Start date 01/06/2023

Background and rationale:

The COVID-19 crisis has added further strain to an already overstretched healthcare system. The rapid transition to digital health and increased appointment waiting lists are a direct consequence of the crisis. NHS Digital reported between 2015-2016 over 7.5 million (6.7% of the total) NHS outpatient appointments were missed in England. An unused time slot costs the NHS £160. Additionally, there are potential health impacts caused by the delay in treatment and longer waiting lists [5]. A knock-on effect is the increased demand in other sectors of the health service, including accident and emergency. The NHS long-term plan (2019) recognises that technology is continually opening up new possibilities for prevention, care and treatment. Our Solution technology can play a central role in realising this ambition by helping patients and clinicians use their time and capacity appropriately, enabling service transformation.

Our Solution aims to offer and make available online appointments to be accessed by chronic patients review , mental health support , prescriptions and reviews , blood test reviews, freeing up time for better patient care while reducing the revenue loss associated with missed appointments. We are also incorporating behavioural science elements and linguistics to understand how the best use of language (with specific language for specific cultural groups) can nudge patients to attend appointments and improve understanding and therefore compliance. Our Solution will aim to improve the efficiency and sustainability of NHS appointment management by significantly reducing one of its biggest drains on revenue/resources - no-shows and improve inclusivity. In line with the NHS Long Term Plan,(Our Solution’s conversational agent) will aim to facilitate preventative, personalised, prudent, equitable, and value-based integrated healthcare.It is estimated that diseases caused by hypertension cost the NHS £2 billion every year. Hypertension is underdiagnosed and the morbidity and mortality associated with this is very high. Our solution aims to identify hypertension earlier and manage it better, improving compliance and control, giving patients more control of their health and therefore reducing secondary complications helping physical and mental health.

A 2022 survey of children and young people’s mental health found that 18.0% of children aged 7-16 had a probable mental disorder in 2022, up from 12.1% in 2017. Among those aged 17-19, 10.1% had a probable mental disorder in 2017, rising to 25.7% in 2022.This has resulted in increased pressure on GP Practices for appointments. A recent study by The Kings fund estimate up to 40% of GP consultations involve mental health. Mental ill health is the single largest cause of disability in the UK, contributing up to 22.8% of the total burden, compared to 15.9% for cancer and 16.2% for cardiovascular disease according to the WHO . The wider economic costs of mental illness in England have been estimated at £105.2 billion each year by the centre for mental health. This includes direct costs of services, lost productivity at work and reduced quality of life.

Our solution provides a safe, flexible effective option for patients to choose how best they want to interact with a professional to receive the support they need at the time when they need it the most without the need to wait reducing the negative impact and future exacerbation and consequences of waiting leading to saving lives improved health outcomes, equitable outcomes and saving NHS money.

Research Questions

• Can the use of the Solution platform increase the number of appointments attended and therefore reduce the costs to the NHS associated with appointment non-attendance?
• Will patients benefit from the introduction of the Our Solution platform into the healthcare system, for example earlier diagnosis/introduction of treatments?
• How do users of the Solution platform describe their needs with regards to appointment booking (offline and via the Our Solution platform) and what are the differences between the needs of different patient groups (socio-economic status, digital literacy, etc.)?
• What are users’ experiences of the Solution platform and how are they linked to whether their expectations can be met by it?

Aims and Objectives:

The feasibility study aims to demonstrate that use of the CheckUp Health platform:

• is compatible with current NHS systems; (integrating with EMIS appropriately)
• meets the needs of users (patients, medical staff, etc)
• allows patients to easily and quickly book, reschedule, and cancel their appointments.
• (via a high level proof of concept) can increase the number of appointments attended, consequently reducing the burden on NHS resources (low DNA rate)

Furthermore, the feasibility study will

• collect quantitative and qualitative data to inform iterative design and development to continue to meet user needs.
• collect quantitative and qualitative data that will inform a future definitive trial, such as
  • the % of missed appointments,
  • Typical presenting complaints
  • Age range or demographics of those using the services
  • Percentage of patients requesting consultations in one of the five foreign languages provided by the platform.
• Conduct usability testing sessions with participants representing key user groups, analysing feedback to inform future iterations.
• assess the effectiveness of Our Solution in altering the course of action, i.e. achieving appointment attendance greater than that usually seen in primary care.

