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CAMHS won't see you now

About time NSAIDs were regulated

A pioneering practice in Somerset has helped to develop a patient text messaging service to crack down on DNAs ­ managing partner Deb Farnworth-Wood explains the surprising results

We are a progressive practice with more than 13,300 patients in one-stop-shop premises. With the wide range of additional services we offer and our use of multidisciplinary teams, it is important to us that appointments are fully utilised and that staff time is not wasted.

Over the years we have monitored DNAs and their effect on the practice, and with changing models of care we started to see new trends in DNAs, with specialist clinics being the most affected. DNAs for short appointments are less of a problem as the doctors and staff can fit in extra patients or use the time as 'catch-up'.

In reality, with urgent and extra appointments, we probably overbook surgeries, building in a factor for patients failing to attend. This does often backfire though, causing some days to be very stressful for those involved.

Wastage was increasing

We realised, however, that new care pathways, specialist staff and multidisciplinary working has significantly increased the wastage caused through DNAs. For example, while a patient missing a 10-minute appointment with their GP is inconvenient, longer appointments slots are more precious in that there are fewer of them and wasted staff time is greater.

Smoking cessation, physiotherapy and smear appointments are all 30 minutes while the counsellor's appointments are an hour. The members of staff undertaking this work are not necessarily able to help out elsewhere and thus their time can be wasted.

Across the practice our average DNA rate is less than 0.5 per cent, representing about 70 appointments a month, but certain areas stood out as having significant variation: health care assistants 6 per cent, physiotherapy 4 per cent, smear clinic 6 per cent, smoking cessation 5 per ent and warfarin monitoring clinic 3 per cent.

Mobilising mobiles

We came up with the idea that with the growing use of mobile phones we could text reminders to patients for the problem clinics, and that this facility would also be of use to our complementary therapy centre.

Initially we looked for an off-the-shelf package but discovered these required significant user-input which incurred significant staff costs. We wanted a system that was more automated and required minimum staff effort to use.

Prices for text services varied, and we felt certain we could get a better deal. In the end we enlisted the help of Stream Partners, a company we had worked with before and which specialise in health care IT systems. We asked them to develop a piece of software that would allow interrogation of our EMIS system for groups of patients or patients with appointments in specific clinics and then text them reminders using the computer.

In January we had mobile phone numbers for just 10 per cent of patients but within a month we had increased that to 14 per cent by a combination of raising awareness of patients via our plasma screen in the waiting room and by asking all patients making appointments for the four clinics above to provide a mobile number.

Trial difficulties

Our initial pilot targeted three specific groups of patients: smoking cessation, smear clinics and appointments with the health care assistants. We then searched patients with appointments in those clinics and text messaged them the day before to remind them to attend.

During the initial two-week trial, we encountered two difficulties. First, because we restricted the pilot to only a few clinics, the actual numbers of patients and texts were small. Second, the staff often forgot to ask for mobile phone numbers. Overall, however, the trial had promising results with a greater number of people actually phoning to cancel appointments that they couldn't attend and actual DNAs reduced too.

The most pleasing aspect of the trial was that it quickly became apparent that text messaging provided other opportunities. We can remind patients to come in for medication reviews, announce flu clinic dates to patients in the target groups, and send reminders for chronic disease clinics.

The time involved in searching the patients is only a few minutes now we have a search set up and we have one standard text message that goes out for all appointments.

We also have the opportunity to save several text messages which means we do not need to retype them for each batch of patients.

Each text currently costs 10p but this price will reduce significantly with volume.

There were of course a number of hurdles to overcome before we launched the service, confidentiality being the main one. We had to agree what would be inoffensive wording - just in case other members of the household saw the SMS message, but as mobile phones tend to be personal we felt this was low risk.

Reminders for appointments simply say 'Reminder ­ you have an appointment tomorrow please call (tel. no) if you are unable to attend'. And the originator of the text is shown as EQMC (short for East Quay Medical Centre).

Of course not all patients have mobile phones, but the number is rising and we have been pleasantly be surprised by the wide age range of those that have them. Nationally, the growth of mobile technology has exploded in recent years.

Evaluating progress

In 2004 25 billion text messages were sent in the UK. According to an Oftel survey, nearly 80 per cent of all adults own or have access to a mobile phone. Ownership of mobile phones varies with age, with 90 per cent of 15- to 34-year-olds using a mobile phone and almost 30 per cent of over-75s using mobile telephones.

It's this last mentioned generation that sees the most significant increase year on year, having nearly doubled in users within the last two years, so time invested now in setting up the system is a good investment.

Following the trial the software was enhanced to allow the patient to text back a cancellation rather than call, providing the patient with another option and ensuring that we do have the opportunity to re-use the appointment.

It is early days yet and we are continually evaluating progress. The next step will be to identify groups of patients on specific medications that may reflect a hectic, disorganised lifestyle, providing an opportunity to remind them to attend their appointments too.

Deb Farnworth-Wood is the managing partner at New East Quay Medical Centre, Bridgwater

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