Appt Health in North Kirklees

1.1 Executive summary

Curo Health Ltd (Curo) is a federation of 27 GP practices in North Kirklees, Yorkshire. Curo has been responsible locally for the Targeted Lung Health Check programme, which is being piloted nationally in 23 areas of England.

To improve the efficiency and overall performance of the Targeted Lung Health Check programme, Curo implemented Appt’s automated patient engagement service. Curo carried out a ‘before and after’ evaluation over the course of twenty-four weeks, comparing the performance of the programme over the twelve-weeks before Appt’s service was implemented and the twelve-weeks immediately after Appt was implemented. Curo found that Appt’s service had a massively positive impact on the programme, including:

1. Increasing total bookings by 58%
2. Increasing patient uptake by 18 percentage-points
3. Reducing the cost per booking by £1.05

This case study describes the findings of this evaluation in detail. It also explores some of the additional benefits that Appt and Curo have identified as we have continued to work together post-evaluation.

2.1 Curo’s starting point

Curo had been working on the Targeted Lung Health Check programme since October 2021. This is a new preventive healthcare programme being piloted in 23 areas across the country. The programme has the potential to create a significant improvement in cancer outcomes in England, promising to identify over 3,000 asymptomatic cases of lung cancer each year.

But – like most preventive healthcare programmes – achievement of these outcomes will require high public uptake of the programme. Simply put, for the programme to be a success Curo needed patients to book and attend the Targeted Lung Health Check appointments in sufficient numbers.

Stephen Lees is the Targeted Lung Health Check Programme Manager at Curo Health. He explained the situation in North Kirklees:

I was new to the project, which had been running for a couple of months when we first started working with Appt. At that time the project faced a few challenges.
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First, we needed to ramp up activity to meet our targets – our total clinical capacity was increasing and we needed to increase the number of patients that we could book in week-on-week.

Second, we had an ambition to improve our overall patient uptake rates. So far, 42% of our patients were taking up the Lung Health Check. This compared positively to the national average of 38%, but we knew that uptake was critical to a programme like this, so we aimed to increase uptake as high as possible.
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— Stephen Lees, Programme Manager, Curo Health

Stephen had access to high quality data going back to the beginning of the programme in North Kirklees, and he saw the initial roll-out as an opportunity to evaluate the impact of Appt’s service on the programme through a before-and-after study. He gathered data from the first 12-weeks of Appt’s activity and compared it against the 12-weeks immediately before Curo had gone live with Appt.

2.2 How Appt increased total bookings of Targeted Lung Health Checks

In North Kirklees, the service contract that Curo was delivering required patients to be invited twice, by SMS or letter, followed by a phone call from the Curo administration team. This is standard practice across the NHS, but many don’t realise just how much it can restrict throughput by creating severe administrative bottlenecks.

The typical call-to-action for a patient invited by SMS or a postal letter is to “please call the practice” – but if the phone-lines are busy with invitees calling to book, how will the admin team find time to call out to patients that must be recalled? Another question worth asking is: how can a willing patient call and book in response to an invitation if the phone lines are busy with other patients?

In the 12-weeks before going live with Appt’s service, the Curo Health administrative team were booking an average of 116 patients into Lung Health Checks per week. However, in the 12-weeks since going live with Appt they booked an average of 182 patients per week. That’s a 56.9% increase, more-or-less overnight.

Stephen explains how the team at Curo reacted to this improvement

We were totally blown away. We had been concerned about how we’d meet the increase in our clinical capacity, but with Appt it was no problem. It really exceeded our expectations.

— Stephen Lees, Programme Manager, Curo Health

2.3 How Appt increased patient uptake of Targeted Lung Health Checks

In the short term, increasing overall activity is clearly an important metric for a screening programme like this: commissioners set activity targets that must be met. But in the long run, patient uptake rates are the most impactful metric.

Screening programmes often take a population approach in which the entire eligible cohort is invited and encouraged to attend over a period of time. This ensures that asymptomatic cases in the population can be identified. This leads to targets – like the 80% acceptable uptake rate for the national cervical screening programme. But achieving high public uptake is a challenge – indeed only one (out of over two hundred commissioning regions) achieved the ‘acceptable’ cervical screening uptake rate in 2021.

In North Kirklees, Targeted Lung Health Check uptake rates were 42%, placing them above the national average of all pilot sites (38%), but some way off the top performing pilot site, which was achieving a 48% uptake rate. Appt changed that.

Appt’s SMS invitations have been designed with behavioural science principles in mind, to maximise reach, trust, and accessibility. These are all crucial components of an effective invitation and Appt’s approach led to a significant increase in Targeted Lung Health Check participation: increasing overall uptake rates by 18 percentage-points.

