It was a cold afternoon in late 2003. I was sitting in the waiting room of the GP practice with family for a check up when I noticed the notice on the wall; it read ‘Last month, 417 patients missed their appointments! Please keep it or cancel it, but don’t miss it’.
I started thinking, gosh, that sounds like quite a lot of missed appointments for a single month for a GP practice; it looks like quite a wastage of time for the medical team here…. and, if those 417 people had not missed their appointments, perhaps our appointment as well as for others sitting in the waiting room would have been possible much earlier.
That evening, being curious, I sat in front of the computer and did some research- what I found was incredible and blew my mind.
The notice I had observed at the practice was from a campaign by DPP (Developing Patient Partnerships) encouraging more responsive behaviour from patients- to to cancel or rearrange their appointments if they can’t keep it. The problem of the missed appointments was of astronomical proportions. According to the DPP and BBC reports, and there were 17 million missed appointments a year for the GP doctors and Nurses! 17 million, (and that’s not counting the appointments for Surgeons, consultants or hospital related visits, MRI / CT scans / Angiography, wasted Ambulance journeys when patient aren’t ready etc.) According to the DPP Missed Appointments Survey 90% of the respondends of DPP said reduction in missed appointments would save money for the NHS / UK tax payers as well as reducing the waiting times.
For a while (and occasionally even now), I used the 17 million missed appointments figure as an interactive quiz when discussing the issue of missed appointments, providing them with a Higher or Lower hint to gravitate towards the actual number. Invariably, people start with few hundred thousands, then go to millions, when they reach ten million, and I still say its higher, there is disbelief in their eyes and inevitably, the scale of the problem dawns on them. The costs of missed appointments run into hundreds of millions of pounds, according to BBC costing NHS £575 million per year.
This seemed like a big enough problem, a stretching challenge; with big impact on people’s lives that something had to be done about it. I figured that current state of technologies ought to provide a solution to save some part of that huge wastage of the tax payers’ money. Given that there were long waiting times in the NHS- gaps of many months between booking and actual appointments- it seemed likely that people forgot when their future appointment is occurring. The obvious answer (well, obvious to me at that time anyway), was to remind patients about their up coming appointments to ensure they don’t miss them. A text messaging service would be ideal to solve this issue (remember it was 2003, at that time, apart from one hospital in London, no one was talking about or implementing the text reminder service for health services). When faced with the dilemma that not everyone would have mobile phones, especially the elderly, I figured that we could provide an Interactive Voice Response (IVR) system that would allow the patients to receive appointment reminders on their land line phone as recorded audio messages. The service can then be used to take the patient’s confirmation (please press 1 to confirm you will be coming) or allow them to indicate they can not make it (please press 2 if you can not come). Indeed, the concept would allow cancelled appointments thus captured- when patient has pressed 2 to indicate they won’t be coming- to be offered to other patients further down the line; e.g. calling patients on the waiting list, with the message, ‘There is a short notice appointment in your local hospital available for tomorrow at 3 pm; if you would like to take this appointment press 1 in the next 60 seconds, if you do not wish to take it, just hang up, in which case your original appointment would remain unchanged.’
Any appointments moved to the early slot would make its own original slot available, for which other patients further down the line could be asked if they want to come early. The process would have a hopping effect where patients could receive invitation for earlier appointments move and allow others to move in their place- net effect, shortening of the waiting lists and waiting times (which for many departments back in 2003-2004 were like 6-9 months (if you broke a tendon, it was around 6, 7 months before a consultant or surgeon could see you- all the while the patients had to endure the pain and discomfort of their ailments). And best of all, we could make it multi-lingual, having inclusion and accessibility, getting more brownie points and enabling a really good service to help needy patients, reducing wastage in the system and saving money for the government. It was just perfect.
Except for two things, which happened in quite quick succession. First, I found out that NHS moves at a glacial pace, some of the decision making committees only meet once in 5, 6 months, and there is enough on their agenda already so they do not discuss any thing new. I discovered that generally, there is a change averse culture and every thing needs to go through trials, re-trials, re-validations, and layers of approvals, but what surprised me most were the the attitudes in some areas, attitudes that seemed to me based on arrogance or ignorance. The problem also was that while the waiting lists and waiting queues problem was a huge problem, it was “no one’s” problem. There wasn’t anyone responsible, accountable or answerable, there was no danger of heads rolling if the problem was not effectively solved. Therefore, there was no particular urgency or need for any one to solve it. It seemed no one wanted to put their head above the parapet and do something that may have a chance of failure.
The other thing, was a chance encounter with an elderly lady.
Being an entrepreneur, we mainly run with our hunches, with the gut feeling- and most of the time, the initial gut feeling is right also. However, Entrepreneurs also tend to verify assumptions and take stock as we go along. As I was developing the concepts, frameworks and solutions for the grand ‘missed appointments’ problem, I found myself routinely getting engaged with people, especially the elderly, when travelling in the trains and buses. The discussions in variably turned to NHS, the appointments and what can be done to solve the issues. I liked to listen to them as they defined the problem in their own way, and shared their experiences. And then I would gently introduced the ‘What If’ proposition, the reminders solution that may be able to assist, inviting their thoughts on it. By and large, people liked the idea of a simple solution that reminds them of an upcoming appointment, through a phone call and a human recorded voice provides that.
But this elderly lady I met on a train journey to Falkirk, said, “But text messaging is not the answer dear…”, she continued with a twinkle in her eyes, “you see, I don’t forget my appointments, but sometimes, I have to go pick up grand children from the school or some other requirement has come up, so I can’t get to the appointment. I call the hospital or the practice 2 or 3 times, but you know they are always engaged, their voice mail is also full so there is no way to talk to them, to tell them I cannot come. So after a few tries I give up, usually thinking why can’t the bloomin’ hospital or practice put in more phone lines!!!”
That was an aha moment for me… that the real problem is not that people forget and therefore need reminding (although they do- and text reminders would certainly help). The real problem is to provide an alternative channel of communication that is not suffering from capacity constraint issues. Phone lines are a scarce resource, receptionists even more so. They have to deal with the patients in front of them, make appointments on phone for patients needing to be seen, and deal with other tasks like prescriptions, paperwork and payments etc. And after 5:00 pm or 6:00 pm when the practice is closed, there is no one to answer the call- what if the tired teacher or office worker returned home after 6:00 and wants to engage with health services -although, in recent years there is a message on the answering machine for emergency contacts, but if it is not emergency, then there isn’t much option to touch base with the health services to manage one’s appointments.
Suddenly it all made sense. While we had nearly completed the solutions (we called it internally as AudioDiary and automated appointments Re-Allocator), it was time to go back to the drawing board and think afresh about the actual problem that the people were telling me about.
Fast forward a few years, with a lot of discussions with customers / patients and health care professionals, with heavy R&D, we made the core platform of AppointMentor. The vision, albeit grand- is a simple one. Allow people (patients or customers) to be able to book, cancel, and manage their appointments 24×7, from any device, from anywhere. Through AppointMentor, we can surface the service provider available appointment slots, allowing patients (or customers, if it is a non-healthcare organization) to book appointments for the services that the practices or organizations have marked as available for Online Booking. It has a lot of intelligence built into it (probably subject for another blog post) as well as flexibility and easy / intuitive user interface. And now it is operational and provides many millions of patients the ability to manage their appointments online, with ease and without hassle.
Funny how a sentence on a train journey can change the direction of your thinking and solution building activities…