I didn’t see the appointment letter in the first place!
Most of us have probably missed an appointment at a hospital or clinic for one reason or another. You forget, you have mislaid the appointment letter, got the wrong day, something urgent crops up…or maybe something more appealing like lunch with a friend. Of course, it’s possible the dog may have chewed it up and deftly removed any tell-tale traces, dogs are usually quite good at that.
However, the number of appointments that are missed every year is staggeringly high and the cost will astound you. Yet how many people never saw the letter in the first place when it arrived through their letterbox and remained on their doormat in one piece, only to be discarded with the recycling?
Seeing is believing
GP’s, opticians, dentists and hospital outpatient clinics all suffer the same problem of patients not turning up when a time has been booked out for them. Yet if you have low vision, partial sight or any sight impairment, the chances of you even knowing a letter has arrived is probably quite low. Many people with low vision live alone, happily independent; it cannot, and must not, be assumed that there is ‘bound to be a helper or relative’ to check up on their day-to-day needs, appointments and correspondence. This assumption undermines perfectly able people who only need additional – and usually small – extra support.
The reason people with low vision can’t read letters is of course obvious, because the print, albeit fine for anyone with reasonably good vision, is often too small for them to read. Many thousands of elderly people have limited vision, as well as younger people with congenital conditions and those who have lost their sight for other reasons. Whilst this cohort of patients will not account for the entire ballooning cost of missed appointments, the number is significant and most people in this group would not have intended to do so. They are likely to feel at worst, upset, and at best, cross that they did so, and through no fault of their own, yet it would also be very easy to rectify this.
We’re all equals
Administration at hospitals and clinics across the length and breadth of Great Britain is now digital. Modern computers are used in every reception area and the facility to enhance and enlarge the print is a simple click of the mouse. It doesn’t take a tech boffin to understand how to set the computer to large print and produce a letter and even the most junior member of staff can cope with this so it beggars belief that this simple solution hasn’t been factored into the process of organising and arranging clinic appointments for people with low vision.
It would be another simple procedure to categorise patients with significant sight impairment into a separate register in order to facilitate the process with maximum efficacy so of the millions of missed appointments, at least several thousand could be saved, lessening general irritation as well as losing the NHS valuable cash resources.
Are the practice management systems fit for purpose and do they allow for patients accessibility requirements? We know that health and social care systems need to join up more effectively, so if a patient with low vision sees their local Optometrist and they refer them for Ophthalmology input, why at the same time could the system not refer them automatically to social services or local sight loss charities?
What about the Equality Act 2010, you may be wondering? What about it indeed. Yes, by not including people with visual impairment in communications by making reasonable adjustment to standard procedures, this is now classed in law as discrimination. Of course, it’s not intentional by the NHS but it is, nevertheless, indirect discrimination. To expect someone with low vision to be able to read an official letter, written in standard sized print, from a public body such as an NHS hospital is demeaning and disrespectful and protection against this sort of judgement is enshrined in law.
What is remarkable is that this comes at a time when the NHS is crying out for funds, begging successive governments to allocate extra millions of pounds; on top of this, it makes no sense that NHS England is urging patients to cancel appointments rather than just not show up because it has documented that over 15 million appointments are lost each year through people not turning up – what a forbidding waste.
This further denigrates those with low vision who missed their appointments due to not being able to see the letter when it arrived, making them feel side-lined as if they can be dismissed from the tide of those who don’t turn up; in other words, they don’t count, exactly what the Equality Act 2010 seeks to eliminate.
The Equality Act states that service providers must make ‘reasonable adjustments’ but also anticipate what adjustments could be expected; for example, an eye hospital knows that many of their patients won’t be able to see very well, hence why they are accessing this service. Therefore, they should anticipate that people may need letters in a range of formats including, email, Braille, audio, easy read and large print.
But Doctor, can I see you?
Furthermore, approximately 7.2 million of these no-show patients are with family doctors so this is often the first port of call for a person seeking advice or specialist treatment. If patients are not seeing letters at this early stage, what hope do they have for seeking prompt action for further help for what might be a serious problem concerning their eyesight? It doesn’t instil people with low vision, including those who are fearful and feeling anxious about deteriorating vision, with much confidence in the system and how many patients are going blind as they couldn’t see the appointment letter?
There is yet another side to this; we are constantly hearing that GPs are in short supply, yet the latest figures from NHS Digital reveal that these wasted appointments amount to a shocking 1.2 million GP hours being squandered away each year, about 7.2 million of which are with family doctors which is the equivalent of more than 600 GPs working full-time. Patients are being urged to inform the surgery rather than just not attend but how can they inform when they were not aware of the appointment in the first place?