2.4 How Appt reduced the cost per booking in North Kirklees

Not only did Appt’s activity improve the performance of the programme, but the service was also highly cost-effective. Stephen calculated the average cost per booking before Appt was rolled out at £4.59 per booking. This figure was found by summing the costs of all patient communications (letters and SMS) and the administration time spent telephoning patients, based on all activity data for the twelve-weeks running up to Appt’s deployment. The same calculation was performed for all activity during the twelve-weeks after Appt’s deployment (Appt’s costs and fees were included in this calculation).

After rolling out Appt’s service, the cost per booking came down to £3.54 – representing a £1.05 saving per booking. Applied to the entire programme these savings are worth a total of £9,453.

3.1 North Kirklees is now one of the best-performing Lung Health Check pilot sites

Appt’s engagement by Stephen and the Curo team has helped to transform the performance of the Targeted Lung Health Check programme in North Kirklees into one of the best performing pilot areas in the country. But the most important measure of success is the health outcomes achieved as a result of Appt’s roll-out.

During the 12-week treatment period of this before-and-after trial, Appt booked an additional 730 eligible members of the public into a Targeted Lung Health Checks. Based on the published results of the Manchester’s Lung Health Check Pilot, this increase in uptake would mean approximately 8.5 additional lung cancer cases identified at the asymptomatic stage (1.16% of the screened population). It also means that 9.2 significant but non-cancerous findings that can be referred for further treatment and 44 lung nodule cases which would benefit from ongoing clinical monitoring.

Jason Pawluk is the Programme Director for the West Yorkshire and Harrogate Cancer Alliance (which covers the North Kirklees programme). He recognised the huge benefits from Appt’s intervention:

We are delighted to see the results which have been achieved working with Appt-Health. Effectively, the system has helped to significantly improve uptake rates and did not attend rates, which is a significant gain for service planning.
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It’s a relatively simple innovation which makes the process of booking and attending appointments more straightforward, mirroring the approach that people would often use outside of a healthcare setting.
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We feel that there is potentially broader applicability from the solution and are currently working with Appt-Health to extend its use for further benefit of the West Yorkshire and Harrogate population.
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— Jason Pawluk, Programme Director, West Yorkshire and Harrogate Cancer Alliance

3.2 Appt has helped deliver Improved health outcomes and health economic benefits

These health outcomes are positive for the population of North Kirklees, but also for the integrated care system, where early action can be taken to treat these patients, reducing the cost burden from more expensive courses of treatment in later years.

A study published in the NIHR’s Health Technology Assessment journal evaluated the targeted lung cancer screening pilot programme. It explained how the service would lead to downstream cost avoidance:

The eventual presentation of the [lung screening] cancers, had they not been detected and treated by screening, would have entailed costs of investigation and treatment following symptomatic presentation. The act of screening allowed these costs to be avoided, and it is appropriate to offset any such cost savings against the current screening-related costs of detection and treatment.

This study also explained that each additional lung cancer case diagnosed through screening led to an average benefit of 1.6 quality adjusted life years (QALY). That means 8.5 additional cancer cases would lead to 13.6 additional QALYs.

Whilst putting a pound (£) figure on the health economic value of an intervention can be challenging, QALYs can be used as a crude measure by using willingness-to-pay as a proxy for value. When deciding what care to commission, the National Institute for Care Excellence (NICE) values each quality adjusted life year between £20,000 and £30,000 when assessing new treatments.

Even at the lower bound of this valuation, Appt’s intervention in North Kirklees during these 12-weeks could be estimated at £272,000.

Since the end of this before-and-after evaluation, Curo have continued to use Appt’s service in North Kirklees, cementing their position as one of the top performing Targeted Lung Health Check pilot sites.

4.1 About Appt: how to transform the uptake of preventive healthcare

Appt Health is a social enterprise with the joint mission of increasing public uptake of preventive healthcare and the reduction of health inequalities. Since 2017 the Appt team has been working with primary care providers to transform the performance of preventive healthcare programmes through their Appt Recall service.

Appt Recall is a complete patient engagement service. Practices can manage multiple preventive healthcare targets (health checks, screening, immunisations) through Appt’s web application – automating patient outreach and booking over multiple rounds of invitations. Appt automatically targets patients with the channel most likely to reach them and the service automatically follows up with patients who don’t book over multiple rounds of invitations.

4.2 Behavioural science can help more patients to access and benefit from prevention

Behavioural science tells us that for any behaviour, there must be the motivation, the ability and a trigger to perform the behaviour. Appt’s workflows are designed to ensure that each of these criteria are met when a patient is invited to book – leading to higher patient uptake rates and improved performance.