Against the backdrop of monumental efficiency challenges facing health and social care, the NHS needs to achieve up to £20B of efficiency savings by 2015 through a focus on quality, innovation, productivity and prevention (QIPP).¹ The QIPP programme was developed to ensure value for money through cost efficiencies and improved productivity, while simultaneously working towards better patient outcomes.¹ Missed health-care appointments are a major source of potentially avoidable cost and resource inefficiency that impact on the health of the patient and treatment outcomes.

Since 1999, the cost of missed appointments to the NHS has tripled, and in 2009 was estimated to be more than £600M for that year.^2,3 A recent report by the Department of Health, England, reported that, of the 15 million appointments offered at consultant-led clinics between October and December 2012, around 1.5 million patients did not attend.⁴ In the UK, more than 12 million general practitioner (GP) appointments are missed each year, costing the tax payer in excess of £162M.^2,5 There has been little research into the costs of missed appointments at outpatient clinics led by Allied Health Professionals (AHPs) and nurses; however, Gleeson et al.⁶ reported that the average annual cost of missed appointments to one occupational therapy department was equivalent to a full-time member of staff. In addition, several studies indicate that non-attendance rates at physiotherapy clinics are frequently between 6% and 30%^7–9 and could be as high as 46% in some services.¹⁰ Nursing studies have found similarly high non-attendance rates.^11,12

In addition to the costs identified above, non-attendance may lead to increased waiting times for appointments,^5,13 increased cost of care delivery,^11,12 under-utilisation of equipment and personnel,¹² reduced numbers of appointments available for all patients,^5,11 reduced patient satisfaction^14,15 and negative relationships between the patient and staff.^5,13 The delay in presentation at health-care departments and consequent lack of monitoring of chronic conditions may predispose patients to exacerbations of their condition and its related complications, leading to unnecessary suffering and possible costly hospital admission.^12,16 In addition, the impact of patient non-attendance, coupled with pressure from referring agents to manage waiting list length, can potentially increase health-care practitioners’ stress, anxiety and fatigue levels.¹⁷

Reducing the rate of missed appointments may lead to many benefits, including reduced NHS costs and improved treatment outcomes.¹⁸ At an estimated cost of around £100 per appointment,³ a 1% reduction in missed appointments could result in savings of £6M per year on consultant clinics in England and in excess of £16M per year in savings to GP practices. Potential cost savings to AHP and nursing clinics are also considerable. Reducing the number of missed appointments may be a relatively inexpensive way to support the intentions of the NHS to treat patients within 18 weeks of GP referral,¹⁹ while simultaneously supporting the NHS QIPP agenda.

In an attempt to manage the negative effects and improve the efficiency of appointment systems, many health-care organisations are increasingly investing in short message service (SMS), telephone and e-mail reminder systems. Many patients welcome the use of reminders, and patients who did not attend their appointment report that they would have been more inclined to attend if they had received a reminder.²⁰ However health-care organisations frequently employ a ‘one-size-fits-all’ approach, with little evidence of differential effectiveness or acceptability for particular populations or subgroups. This research systematically examined the published evidence around different models of patient reminders and their effectiveness for, and acceptability to, particular population groups who use outpatient clinical services. Identification of those reminder strategies that are most appropriate for particular subgroups of patients may help health-care organisations to improve attendance at outpatient clinic appointments. The output of this study is a practice guide to help managers identify which approaches are likely to be most effective for reducing non-attendance rates for their service and client groups.