Positive psychology to reduce missed appointments

Shirley Bull, Ley Hill Surgery, Sutton Coldfield, Birmingham 

The problem

In our GP surgery, like many others, staff and patients were frustrated when people did not attend their booked appointments or cancel in time to free the appointment up for another patient. Missed appointments reduce healthcare availability for patients and put extra pressure on already stretched health services. Though there are many reasons patients miss appointments, surveys indicate that often they simply forget.

Solutions to address this issue are difficult to come by, with some staff feeling patients should be fined or face barring from the practice for missed appointments. Others worried this could be seen as uncaring by patients and research suggests that people could become more unwell, leading to increased use of emergency services. Notices in the waiting room pointed out the number of missed appointments or the consequences of this, to try to make people take this more seriously, but psychology research suggests that other strategies are likely to work better.

The Bright Idea 

In meetings of our Patient Participation Group, our GP partners and practice managers explained the difficulties the practice was having with missed appointments and asked for help. A PPG member who is also a psychologist suggested that two aspects of behavioural psychology i) social norms and ii) active commitments, could be helpful and have been tested in previous short-term research in primary care 

Social norms: People tend to follow what they think most people do, so notices showing most people in the surgery keep their appointments or cancel in good time highlight the social norm of people doing the right thing are likely to be more effective than those lamenting the waste of professional time when people don’t. 
Active commitments: The more actively involved we are in making a commitment, the more likely we are to keep it. Active commitments involve staff inviting patients to write down or repeat back their appointment when they book it. 

The PPG group and practice staff were excited to try these low-cost strategies out over a 12-month period in the practice to see if they could impact on missed appointments and cancellations. The psychologist worked closely with the practice manager and receptionist staff to change notices in the practice using each month’s figures (for instance ‘95% of our patients came on time to their appointments last month in January. Thank you!’) and the psychologist trained reception staff (2 x 30 minute lunchtime sessions before the project, 1 x 30 minute refresher session midway through) to invite patients when booking appointments to actively commit to cancel their appointment if needed and to write down their own appointment details. A health psychologist from the University of Manchester advised the team on the running of the study and data analysis, and helped make a short animated video to share the project findings. 

The bright idea was a very low-cost solution, with no equipment or specific funding needed. The project did need time for planning, but once the training was completed, the practice manager estimated time commitment to be 2 hours a month.

The impact

  • Patients: We improved access to GP appointments with patient originating innovation. Members of our PPG group supported all stages of development. This is a meaningful example of patient participation as a joint venture between a PPG member and the staff at the practice.
  • Staff: Members of staff were almost unanimously positive about their own commitment, understanding and confidence in using the bright idea.Staff felt well supported from their other receptionists and team leaders. Staff felt empower to be able to make a difference to DNAs. 
  • Practice: Reducing missed appointments by an average of 20% (up to 33% some months) 
    Increasing early cancellations by an average of 21%. Average of 37 fewer missed appointments per month, or approximately a working day saved every month.




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