Increasing uptake of free appointments like the NHS Health Check is still a conundrum to public health and general practice professionals. There have been numerous studies into methods of patient recall that increase uptake for health checks, but how should you make sense of them all?
We reviewed the research into innovative new recall methods (like behavioural economics and text message reminders) to tell you what their results were. If you’re tight on time, skip to the end to read our conclusions and suggestions because these tips could help you save practice staff time while improving patient outcomes at your practice.
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Letters are a promising and simple method of patient recall and a lot of research has been done to optimise them.
The main studies had varying results, but as you'll find out one format stands above the rest in getting the most number of patients to book an NHS Health Check appointment.
This research project aimed to test two things. Firstly, whether including a behaviour questionnaire with the invitation letter would improve attendance at health check appointments. And, secondly, whether offering eligible patients a £5 shopping voucher for filling out the behaviour questionnaire would improve uptake.
The researchers wanted to understand if the ‘question behaviour effect’ (QBE) would work to increase uptake. Behavioural scientists previously theorised that asking people questions would induce behaviour change, so including a questionnaire with an invitation might make patients more likely to engage with their GP practice and book an appointment. They also believed that adding a financial incentive would encourage more people to engage with the QBE, increasing the effect further.
Unfortunately, the results showed nothing significant. They showed:
An interesting finding from the research was that even out of the 14-15% of people who attended an appointment within 6 months, only 37% of them did so because of the letter. The rest were picked up opportunistically while visiting the practice for another reason.
Ultimately this study of 12,459 people showed a very poor response rate from both the control letter or an enhanced version. So it doesn't give us a lot of guidance to go on. But one thing we have learned is that neither QBE nor £5 shopping vouchers will boost uptake at your practice.
While this study focussed on more than just letters (which we will get to later), Gidlow et al aimed to test whether personalising each letter based on the CVD risk of each patients could increase uptake.
Patients were sent risk-personalised letters that included messages that matched their % 10-year CVD risk score. They worked closely with the Public Health England Behavioural Insights Team to develop the letters that let patients know what category of risk they fell into.
The letters sent seemed to have an effect, but the sample size was too small to tell. The results showed uptake was:
The results indicate that if a patient who is high risk of CVD receives a personalised letter indicating this fact, they are much more likely to attend that if using a standard letter. However, the effect is negative for other risk profile groups.
*Note: Practices sent between 1 and 3 letters per patient so we can’t determine fully the effect of one letter alone.
This study into patient recall methods for the NHS Health Check is one of the most renowned among health check trials. The researchers invited eligible patients from 28 GP practices in the London Borough of Southwark using a variety of letter and text message combinations.
Their study aimed to assess new, behaviourally enhanced invitation letters against the standard national GP template. They also tested a pre-notification SMS message, sent to patients before the letter to let them know it was coming, and a reminder SMS to prompt patients to respond to their invitation letter.
Here are the four letters tested.
12,244 invites were analysed, and the results showed success. Their uptake was:
They found that the reminder SMS increased uptake for all intervention letters. However, a pre-notification SMS did not help at all.
The official NHS guidance updated following the Southwark study. They suggest invitations as part of your patient recall process should use letter two instead of the old letter, so it has become the national template for NHS Health Check invites.
The NHS trusted the results of the Southwark study above all other letter studies so we recommend you do that, too, to increase uptake of health checks at your practice. However, to get the best results we advise you to send a reminder SMS so that patients don’t forget to respond. If you wanted to go the extra mile, you could consider separating those patients who have a ‘high risk’ of CVD and personalise their letter to increase their attendance rate (although the evidence is not yet strong enough that we can guarantee this will work.)
There have been fewer studies into the efficacy of telephone calls for increasing uptake of NHS Health Checks. However, results show calling patients is both the most effective way to get high uptake and the most cost-effective method for your practice.
The previously mentioned HECTR trial asked practices to stick to a devised template when on the phone with patients. Across the 1,270 patients 43.8% attended an NHS Health Check appointment when invited by telephone compared to the roughly 30% who received a letter.
