Children’s missed health care appointments: an initial scoping review

Dr Catherine Powell, Dr Jane Appleton, Lindsey Coombes

BASPCAN Congress PresentationApril 2015

Background

This study builds on our previous work & presentation at BASPCAN Congress 2012

Children have a fundamental right of access to health care (UNCRC, 1989)

Failing to ensure a child’s access to health care sits within statutory definitions of neglect (e.g. HM Government, 2013)

Missed appointments are a known feature in the history of children who have suffered serious child maltreatment (e.g. Brandon et al.,2012)

Research Question

How do health care organisations respond when children do not attend/were not brought to their health care appointments?

Methods

The study, which began in August 2013, involved two work packages:

1. A web-based scoping review of NHS provider policies for managing missed appointments. The scoping review involved accessing health care provider web-sites across England, Scotland, Wales and Northern Ireland;

2. A case-study at one NHS Hospital Trust utilising a number of data sources (documentary analysis, semi-structured face to face/telephone interviews with 13 respondents, examination of the ‘systems’ in place, feasibility of case-tracking) to ascertain how a hospital system manages children’s missed health care appointments in practice.

Work package one:Web-based scoping review

Findings: web-site searches

180/185 web-sites for Trusts in England (17 policies) Seven Health Board web-sites in Wales (one policy & one guidance

document)

14 regional Health Boards web-sites in Scotland (national guidance)

Five ‘Health and Social Care’ web-sites in Northern Ireland (one multi-site policy and one guidance document)

Four Independent Provider websites (no policies)

Google search (three additional policies)

Findings: declaration of compliance(England)

Trusts in England are expected to have a public ‘declaration of compliance’ against safeguarding children standards (Care Quality Commission, 2009);

144/180 declarations were found and scrutinised for a mention of a policy for the follow-up of children’s missed appointments;

125/144 had an overt mention of such a policy on their websites.

Example of a declaration

Findings: Policies

Our concerns at the outset that the majority of providers would place their policies on ‘intranets’ rather than ‘internets’ proved to be the case;

The 24 policies/guidance that were elicited were rated against six pre-determined standards: 0 not met, 1 partially met, 2 fully met;

Mean score was 7.2, range 3-11.

Standards for rating policies

1. The policy/procedure provides a definition of childhood that recognises that childhood goes up to 18 years of age

2. The policy/procedure reflects the UN Convention/Children Act 1989 and the duty to meet the welfare and protection needs of CYP, including access to health care

3. The policy/procedure provides a statutory definition of neglect that includes the failure to ensure access to health care

4. The policy/procedure makes reference to the importance of following up children who miss health care appointments (rationale - evidence – research - SCRs)

5. The policy/procedure provides clear guidance on the action that should be taken to follow up children who miss health care appointments (action staff expected to take)

6. The policy/procedure provides an auditable quality standard in relation to following up children who miss health care appointments. (ref to audit in practice)

Findings: additional material

Additional material relating to cost-pressures and strategies to reduce ‘DNA’ rates more generally was found through the web-based searches (e.g. Board minutes) and reflect the efficiency pressures on the NHS at the current time;

However, the emphasis in many cases appeared to be primarily about managing 'the system' and introducing penalties for those who do not attend their appointments as scheduled;

There appeared to be an element of disconnect between the compliance statements on the one hand and the strategies and policies to address 'DNA's on the other.

Work package two: Case Study Findings

NHS professionals and staff continue to use and favour the term 'Did not Attend' (DNA) rather than ‘WNB’;

Sympathy for the parent can prevent the professionals from 'seeing the child' and serving their best interests

Sympathy for the parent can prevent the professionals from 'seeing the child' and serving their best interests;

Older children should also be involved in decisions about their care and this would include actions that may be taken if they fail to attend for health care;

The degree to which a busy General Practice is able to provide the monitoring, assessment and referral (back into the 'system'), or take a lead in taking forward a missed appointment (or series of missed appointments) is of concern.

