Tom: So welcome to another episode of DrDoctor Will See You Now, the podcast where we explore the intersection between technology and operational change in the NHS. I'm really excited to say today we're going to be talking about a subject which is really close to my heart - giving patients choice, control and agency through partial or choice booking of appointments. This is special to me because the very first thing I ever did when I worked in the NHS was help Coventry Hospital move from a full booking to a partial booking process many, many years ago. I'm absolutely delighted to have Mel, who's Deputy Director of Operations at Imperial Healthcare NHS Trust - I hope I've got that right - and an expert in patient booking models, to come and talk to us about the work they've done.
I want to move us on to something slightly controversial for a moment, which is the size of the elective backlog. As you move to a choice booking system, you end up with more patients not booked, right?
Mel: Yeah.
Tom: So it looks like your backlog is greater.
Mel: Yeah, but I think it depends how you define the backlog.
Tom: Exactly. And I think this is a really important point - one that I wanted to spend some time on, because I don't think that's well understood, perhaps by everybody in the system.
Mel: Yeah, I think you're right, Tom. How we see the backlog is how many unbooked patients you have. Well, OK, but those patients don't need to be booked. It's better if they're not booked. Like, why would you book patients? We had 2027 clinics booked. I don't even know what I'm going to do in three months' time. Not in 2027. I'm not even sure if I'm going to be here. I will have my gastroenterology, rheumatology appointment in August 2027. And we know from the stats that if you book appointments that far out, they will get rescheduled. They will probably DNA. And the whole process is just back to front.
But there are some conditions where you would want to consider a different way of booking - for example, chronic conditions. They will be with us for a very, very long time. There is a case to make that those patients should be booked differently. Because, for example, you will need to be seen every six months. We know you will need an appointment every six months. Why don't we pre-book those patients? And I don't have a problem with that, but it's how do we communicate that so that patients understand - first of all, if you do want to reschedule, these are the tools. Don't expect - please - text messages we can send. This is how you reschedule your appointment. It's important for us not to lose those patients. Because RTT will always take precedent. Cancer will always take. Urgent will always take. So when you start thinking about capacity, that's where the issues can occur.
Tom: So that's interesting. You've got to make sure that person's locked into the system so that they don't get left out.
Mel: Correct, because they're urgent. They will be urgent then. So there is a case to think - and we are thinking about that now - when we know that this works. But does it also work for the specific cohort? We can get better. And I want to be better. Just because something works, it doesn't mean that we shouldn't be improving it. Always. So those are the things that I'm thinking about with the teams I'm working with. How can we use digitalisation to benefit the patients and reduce the administration burden?
Tom: Yeah. And it's interesting, particularly with chronic patients, because they are frequent flyers, they do use the tools differently and they're much more likely to be able to change their appointments. It will be interesting as we move to a world where chronic conditions are managed more using remote monitoring. I think that will change the booking models again.
Mel: Absolutely. But they will always need bloods or something. They will need an x-ray, they will need some sorts of imaging or they will need a phlebotomy. They will always need something. That's why they're chronic. We need to do something to understand it. And that's what I see again - digitalisation. If we know that you need to be seen every six months for the next three years and before those appointments, you need to have your bloods done, it should be as straightforward as that.
Tom: It should, shouldn't it? Can I just touch on that linked appointment point? Because I think that's a really interesting one. So this is where we really get into booking nerdery here. So many appointments have got a diagnostic link to them. How do you manage that in a choice booking process?
Mel: So because we have implemented validation before book, we have developed the waiting list to flag if the patient needs to have some sort of diagnostic done. Because when we look into some of our data, the reason why patients have multiple follow-ups is because we don't solve their problems on the first follow-up. And one of the reasons why we don't do that is because they didn't have their tests completed - because we all work separately. Imaging has their own booking. Bloods have their own booking. We have our own booking. And then some areas are devolved and it just becomes a little bit messy.
But because we have implemented the validation - so in around ten weeks, you validate all of those patients; at eight weeks, you text them - we know now that Mel needs to have her bloods done. So we would call the patients now. We're in the process of automating that with text messages and tell them, listen, you need to have your x-ray. Or if it's bloods, if it's an x-ray, we would call the team and say, can you just prioritise these patients and let us know so we can book the appointment after. And we have improved. It's not as streamlined as it should be, but it is a process. We are only live from August last year. And now it's February.