In our experience, GP practice staff tend to avoid telephone calls as part of their patient recall process because they think it is too time consuming. However, the research also included a cost-benefit analysis of telephone calls and letters. Gidlow et al discovered that the invitation cost per attended health check was:
Letters: £3.95 per patient per attended health check
Telephone calls: £3.07 per patient per attended health check
The cost-benefit analysis shows that because telephone calls are much more effective than letters, overall it works out around £0.90 cheaper per patient who attends an appointment with you. Over 1,000 patients that could be a £900 reduction in expenses.
There are several studies into the effect of SMS reminders on uptake of national NHS screening programmes.
An interesting example tested behaviourally-enhanced text message reminders to improve participation in cervical screening.
The researchers randomised more than 4,000 patients into seven groups:
It was found that of the patients who received no SMS reminder (n=540), 34.4% took up the invite. Whereas of those who received a reminder with their GPs endorsement, 38.4% took up the screening appointment. These two showed the largest difference indicating that endorsed text message reminders can have a big impact on screening participation.
Text messaging is a cost-effective approach as one SMS can cost as little as £0.02. In many areas of the UK an NHS Health Check is incentivised so that practices receive £20-£30 per delivered health check, meaning there is a clear case for cost-effectiveness when it comes to adding an extra SMS to your patient recall process.
Patient engagement software runs on your practice’s computers and automatically invites and books patients into national prevention appointments like QOF, NHS Health Checks, immunisations, and screenings.
Unlike sending a letter or writing an SMS yourself, companies like Appt Health research and study the most effective methods of boosting uptake of these appointments and apply the most up-to-date techniques within their recall process, automatically.
At Appt Health, we are in the process of a yearlong randomised control trial that tests a combination of innovative patient recall methods. We are using automated two-way SMS invitations, behaviourally optimised letters with accessible options for appointment booking, and automated telephone calls. All of which are cheap, effective at getting patients into appointments, and much less work for administrative staff. It may sound too good to be true, but now you can prevent more ill-health and make your practice more profitable and competitive.
Our aim is not just to increase uptake of appointments like the NHS Health Check but also to reduce the workload of patient recall for practice managers. We know that these go hand in hand; we can’t expect primary care professionals who are already overworked to also invest time innovating their patient recall process.
Be the first to find out about the results of our trial by joining our mailing list at the top of this article. You can also check out more tips for increasing NHS Health Check uptake on the rest of Appt's blog.
The research suggests telephone calls are the most cost-effective method of increasing uptake of programmes like the NHS Health Check. However, they are also the most time consuming.
Given that time is something we know practice staff have very little of, utilising the national template letter from the NHS and combining it with behaviourally informed text message reminders seems to be the most best way of boosting uptake of your screening programmes.
The preliminary results of patient engagement software like Appt are promising. They show a high booking rate of NHS Health Check appointments and the best part is that it’s automated. The future of patient recall in general practice is undergoing exciting changes. As patient engagement platforms mature we can expect to see easy patient recall, reduced variation across general practice, and more optimised processes for both patients and practice staff.
1. Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records. Mcdermott L, Wright AJ, Cornelius V, Burgess C, Forster AS, Ashworth M, Khoshaba B, Clery P, Fuller F, Miller J, Dodhia H, Rudisill C, Conner MT, Gulliford MC. 2016.
2. HEalth Check TRial (HECTR): Risk-tailored invitations to improve uptake of NHS Health Checks. Gidlow et al, 2019
3. Pre-notification and reminder SMS text messages with behaviourally informed invitation letters to improve uptake of NHS Health Checks: a factorial randomised controlled trial. Sallis, Sherlock, et al. 2019
4. Behavioural text message reminders to improve participation in cervical screening: a randomised controlled trial. Huf, King, Kerrison, Chadborn, Richmond, Cunningham, et al. 2017
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