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Findings

The importance of considering the consequences for the child of missed appointments was raised by a number of respondents, including:

What are the consequences of these missed appointments for the child/young person?

What is known already about [the family]? Why has there been missed appointments?  Has the clinician spoken directly to the parent about what’s

happening?  Does the parent understand the need to get the child to these

appointments?

Child-focussed?

'That’s a family with fluctuating circumstances whose mother essentially is well intentioned and does understand the issues and sometimes life is a bit much for her, but she will always come back in the end. I suppose that’s an advantage of having known her for about 14/15 years now'

'And the first couple of appointments they attended very well, I think I engaged with mum very well and she was clear that she wanted to do some work on changing his weight and obviously Social Care were pressing me to ensure she attended all appointments.

Recommendations: UK Health Care Provider Organisations

1. Review the title of local policies on children not attending health care appointments to clearly reflect a focus on ‘Did Not Attend’ (DNA) or ‘Children’s Missed Health Care Appointments’;

2. At the front-line, there should be simplified communication pathways to access guidance electronically on children’s missed health care appointments and a simple, one-sheet flow-chart outlining a clear pathway for decision making;

3. Children’s ‘Missed Health Care Appointments’ policies should be subject to audit and evaluation;

4. NHS provider policies on children’s missed appointments could include reference to ‘Did not Wait’ for those children/young people accessing the emergency department/A&E;

Recommendations: UK Health Care Provider Organisations

5. Risk assessments should include a review of whether there is a pattern of missed appointments;

6. NHS provider policies on missed appointments include a requirement to inform families that information on missed appointments may be shared with other health professionals and children's social care (CSC) and that when a decision to refer to CSC is made this is discussed with the family in line with best practice and statutory guidance;

7. That policies on missed health care appointments also reflect the importance of considering the implication of parents (and parents to be) not attending their own health care appointments and the meaning of this for their parenting role (e.g. antenatal appointments, appointments with substance misuse services);

8. NHS providers to review at what time point a cancelled appointment is counted as a Did Not Attend (DNA);

Recommendations: NSPCC

9. To put pressure on regulatory bodies to seek assurance from Executive Safeguarding Leads in Provider Organisations that their policies for managing DNA are congruent with their policies on follow up of children's missed health care appointments;

10. To seek assurance that Equality and Diversity leads in NHS organisations are inclusive of, and responsive to, the needs of children and young people.

Recommendations: further research

11. There remain some gaps in knowledge of 'what is happening' in terms of responding to children's missed health care appointments that can only be addressed through a more extensive study that involves children, young people and their families as key participants. A further study is required to understand missed appointments from the perspective of children, young people and their families and to explore what they perceive as relevant interventions;

12. A tracking study is undertaken to follow a cohort of children who DNA, through their health care pathway with particular attention given to the interface and communications between primary and secondary care;

Recommendations: further research

13.The degree to which a busy General Practice is able to provide the monitoring, assessment and referral (back into the 'system') or take a lead in taking forward a missed appointment (or series of missed appointments) as a safeguarding concern is an area for further exploration. There needs to be an understanding of the degree to which GPs are aware of the importance of children's missed health care appointments, or indeed, whether or not they have been involved, alerted or consulted on policies that directly involve them.

14. That further work is commissioned on the experiences of 16 and 17 year olds who are receiving their health care from adult services.

Further details of the study:

This study has been made possible by a small grant from the NSPCC

We would like to express our sincere appreciation to all the pilot study participants who contributed their valuable insights and perspectives to this study.

We would also like to thank the hospital Trust who supported the study and Tom Rahilly, NSPCC for his support.

ACKNOWLEDGEMENTS

For further information please contact:

•Jane Appleton - jvappleton@brookes.ac.uk

•Catherine Powell – catherine.powell@soton.ac.uk

Thank you for listening