Transformation Directorate

Digitisation of Out-Patient Letters

Background

Appointment letters are a necessity within the NHS, but it is both time consuming and costly to post out physical letters. Without the ability for patients to easily cancel or change their appointments, there can also be a number of wasted appointment slots which can have a major impact on the efficiency of a hospital and the maximum utilisation of clinic capacity.

Situation

Northern Lincolnshire and Goole NHS Foundation Trust (NLaG) wanted to reduce the admin burden for staff, the number of appointments where patients did not attend (DNA rate) and the physical cost of printing and posting their out-patient letters by digitising the process.

As part of the Outpatient Improvement Programme, the trust was also looking to reduce paper consumption and the reliance on paper records across their three hospital sites.

Aspiration

By switching to digital patient letters for out-patient services, patients are able to view appointment letters on their smartphones, providing the ability to confirm, cancel or rebook appointments digitally, improving the trust's confidence that patients are receiving and reading letters.

NLaG also wanted to reduce its DNA rate and make significant savings on postage and printing costs, with the original business case estimating the switch to digital letters would result in cost savings of £136,000 in the first year.

Solution and impact

NLaG began working with Healthcare Communications in September 2020 to implement digital letters, using data sourced from the Trust’s appointment management system, CAMIS PAS.

  • Following a successful rollout of the technology, more than 65% of eligible patients are now using the solution, benefitting from the ability to confirm, reschedule and cancel appointments via mobile, tablet or desktop.
  • Cost savings in the first year equalled £152,000 in postage and print costs

Instead of receiving traditional paper letters, patients can now receive a text confirmation of their appointment from NLaG which includes a link that directs them to the trust’s patient portal. Once they have accessed the portal, they are required to input a PIN number and their date of birth to access their letters. Text messages include the name of the intended recipient, so that the person knows that the message is for them, while parents and carers receive additional information to ensure they can identify who the appointment is for, before clicking through to the portal.

Patients benefit not only from digital letters, but also from two reminder text messages; the first of which is a bi-directional message which allows them to confirm, re-book or cancel their appointment and is sent 7 days prior to their appointment. The second is a non-interactive message sent 48 hours prior to their appointment and confirms the appointment details, including whether the appointment is in person or on-line.

Patient portal for digital appointment letters

Responses to the hospital to change or cancel appointments are sent in ‘real-time’, and clinic or hospital-specific instructions and other essential reading can also be accessed through the portal.

Where the trust has a patient’s latest mobile phone number, they will automatically be opted in; although patients are also able to opt out of the service.

The trust has recorded 540,341 up to date patient mobile numbers in the last year, equating to 70% of all patients. Over 65% of eligible patients have chosen digital letters over traditional printed communications.

The platform also allows NLaG to ensure it is communicating with its patients in their first language, which in a diverse community will improve the patient experience and help to reduce missed appointments through miscommunication.

Appointments, once confirmed, can be added to patients’ own digital calendars, and accessibility tools include the ability to translate pages into 99 chosen languages, the use of text magnifiers and text highlighting, and the choice to have messages read aloud. A live travel map is also included in the portal to guide patients to the correct area.

Since the introduction of digital appointment letters including the sending of two reminder texts to patients before their appointment date, NLaG has seen a reduction in appointments where patients did not attend. Cancelled appointment slots have been given to waiting list patients, helping to reduce patient backlogs and improve the efficiency of the hospital.

Digital appointment letters have empowered both the trust and the patient. In addition to patients being able to cancel and rebook appointments, NLaG can provide up-to-date information to the patient, for example, informing a patient to come in at 11am rather than 8am. This reduces time wasted for patients and contributes to improved patient experience, as well as allowing NLaG to improve the way it manages staffing levels needed for appointments, meaning staff time can be utilised for other value add tasks.

Patient feedback on accessing digital appointment letters

Functionality

  • Uses low cost text and interactive voice messages to communicate with patients.
  • Secure patient portal where patients can view appointment letters, clinic specific instructions, essential reading and other hospital information.
  • Patients can add appointment details directly into their digital calendars from the portal as a further reminder.
  • Digital content converts to 99 languages in two clicks, font can be increased and highlighted and background colour changed to improve patient accessibility.
  • If the digital letter is not accessed within 48 hours, a postal version is automatically sent to patients.
  • Patient responses are reported back to the hospital in real time.

Capabilities

  • Patients can confirm, reschedule and cancel appointments using mobile, tablet or desktop.
  • Patients receive two text reminders about their appointment.
  • Responses to the Trust to change or cancel appointments are sent in ‘real-time’.
  • Patients receive directions by text to securely access their letters on the trust’s patient portal.
  • Clinic or hospital-specific instructions and other essential reading can also be accessed through the portal.
  • Staff can apply tailored messages to letters in house - such as paragraphs advising parking rules for certain locations using templates and profiles.
  • The system can also host specific URL links in the body of the digital appointment letter and in the essential reading links, which enables the Trust to send procedural specific information to patients.

