Several national population healthcare programmes have come under the spotlight recently for low uptake and attendance rates. Failing to get patients to go to appointments like these that prevent ill-health is a big problem for the NHS in an environment of increased demand for services.
Public health programmes in primary care typically cover immunisations, vaccines, disease screenings and health management. Every appointment attended either protects a patient from developing a condition, identifies the condition early enough to treat it, or acts to minimise the adverse effects of a pre-existing condition.
The appointments are valuable on an individual level; most people agree that staying healthy is a priority. They are also useful to society; every £1 spent on prevention returns about £14 in social value. Fewer sick people means reduced pressure on other parts of the health service (fewer sick people = less demand for services), lower social services demand, and higher productivity from healthier communities. Indeed, 89% of deaths in the UK were from causes considered preventable.
Every £1 spent on prevention returns about £14 in social value.
Much of this preventative activity takes place in primary care, at your local GP. Every year there are dozens of these programmes that GPs offer free to their registered patients to help promote good health. While it is typically a regional or national authority that commissions these services, it is each GP's responsibility to get patients to book and attend these appointments. The more patients seen by primary care clinicians, the better pay they receive.
The payments for delivery of these appointments are often attached to targets. For example, Public Health England expects 66% of the eligible public to attend a cardiovascular disease screening, 75% of the eligible public should have a flu jab, and all women between 25 and 64 should be screened for cervical screening every 3-5 years. Usually, this means practices must try their best to get thousands of patients through their doors for one target or another. The process used by practices to do this monumental task is called call and recall.
SIDE NOTE: What is call and recall?
Call and recall, for the uninitiated, is the process used by most GP practices to invite and book patients into health appointments for which they are eligible, which includes targeted screening programmes, immunisations, and health reviews.
Some practices have a structured system in place. An example could be that "each eligible patients receives two letters until they respond and if they don't respond, they receive one phone call invite". Another could be "the HCA spends every morning trying to reach patients by telephone call, working from the top of a list to the bottom alphabetically." Other practices have something less structured in place, where there is a frantic last quarter of the year where they meet their targets.
You have been on the receiving end of call and recall if you have ever been sent a letter or a text message asking you to call the practice and book an appointment for cancer screening, a flu jab or, a routine check-up on an existing condition.
Most practices that we spoke to use some combination of letters, text messages, phone calls from admin staff (alongside opportunistic booking) to encourage patients to book these appointments. Thankfully high-quality research has been done into which patient recall methods work best. The literature suggests that letters followed by an SMS reminder lead to about 30% of patients responding. Whereas, telephone calls from practice staff are much more effective (leading to a ~45% response rate, although it took 1-3 calls and letters it took to achieve these rates.)
It's perhaps surprising, then, that studies have found telephone calls are the least preferred approach by practice staff. And it's clear that despite practices reporting methods that could theoretically achieve a high uptake of appointments, at a national level public health programmes are failing to meet expectations. One recent example is that cervical cancer screenings are currently at a 20 year low, as 1/3 eligible women do not attend.
But, as I'll get to later in this article, it becomes hugely unsurprising that practices aren't able to carve out more time for manual phone calls.
There are many reasons why prevention programmes are failing to achieve high uptake rates. They range from patient opinion to structural inefficiencies. But whatever the cause, I believe getting preventive healthcare right is a big deal, and it is essential to understand the significant barriers we face in becoming a healthcare system that prevents first, cures second.
In this article, I want to talk about why the current call and recall systems in place are not fit for purpose and how they contribute to low uptake across public health care. My experience comes from working on the front-line of call and recall in the admin team at a GP practice. I've also built my business around improving the public uptake of critical prevention services with Appt Health, the social impact business I founded in 2017, and we've grown to work with over 50 GP practices to solve this problem in the first year.
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Recall processes are quickly crowded out by the more urgent matters of practice life. It is unsurprising practices miss targets when the urgent crowds out the important. Public health appointments are essential, but frequently patients are asymptomatic and unaware they need to be screened, meaning it is easy to view them is non-urgent.
I believe it is hard to prioritise preventative care in such circumstances. The problem is two-fold: benefits come months or years down the road when demand for services is reduced because the general population is healthier. As humans naturally discount the future and value the present. So while the wrong approach to prioritise more urgent admin tasks, no-one is to blame but those systems which don't account for this. Secondly, good results from preventative care are not directly visible. Good results can be the absence of something bad happening, rather than an observed improvement.
The problem itself is not that urgent matters occur, but that patient recall processes become crowded out by them. I don't mean to suggest that anyone turning up at a GP practice in the morning should wait in line until the daily preventive workload has been handled, I simply recognise that this trade-off exists and that the call and recall process often loses out.
A symptom of a broader issue: the organisation of primary care around reactive care rather than preventative.
We view this problem as a symptom of a broader issue: the organisation of primary care around reactive care rather than preventative. One that waits for people to be sick and then treats their acute illness - this is how GPs are typically trained, and it makes sense they want to utilise their skill in diagnosis and treatment of disease.
In this system, reactive care will always come first because that's what it's set up to do. Would you close off two hours of GP time in the morning so they can focus on engaging their wider community in health-positive activities? Probably not when there's a queue of sick people at the door.
