Attending hospital appointments is essential for patients to access the medical care they need to maintain and improve their health. Across North West London, individuals living in the most deprived areas and from ethnic minority groups face a variety of barriers to attending outpatient appointments at Imperial College Healthcare NHS Trust. The focus of this collaborative project between IGHI’s Helix Centre and the Trust was to understand why people miss their appointments and to co-design solutions with community members that help them to attend.
Going to the first outpatient appointment can help prevent a chain reaction of health inequity. By attending diagnostic appointments (such as scans), individuals help to ensure timely diagnoses and interventions, which can lead to better health outcomes and more effective treatment and management of their conditions. Trust data showed that people living in the most deprived areas of North West London or people part of a Black, Mixed or Other ethnic groups are more likely to miss their outpatient appointment. In this project, we worked with local community members throughout the project, who were linked to these groups, to ensure the project and any intervention were designed appropriately.
Meet one of the Public Steering Group members
“My name is Phayza and I am a community member involved with Imperial College and as part of the Strategic Lay Forum at Imperial College Healthcare NHS Trust. I was one of the eight people recruited to the Public Steering Group, bringing together diverse voices to shape the project.
“As someone deeply involved in community development and public health promotion, I was eager to contribute my insights to this initiative. My background gave me a unique perspective on the systemic issues faced by minority and disadvantaged populations in accessing healthcare. This opportunity was not just a professional duty but a personal mission to amplify the voices of those often unheard.” – Phayza, Public Steering Group member
Gathering insights from people who had missed appointments
The Helix Centre team interviewed over 25 patients who had missed appointments in several clinical specialties and staff to understand why people could not attend. Through these interviews, we learned that various factors contribute to why someone might miss an appointment, including caring responsibilities, work responsibilities, travel difficulties, distrust with the NHS and communication issues (such as not receiving appointment details via text or letter). We are sharing these findings as widely as possible with relevant groups. The Helix team shared the barriers back to Trust staff to ensure that they were aware of the issues faced by their patients. We recently published an academic paper outlining the barriers, co-author by a Public Steering Group member, Chris. We also worked with the Public Steering Group to design a poster (below) that visually communicates the attendance barriers, which we are sharing with public members involved in the project and a wider audience.
Moving from barriers to solutions
We ran three co-design workshops with local community members from groups facing inequity, to come up with ideas that address the barriers people face attending hospital appointments. We worked with the Public Steering Group to decide which barriers should be prioritised and brought to the workshops, along with reviewing the workshop materials to ensure they were engaging. The workshops were held in local community spaces that people were familiar with, for example the White City Community Centre. The Public Steering Group helped with recruitment for the workshops, by promoting it in local networks, such as the Black and Minority Ethnic Forum newsletter (which Phayza is linked to). A diverse range of people with different knowledge and experience participated alongside NHS staff, with everyone learning from each other. Of the 23 workshop attendees, 16 were from ethnic minority groups and 9 lived in the most deprived areas of North West London.
“What I liked most about the workshops was working together and being very listened to. I appreciated all the effort which had been put into them” – Workshop attendee
The workshops were a melting pot of ideas and experiences. Building on the barriers we heard from initial interviews, people shared and discussed the issues they and their family members had faced attending hospital appointments and proposed solutions. At the next workshop, we developed the ideas further and had to think about whether the idea was feasible. For the prioritised ideas, we further developed what they could look like and shared this back to the workshop attendees for their feedback.
Testing the final ideas in a research study
The ideas taken forward from the workshops address barriers around paying for transport, travelling to appointments and fear of attending appointments. The solutions we developed include extra message reminders sent to patients before their appointments, which connect them to clearly designed web pages with information about how to get to their appointment, whether they’re eligible for travel cost reimbursement or what to expect at their appointment. We are testing these additional tailored reminders in a research study to see if they help people to attend their appointments and plan to roll out any successful changes across Imperial College Healthcare NHS Trust.
Highlighting the impact of public involvement
The Public Steering Group influenced the project throughout, from reviewing interview questions to co-designing the language used in the texts and websites sent to patients in the study. When we were planning the interviews, Mohamed (a member of the Public Steering Group) reviewed the interview guide and suggested that we might have more success with recruitment if we talk about the impact the study could have at the start of the conversation with the patient instead of at the end.
“By beginning with the wonderful impact the study could have that you have given in the end it may in my opinion give the researcher a soft landing and a willing-to-participate interviewee/patient.” – Mohamed, Public Steering Group member
When we were prioritising themes to take the workshop, the Public Steering Group raised transport as a critical barrier to attending hospital appointments, initially not prioritised by the team. This suggestion significantly shaped the project’s direction, resulting in several final interventions aimed at improving support around transport.
Another example of a key recommendation from the group, was to ensure that appointment reminders that are being sent as part of the research study include a phone number for patients to call if they have questions or need to reschedule their appointment. This simple addition ensures that people without access to digital tools can still manage their appointments effectively. Another suggestion was to soften the language in the study’s appointment reminders to adopt a more supportive tone that encourages patients to attend.
“We suggested to change the text message language to ‘Let’s make it easy for you to plan your journey’ to make it warm and supportive” – Phayza, Public Steering Group member
Unfortunately not all of the ideas generated from the workshops could be taken forward, such as having ‘community health navigators’ supporting people with rescheduling or attending their appointments. However, we shared all the ideas back to Imperial NHS Trust to see if they could be adopted in other projects, and the Trust are continuing to use the insights from the project as part of their work to improve outpatient experience for patients.
Learning from this approach
We came up with several ideas about how the approach could have been improved, and have applied these changes in more recent projects with Imperial College Healthcare NHS Trust. The team had organised paid childcare for one of the workshops which was during the half term school break, to allow parents to bring their children to the workshop. However, we could have also made this even clearer when advertising the workshops along with other supports that would help people to attend, such as carers or interpreters.
The Public Steering Group suggested that we recruit patients to interview by ringing them beforehand to schedule a call in advance, as opposed to asking to speak with them then and there. This new approach would have led to more in-depth conversations, as people could speak to us at a time that was convenient for them. We have used this method in another Trust project called Waiting Well, as well as offering the interviewee a choice of whether the interview is in-person (in a location chosen by the patient) or on the phone or on a video call.
“For the interviews and workshops, the team also could have utilised the Trust’s interpreting services so that we could hear from people who would prefer to speak other languages. I am pleased to hear that the team has taken forward all these ideas in other projects.” – Phayza, Public Steering Group member
Empowering community members to shape future initiatives
By involving community members from under-represented and under-served groups throughout the project, we helped to ensure the messages we are testing in our research study were appropriate and accessible.
We are still waiting on the results of the trial, which will be out later this year. We hope to see improvements in hospital appointment attendance, and if so, these interventions can be rolled out more widely at Imperial College Healthcare NHS Trust and beyond.
For more information contact Anna Lawrence-Jones.