Scope of capacity

Digital letters are already being sent for outpatient appointments and will also be rolled out for day case appointments, admissions, diagnostic services and community and therapy services.

The system can also be used for the completion of pre-assessment questionnaires and for patient initiated follow up appointments.

The system also has the ability to host surveys via the e-form platform.

Work is also taking place for the patient portal to be accessed via the NHS app.

Key learning points

Senior leadership buy-in was well established and as a proof of concept it was obvious that the project would deliver cost savings. Senior Leadership were kept informed through the Project Governance and highlight reports.

Staff training is vital and all admin staff have been trained on how to look for and action their patients on Envoy. Drop in training sessions were held twice a month, in addition to a new starter training package which is mandatory for all staff using Envoy. For every new roll out we ask all admin Team Leaders and Service Managers to sweep for anyone who may have changed roles and now uses Envoy.

We found it useful to have tiers of training: Super User training, which is Team Leaders, Service Managers, Training Team, PM and Project Team. Once a roll out is completed, the training guide is updated and the new version uploaded to our hub. We also have admin team training, and if necessary the training team are available a few weeks post go live for floor walks.

The service was promoted through our Comms Team, key stakeholders in our Project Team who ensured that Comms went through the relevant Governance.

Comms will usually take a number of forms:

  • GP and Primary Care Comms
  • Patient Comms
  • Proactive media release
  • Social Media Comms (FB and twitter on the Trust’s corporate media pages)
  • Internal Comms, usually on the hub page for the Trust
  • Posters
  • Hot topics, usually close to the launch date to keep it fresh in everyone’s minds
  • Screensavers
  • internal emails from Comms Team and or PM

Comms included key messages, go live dates, benefits of the new system and also very importantly asking patients to ensure that we have their most up to date contact details.

We also interacted with patient stakeholders through our Patient Engagement Group, where demonstrations of the front facing portal were given, and comments/queries taken back to the project team.

Out Patients (OP) was rolled out first as it had the potential for the biggest cost savings, but also because the Trust wanted to reduce the DNA rate and make better use of their clinic slots. OP was too big to be able to roll out anything else alongside it.

In Patients (IP) was rolled out next along with Endoscopy. IP had the technical requirement to be able to add links to leaflets associated with a patients admission. It was also essential to be able to add correct starvation instructions into the bulk of the letter. The roll out of IP was supposed to be all IP specialities, but due to logistics with the leaflet configuration, we took the initiative to split the roll out into non leaflet and leaflet. That way we could get some specialties up and running, supporting the Divisions with their KPIs, whilst allowing the Project Team more time to understand how to build a front end to CAMIS which would allow us to configure URL links to the digital letters to house the leaflets.

We are the very beginning of Phase 3, which includes Community, therapies, Diagnostic, Radiology and Audiology. This roll out isn’t based on our PAS system. There are numerous systems involved in these areas, which means that NLaG and HCC will be working with new systems to implement digital letters.

Feedback has been gathered through staff questionnaires and patient surveys.

64% of staff who responded to the staff survey found Envoy, HCC’s software, easy to use. Envoy can be used to audit patient responses and check that everything has been sent to a patient via either the portal or SMS messaging and is intended to help a service become more efficient.

Administrative duties now include actioning Envoy responses from patients, rather than enveloping appointment letters.

Digital equalities

Patients unable to access their letters through the Trust’s patient portal within 48 hours, or who don’t own a smartphone or similar device, receive letters by post.

Patients who contact the hospital and specifically tell us that they don’t want to be included in digital letters, can opt out and they will automatically receive paper copies of letters.

The Healthcare Communications appointment management system includes a number of tools to support accessibility such as:

  • the ability to translate pages into 99 chosen languages
  • the use of text magnifiers and text highlighting
  • the choice to have messages read aloud in 46 languages
  • ability to change the screen and text colour combination to allow for easier reading

Key figures/ quotes

  • Cost savings in the first year equalled £152,000 in postage and print costs
  • 360,563 digital letters were sent in the first year
The most important benefit for us is that it allows us to be much more patient-centric. In addition, patients come in and sometimes have to do a pre-assessment questionnaire for surgery; they can do that at home now and send it in, rather than spend 30 to 40 minutes sitting in the hospital carrying out that procedure.
I really do believe technology can impact the patient experience. Being able to use digital means we can fill all our appointments, and we can reduce the waiting list.
We now send the majority of outpatient letters digitally, and since we introduced them, we’ve saved more than £150,000 in printing and postage costs and we’ve seen a reduction in the number of patients failing to turn up to their appointments.

Key contact

Jackie France, Associate Director, Patient Services, Northern Lincolnshire and Goole NHS Foundation Trust
jackie.france@nhs.net

Catherine Sowerby, Outpatient Transformation Programme Manager, Northern Lincolnshire and Goole NHS Foundation Trust
c.sowerby@nhs.net

Jade Hindley, Marketing Executive, Healthcare Communications
jhindley@healthcomm.uk

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Page last updated: October 2022