not a patient cancels and rebooks will be influenced by patient perceptions of how easy it is to rebook (evidence category Va)].
• Health services need to ensure that there are sufficient resources in place to make a cancellation system work [see Appendix 3, themes E.2 and E.5, and Chapter 4, Evidence statement (E.2 and E.5): strong consistent evidence indicates that system factors related to appointment systems will hamper patient intentions to cancel/rebook (evidence level Ib)].
• Patients should be informed about the costs to the service of FTA and the opportunity costs to other patients of lack of access to appointments. This may also increase a patient’s sense of obligation to cancel an unwanted appointment [see Appendix 3, theme E.7, and Chapter 4, Evidence statement (E.3 and E.6): there is indicative evidence that for patients who intend to take up the offer of an appointment, whether or not a patient cancels and rebooks will be influenced by structural factors that facilitate/hamper patient intentions to rebook (e.g. has to be done on line and no internet access) (evidence level Va)].

Clinical scenario 8

If it is a high priority that patients reschedule their unwanted appointment in order to receive priority treatment:

• Make cancelling and rescheduling easy (see Clinical scenario 9).
• Consider initiating contact with the patient in order to reschedule the appointment. For groups who find it difficult to engage with health services, consider more intensive/or individualised support systems to encourage attendance, e.g. patient navigation systems (see Chapter 6, Utilise new ways of managing appointment systems).
• If it is important that the patient attends a further appointment, then consider whether or not it would be relevant to send out a reminder asking the patient to reschedule when he or she is better.
• Offer flexibility to overcome those barriers to attendance; this is likely to be service specific in relation to important contextual issues.
• Provide clear explanations of how the patient can overcome the barriers.

Clinical scenario 9

If you want to make it easy for the patient to cancel or reschedule:

• A personal telephone call will increase the likelihood of the patient cancelling or rescheduling the appointment.
• Short message service reminders do not increase the likelihood of the patient cancelling or rescheduling, but work better when the patient can respond directly to the SMS and does not have to call a telephone number given within the body of the message (see Appendix 3, themes E.3 and E.6, and Chapter 4, Evidence statement (E.3 and E.6): there is indicative evidence that for patients who intend to take up the offer of an appointment, whether or not a patient cancels and rebooks will be influenced by structural factors that facilitate/hamper patient intentions to rebook (e.g. has to be done on line and no internet access) (evidence level Va)].
• Ensure that the systems to enable cancellation or rebooking are easily accessible by the patient. For instance, patients will not wait for long periods on a telephone. Consider having several automated options for cancelling, e.g. SMS reply, answerphone, e-mail. Consider rescheduling systems that also work outside conventional working hours and are, therefore, accessible [see Appendix 3, themes E.1, E.2, E.4 and E.5, and Chapter 4, Evidence statement (E.3 and E.6): there is indicative evidence that for patients who intend to take up the offer of an appointment, whether or not a patient cancels and rebooks will be influenced by structural factors that facilitate/hamper patient intentions to rebook (e.g. has to be done on line and no internet access) (evidence level Va)].
• Ensure that the internal systems are able to capture, record and relay the cancellation information to the service provider for fast action, which will allow health services to reallocate appointments [see Appendix 3, themes E.1 and E.4, and Chapter 4, Evidence statement (E.1 and E.4): there is indicative evidence to suggest that whether a patient cancels and rebooks will be influenced by patient perceptions of how easy it is to rebook (evidence category Va)].
• Provide patients with clear information about how to and how easy it is to cancel or reschedule an appointment. Cancellation and rescheduling systems need to be adequately resourced to prevent patients giving up on cancelling [see Appendix 3, themes E.1 and E.4, and Chapter 4, Evidence statement (E.1 and E.4): there is indicative evidence to suggest that whether a patient cancels and rebooks will be influenced by patient perceptions of how easy it is to rebook (evidence category Va)].

Clinical scenario 10

If the health service has to re-schedule an appointment:

• First be aware that patients may perceive that the appointment cannot be important if it is cancelled or rescheduled multiple times by the service (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).
• Letters need be sent in time, and with sufficient priority that they reach the patient before the appointment date/time. If an appointment is cancelled in writing, then the message needs to be clearly laid out and prominently display the new appointment date/time (as the letter includes the old date/time as well) (Public Governors’ Comments, see Chapter 3, Involvement of patient steering group).
• Ensure that rescheduling is easy and convenient for patients (see Clinical scenario 9).