• Analysis
  • November 22, 2018
  • 8 minutes
  • 1

Missed appointments cost government billions — can behavioural science help?

If services aren't accessible, their impact is lost on the communities that need them most

Designing better services with paper and an iPhone

Lost diaries, missed trains and scheduling mix-ups — there are countless reasons why people fail to turn up to appointments. But for governments, no-shows at services don’t just waste time — they cost vast amounts of public money too.

Countless working hours and huge sums of money are poured into designing and delivering frontline services. But that’s all for nought if people don’t use them, or fail to attend when they’re meant to. In 2016, missed patient appointments cost the UK’s health service in excess of £1 billion ($1.3 billion). And it’s not just the health services that suffer: job centres, prison exit schemes and antenatal care all over the world haemorrhage money from poor attendance rates.

Now, researchers are turning their eye to the practicalities of making people turn up, from the technical difficulties of flexible scheduling to new frontiers in behavioural science. The field is still relatively young, but with any luck, proponents argue it could transform service design and delivery and slash wastage the world over.

Push and pull

According to Yulia Shenderovich, a researcher at the University of Oxford, the factors influencing people’s attendance are varied, complex and largely understudied. One of the main problems, she argued, was that there’s still no consensus on universal push or pull factors.

“What encourages attendance in one context might not work in another,” she said. But her research, and another recent paper in Australia, suggests that traditional stressors like poverty have very little impact on attendance rates. Instead, certain minimal conditions need to be met for people to attend.

Flexible scheduling was perhaps the most important. “In our study, families dropped off at the end of the month. That was when they had to pick up their welfare payments,” she recalled. Families in full-time work also struggled to attend classes. Offering sessions during the evenings or at weekends could be one route forward, Shenderovich argued.

In 2016, missed patient appointments cost the UK’s health service in excess of $1.3 billion

Accessibility is another vital factor. Interventions should always take into account local transport links, particularly if targeting low-income families who might not own their own means of transport. If families cannot reach appointments — or are forced to travel inordinate distances to access services — it’s perhaps not surprising that their attendance rates suffer.

But according to Jamie Lachman, also of the University of Oxford, it’s also about understanding local rhythms and cultures, and then taking services into communities. An agribusiness and parenting program he evaluated in Tanzania managed to entice an unusually high number of men into attending the classes — no mean feat when emotional labour like parenting is all too often foisted upon women.

“If you meet men where they’re at, in their spaces, they will attend,” he said. By working within farming communities and offering practical professional help alongside parenting skills, the program incentivised attendance and alleviated the pressure of gender norms that discourage men from participating fully in child rearing and the domestic sphere.

But what works for small-scale interventions can’t always work in complex national services where flexibility is often a casualty of the bureaucracy required to keep the system ticking over.

Nudging norms

The UK’s Behavioural Insights Team is a world leader in applying the insights of behavioural science to policymaking. First founded as a section of the UK’s Cabinet Office, the team now exists as an entity in its own right — and works well beyond the borders of the UK, pulling in £14 million ($18 million) a year in revenue.

According to Jessica Heal, “it’s about understanding people’s context” — what makes them tick, what turns them off, and what’s likely to engage them.

That can take different forms, whether in making program design more user-friendly, or in adding nudges to pre-existing services.

The BIT’s study supporter program encouraged struggling pupils to nominate someone close to them who was willing to help them achieve in their academic career. The nominated helper received text messages and prompts to check in with the student, and encourage them in their academic work. “Not only did it improve attendance, it also increased attainment,” said Heal. “At a certain point, you don’t just want people to turn up, you also want them to get something out of it, and behavioural insights can help with that.”

“If you meet men where they’re at, in their spaces, they will attend”

The BIT is currently conducting research for the Forces in Mind Trust, a charity dedicated to supporting veterans and their families, to understand how to make the transition into civilian life easier for military families.

The project has only just concluded its exploratory phase, but behavioural science is already helping researchers understand why veterans can struggle to engage with transition services.

“The process is really long,” said Heal. Veterans need to register their intent to leave service a full year in advance, and some delay their preparations for life after the service until they’re back in civilian life.

“Maybe we need to reframe the way we talk about this process,” she added, suggesting that talking about leaving the forces in terms of tours — not years — might be more tangible to serving officers. Another promising avenue is communicating not just with the person leaving the services, but also with their family as a whole, helping their partners or children to prompt them into accessing the array of services currently on offer.

Shots in the dark

For now, upping attendance rates remains more of an art than a science, with few steadfast rules and solutions. But helping people to understand how their lives could benefit from accessing services is the common thread uniting disparate approaches.

Whether its behavioural science, text message nudges or user-centred design, putting service users first in the design process is the basic idea that could save hundreds of billions in government dollars across the world.

“We’re still not certain about what works,” said Shenderovich, “but we know that many programs could do a lot better than they currently are.” —Edward Siddons

(Picture credit: Pixabay/FirmBee)


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