GP surgeries are consequently overwhelmed by patient demands for services, and at the same time are understaffed, underfunded, and frankly, stressed out by their patients.
All parts of an NHS GP practice are inescapably busy. I know that first-hand. I still remember my ears ringing after a shift working on reception in an East London GP practice as part of the Year Here programme. It felt like the phone hadn't stopped ringing from the time I sat down at the desk that morning to the time my shift ended. It is the kind of environment where just one clinic running late or one team member falling sick can turn what is supposed to be a regular day into a nightmare, where you can never quite get on top of things.
Some weeks these kinds of days happened more often than not. When things are this busy, when there is one fire after another to put out, it can feel like there just isn't enough air in the room - there's no breathing space. On days like this, it simply isn't possible to carve out an hour to call and invite patients for an asthma clinic in a couple of weeks. No wonder practice staff resort to costly, inefficient, but the least time-consuming, methods of recall (i.e. letters and one way text message blasts.)
Beyond having time to and will to begin the patient recall process, I'd argue that many of the tools that GP practice staff have at their disposal to run this process fall short of what is needed. Without the right tools, it is hard to do any task well.
In several practices that I have visited, simply knowing which patients are eligible can be a challenge. GP surgeries typically use searches in their patient administration systems to identify which patients to target. Searches can are either created by practice staff (for example, filtering patients by age, gender, and existing conditions), which can lead to all kinds of errors. Or, searches are constructed by a kind non-governmental body who has identified creating accurate searches is an easy win for public health.
Frequently, however, the wrong searches are used, or the search returns the wrong patients because the practice has not coded patients accurately.
Let's say that a practice jumps these hurdles and is in possession of accurate lists of eligible patients for all their targets: even now they require a feat of exceptional project management to hit all their targets. Different authorities set different goals for different programmes. Practices must track progress against each separate target (the conditions for which can change year to year) and then balance that external objective with the internal requirement of balancing the supply of appointments available for preventative appointments with the daily demands from patients.
Many practices turn to a combination of different systems to manage this complexity, their patient administration system, multiple excel sheets, and the staff rota, to name a few. Using these, they create a strategy for hitting their targets.
Usually, something has to give, and practices fall behind where they might hope to be, and the end of the financial year (most targets run April to March) can be a very stressful time. I've seen many practices then take an 'all hands on deck' approach to salvage these targets. This approach is less than ideal - it creates a stressful experience for managerial, administrative and clinical staff, typically during winter, when there is additional pressure on services.
We are over halfway through this post, and I have barely mentioned patients at all. Sadly, I think that this draws parallels to the design of many call and recall processes.
The commercial sector has become expert at designing creative communication, intuitive design and frictionless experience. This couldn't be further from the truth with call and recall.
The usual one-way invite (text or letter) will let the patient know they are eligible and to call their surgery to book an appointment. The burden of responsibility of an invite like this lies fully on the patient. Patients must now overcome the numerous barriers to booking like:
Richard Thaler, the Nobel Laureate in behavioural economics, said that "if you want someone to do something, make it easy". Right now, we are not making it easy for patients. What we have now asks patients to do something they don't understand the value of and then makes it hard to do.
I recognise that it may have felt a little bit doom and gloom up til now. But fear not, this is where I reward you with a teaser of a future post and the reassurance that a better version of call and recall is within reach.
When the management of a high-value activity (like the call and recall) is manual, complex, and repetitive, with an unambiguous definition of success (the uptake rate), there is an opportunity. An opportunity to bring design and technology to the table to develop a system that executes tasks and automates wherever processes can be automated.
Done correctly, an automated patient recall system would lead to better results than the original process while freeing up human effort to be applied where it can be most productive.
The founder of the Stanford Persuasive Technology Lab said that if you want anyone to do anything, three preconditions must be satisfied:
Accessible digital technology allows us to be a bit more creative in how we design call and recall processes to satisfy these conditions with each patient engagement.
In his book, The Health Gap, Michael Marmot advocates for what he calls proportionate universalism (PU). PU is the idea that services should be available to everyone, but greater resources and effort should be directed to those who need them most. PU will reduce the gap in health outcomes between the very rich and everyone else.
I agree with this entirely, and believe that we must ensure that preventative healthcare is reaching as many people as possible - but especially those at the sharp end of inequality. A better call and recall process would use data analysis to assign more resources to those who need the services most.
Victor Adebowale, the CEO of Turning Point (a social enterprise that runs substance misuse and mental health services across the country) said that "in the NHS it's possible to hit your targets but miss the point".
This might be true for the call and recall process itself and, indeed, several preventive healthcare programmes. High uptake itself is not the primary objective; it is just a proxy measure for good population health outcomes. But how sure are we that the targets we have set are the right ones? How sure are we that the negative knock-on-effects in GP practices from striving to hit these targets does more harm than good? How can we be sure that these programmes are the best way to achieve our goal?
I'm not sure, but I am sure that we need to think carefully about how we approach the delivery of preventive healthcare. As stated in the 2014 NHS Forward View: "If the nation fails to get serious about prevention, then recent progress in healthy life expectancies will stall. Health inequalities will widen, and our ability to fund beneficial new treatments will be crowded-out by the need to spend billions of pounds on wholly avoidable illness".
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