Project:

Providing two GP practices 12 hours of NHS appointments per week for 12 weeks as a pilot project as we align and develop the systems.

Total: 144 hours of appointments per practice.

Logistics:

• CheckUp Health will manage all aspects of the project.
• NHS Practices do not at this stage need to use the CheckUp Health platform.
• The NHS practices may receive direct tasks on EMIS from the CheckUp team requesting referrals be transferred to NHS templates and blood test requests.
• NHS practices will have full visibility of appointments on EMIS, and can have input on when we release these, but not be able to directly book in at this point in time
• Patients can be directed directly to the app or CheckUp customer services: 0345 5652081
• A two weekly short meeting just to refine processes/pass on concerns/compliments/ideas etc!

Study Design and Sample Size

The key outcomes from the study to demonstrate proof-of concept of Our Solution are that

• use of the platform increases the uptake of appointments/ has a low DNA rate
• Patients are able to complete a booking, rescheduling, or cancellation journey first time with minimal to no medical receptionist intervention

Patient Inclusion/Exclusion

• Patients must be a registered patient at one of the two pilot GP sites.
• Likely to need a basic level of digital competence / skills
• Must be an Android or iOS user

Measurable outcomes:

• Number of appointments provided: 54 20 minute appointments
• Proportion of appropriate appointments (ie - patients should have gone to A+E or other care providers): 100% appropriate
• DNAs: None 0%
• Monthly growth in utilisation of appointments: 575% growth from month one (full month-June) to final month (full month-September).
• What the appointment is for: Minor illness, mental health were the main most frequent presenting complaints.
• Most common day for appointment usage: Monday
• Age range of patients: 1-76 years old. Median age: 42 years
• Male: Female ratio: 43% male: 57% female.
• Foreign consults: 3.7% of consults.

Who used the services:

Appointment uptake:

Challenges:

• Initial challenges included IT difficulties such as registration trouble that was quickly fixed.
• Patient perception of online services
• Encouraging the GP surgeries to inform their patients of the service.
• Small sample size, small trial length

Conclusions:

The feasibility study demonstrated that use of the CheckUp Health platform:

• is compatible with current NHS systems; (integrating with EMIS appropriately)
• meets the needs of users (patients, medical staff, etc)
• allows patients to easily and quickly book, reschedule, and cancel their appointments.
• does increase the number of appointments attended, but further appointments or further time would be needed to demonstrate that this consequently reduces the burden on NHS resources.
• Is used by patients with a wide range of age between 1- 76 years old which highlights the ease of use of the app and its inclusivity.
• Is used to consult in a foreign language.
• The system was used appropriately, no poorly patients waited for an appointment rather than seeking emergency help. Patients are improving at knowing what problems can be dealt with remotely and the triage system prompts may aid with this.
• Time was saved with no missed appointments - standard rate is roughly 2-3% DNA rate which would have converted to 1 - 2 missed appointments in the sample size.
• The monthly growth highlights as patients know and hear about the services the credibility goes up and others book in. There will have been an element of the GP staff getting used to offering the CheckUp Health platform as an alternative solution to their patients.
• The most common problems entailed minor illness such as tonsillitis to mental health issues. the platform is well set to offer mental health appointments as quite frequently these are the patients crippled by anxiety now always willing to come to the GP surgery. CheckUp Health allowed patients to book in at their convenience without having to speak to anyone and at times that suited - which was traditionally the evening - times not usually offered by GP core services - only the out of hours services which are not always the most appropriate services to deal with declining mood, anxiety etc.

The feedback was positive and the pilot surgeries have been happy to continue on with the service provision so we can continue to modify and improve the services provided and IT solutions.