You can see the scale of the problem, it spreads further than just a simple letter that was overlooked; the latter word says it all, it wasn’t looked over at all. To put this into further context, here’s another surprising twist you may not have thought about; each year, there are on average about 307 million scheduled appointments with GPs, nurses, therapists and other health practice staff. It is estimated that around 5% of these are left unattended which doesn’t seem to amount to much when you put it like that, however, when you realise that 5% translates to one in twenty appointments left blank, it works out at around 15.4 million missed slots. That is a huge number of gaps that would easily be filled if enough notice were given to inform other patients that there has been a cancellation. Furthermore, many of those patients who could have been given an earlier appointment time, whether they are patients with low vision or any other condition, may well be people who are worrying about a health problem; this adds to their burden of anxiety which, in itself, is going to have a detrimental effect on their metal and/or physical health.
Working it out
Without wishing to add fuel to fire, I am not exactly gong to fan the flames when I say that some of these patients waiting for an available appointment slot may well be sitting at home off work, either through the stress of awaiting diagnosis or from the condition itself. Now, if anyone is self-employed and off work, they will not be paid a salary during this time adding to the strain under which they are already suffering, trying to cope with paying bills. The flames of this bonfire really begin to lick the economy when you consider that without earning there is less tax being paid to the Treasury and less tax in the system means less money being poured in to cover the cost of increased revenue which the NHS so badly screams out for.
This escalates into a preposterous leap of flames because each appointment costs an average of £30. Therefore, the total annual cost to the NHS is over £216m which would fund the annual salaries of 2,325 full time GPs or 8,424 full time community nurses, it could pay for 224,640 cataract operations or 58,320 hip replacement operations as well as 216,000 drug treatment courses for Alzheimer’s
Can you now begin to see the effect that missing a clinic or surgery appointment has and how it helps to fuel a volcanic mushroom of flame and ash? If patients with low vision were sent letters in their preferred format, it would at least make a dent in this disastrous crisis and save a lot of annoyance, stress and worry.
Accessible Information Standard
On a more uplifting note, NHS England has developed the Accessible Information Standard (AIS) which came into effect on August 21st 2016 and work is being done to ensure surgeries and clinics are compliant with its mandatory standard; it is all about making health and social care information accessible
One of the directives of the AIS is to adopt a consistent approach towards the communication needs of people who have a disability, impairment or sensory loss and who use NHS services – including carers – and under its rules, each trust should deliver the same standard according to the directive.
Patients should be asked if they have any communication needs or need to be given information in a certain way or require support with communication and these requirements need to be recorded without complex understanding so that anyone can access it. The question is how many health care professionals are aware of this standard and are implementing it in their division?
These simple steps alone would make a huge difference to improving the experience of people with a disability, impairment or sensory loss; the same applies to SMS reminders.
The further good news is that all organisations which provide NHS care or publicly funded adult social care are also legally required to follow the AIS which was further revised in August 2017 following a post-implementation review of the Standard. This will go a long way to avoid the discrimination of receiving a letter that you cannot see due to the print being too small.
It is not the whole answer to missed appointments as patients need to be better informed to notify their health clinic if they no longer need their appointment or cannot make it, but it would make a difference for those with low vision and take away the worry. Similarly, evening and weekend access to surgeries is in the early stages of being rolled out and will help avoid inconvenient times.
On trial
The next bit of good news is that the NHS is conducting a trial with digital innovation to slash the number of missed appointments and save up to £20m. This is also where the need for large print becomes necessary if it is going to help patients with impaired vision or other sensory difficulties.
The online portal under trial is called DrDoctor and by using this facility, patients will be able to book and change their medical appointments online, receive text reminders about their scheduled appointments and can fill in medical forms before they arrive at the clinic. They can also receive appointment letters digitally – which, one hopes, will be with an option for enhanced font size – and can access maps which will clarify where in a hospital they need to go to get to their appointment which is another area which can be immensely challenging for anyone with visual difficulty. The tool is set to be trialled in ten hospitals and needs to take into account patients with low vision.
The ten current hospitals where DrDoctor is already in operation include Guy’s and St Thomas’ NHS Foundation Trust in Central London and Frimley Health NHS Trust and it is no surprise that the hospitals in the scheme are already announcing savings of up to £2m a year by cutting missed appointments and have seen a remarkable drop of almost a third in the number of no-show appointments. This has also meant a significant lowering of postage costs by more than a quarter to send out repeat letters, offering an alternative time.
In view of the financial struggles of the NHS it may be apt to end with the notion that preserving and utilising available funds is more about, ‘Not a penny more, not a penny less.’
Daniel Williams is a Man on a Mission with Low Vision and Founder of Visualise Training and Consultancy. Please feel free to join the conversation by commenting below.