Action Points:

1. Adding in an additional booking pathway for patients so that the reception team can book them in from their EMIS screen, this will hold the appointment for up to 2 hours to allow time for the patient to register for the services.
2. Further development of more languages
3. Continue to gather data as more numbers use the service. After discussion at the end of the project, the numbers of appointments for October have gone up considerably so just having the staff aware on how to direct their patients to our services.

The project continues while changes are in progress.

Project Extension: (Phase 2 of project roll out)

Aims & Objectives:

Continuation of the overflow appointment trial while development works to implement the change in booking system were being developed. It was felt it would be detrimental to the service and local provision to withdraw services completely while the said improvements were taking place so this was looked at as a holding phase.

Appointments were offered to Park View Medical Centre in Manchester by CheckUp Health at various times of the day between Monday – Friday. Upto a maximum of 8 hours per week were offered to the surgery between 1st October to 25th January 2024, with set planned closures in November and December for system updates and improvements.

The trial was continued in this phase where possible:

• To develop a better understanding of who and what the service is best at dealing with.
• To receive further patient and staff feedback to continue to shape future developments.
• To further develop relationships with the staff at the surgery the patients and their familiarity with the product.

The inclusion and exclusion criteria remain the same.

Results:

A further 250 appointments were offered over a 3.5-month period. 36 appointments were booked, and all were attended.

Appointment uptake increased to 14.4% of appointments offered.

Measurable outcomes:

• Number of appointments provided: 36 20-minute appointments.
• Proportion of appropriate appointments (ie - patients should have gone to A+E or other care providers): 100% appropriate.
• DNAs: None 0%
• What the appointment is for: Gynaecology, mental health then musculoskeletal problems were the main most frequent presenting complaints.
• Most common day for appointment usage: Monday, followed by Thursday.
• Age range of patients:
  • <18 = 2
  • 18-45 =23
  • 45 – 66 = 9
  • >66 = 2
• Male: Female ratio: 25% male: 75% female.
• Most popular consultation time: 19.20 – 20.20.
• Most appointments are booked: On the day of the appointments.

3 trust pilots were received over this period, two were 5 stars praising the service, one was 3 star due to restriction in not currently having the ability to provide an NHS prescription.

Conclusions:

1. Accessibility:
   1. Patients can book an appointment on the day they required (Reducing the burden on the GP practice and helping patients earlier. It also may highlight that patients are only aware of the service as and when they are contacting the GP’ surgery for an acute problem)
   2. Patients of all age groups (1-76) are using the app showing how user friendly it is.
   3. Evening appointments – appointments that suit busy patients juggling work and life – the uptake of the evening slots were the most popular and offering patients times usually not possible with the GP practice.
2. Uptake: is increasing as staff and patient are more familiar with our services.
3. Money Saved:
   1. The 0% DNA rate continues with saves money on missed appointments.
   2. Offering patients same day appointment hopefully helps patients recover faster with less time off work and less need for more lengthy appointments due to any complication missed due to delay in initial diagnosis.
4. Languages:
   1. We have on offer 5 different languages – the app can be used in and appointments can be booked in them. Patients can choose to consult in English but have their app in their chosen language if they prefer and vice versa.
5. Improvements: NHS prescribing is essential in the long-term plans. During testing there has been a shared agreement between the teams for prescriptions that could be raised by the duty doctor. CheckUp could also provide private prescriptions if required.

Evaluation:

Positives:

1. Accessibility remains favourable.
2. language options distinguish CheckUp Health from other providers, increasing Inclusivity.
3. Increasing resilience of the GP practice offering additional support.

Improvements:

1. The biggest barrier is getting the service known about – as this has been beta testing no budget was allocated to marketing. With adequate marketing the uptake could increase upto 100%.
2. Development of the NHS prescribing capability

Plan:

1. To implement a further period of testing following recent updates on the EMIS API functionality which allows practice admin staff to book directly into the CheckUp Health system, improve patient appointment access experience through a seamless diary and more options for health monitoring.
2. To continue to work towards being able to offer NHS prescriptions raised from the platform so that we can ensure workload is entirely managed by CheckUp Health team.