Tom: Yeah, it's a long journey. And two things that matter here, I think - just having a process is step one, right?
Mel: Correct. And it doesn't have to be perfect, but we have to do something. We have to do it consistently and we can improve it with time.
Tom: Changing the NHS is really hard. And I think sometimes people think that they have to jump all the way to the perfect solution. Actually, I think the best way to do it is design it, make it really clear what you're going to do, but be happy to do it piece by piece by piece.
Mel: Yeah. And we were comfortable with that. Well, not all of us, but I had the support from my chief exec and also from the executive directors.
Tom: Which is critical here.
Mel: It's impossible. If you do not have their support, it just won't happen. I was very lucky to have that support and that they understood that I just want to try something else. And if it doesn't work, listen, it doesn't work. Let's go back to the drawing board. And I'm quite open. I don't have a problem if we fail. I don't believe in failure. It's just a lesson.
Tom: And this is so rare in the NHS. It's one of the reasons that you're very special and Imperial is very lucky to have you - you are willing to just give it a go.
Mel: Yeah, but I understand my colleagues. We are quite heavily regulated. The errors in the NHS are not expensive - I don't mean that in terms of money, but we're talking about the human cost. So I understand that. I also think that there needs to be a balance because we work for the NHS, which does the most amazing research. Imperial is a leader - if I can say that. And it is my favourite organisation, of course. But why can't we be like that in administration? We need to aspire to something better. And I was never OK with accepting something that we know doesn't work, when we are not willing to even try to change.
Resistance to change is real. And even I don't think I have appreciated it as much, because I love change. Not when it comes to my hair or my fitness regime - I'm very stubborn. I don't change my club for like ten years. But I love change at work. I do believe that you need to aim for the better. If you're just happy where you are, well, the progress - you have to continue pushing forward.
And where we were when we were rolling out the partial booking so long ago, the technology has moved on. We became so much better. Imperial is quite advanced when it comes to technology. But we didn't move the operational processes because we had scars from the previous changes. I wasn't there for the beginning. I just saw the end. So I kind of didn't have those scars.
Tom: You didn't have the scars so you could move forward.
Mel: And I also just wanted to try something else, because I was a little bit tired of listening that the team was not doing chronological booking properly. And then I was like, OK, so why aren't we doing it? I went to the five whys. I didn't do any smart methodologies. I built my house on the five whys, which I think is the best methodology out there. And I applied it here. Like, why, why, why, why, why? And then - OK, so this is what we need to try. If it works for Toyota, I think it works for us, right?
Tom: And people get so worried about the administrative overhead of moving to a choice booking process. But your point about the technology is key here. The technology has come so far that we're not doing this on pen and paper. We've got really good tools around us to support the process.
Mel: Correct. It's not anymore an Excel spreadsheet saved on some T drive or an edge drive. And then when I go, that edge drive goes with me and then we lose all of this data. That's not where we are anymore. We have structured data. We have teams who own that data for us. We have a very good BI team at Imperial and the performance team who controls our waiting list very well. So I was monitoring it weekly when I was rolling it out. My teams are doing it every day. Now I'm doing it once a month. There is some other stuff to do, but I do commit myself once a month to go through all of the data sets and see - new follow-up booking, are they dropping? Why are they dropping? What are we seeing in the DNA cancellations? I think it's important to have that and it keeps you grounded.
Tom: Yeah, totally. Use the Toyota example - these are the metrics of your machinery. They tell you how your organisation is running. They probably talk to you about the health of the teams, leading and lagging indicators on how patients are. It's everything.
Mel: Correct. We have implemented patient feedback in really everything that we do. We have rolled out surveys - we're sending them by DrDoctor, but we're using the other platforms that we have. We're trying, every month, to analyse all of that, understand what is happening, where are the problems. We can't solve all capacity problems. That will take a bit of time and quite a lot of changes need to happen there, but we can definitely improve.
Tom: And it's steps, because I think the other thing that holds people back here is the capacity challenge - and every hospital has a capacity challenge. But if you don't start somewhere, you will never solve it.
Mel: We went about it, I thought, in a quite safe way. We considered a couple of options to roll out the choice booking. One was mass cancellations. Now, if Imperial does mass cancellations, that's going to raise quite a lot of questions. So we disregarded that.
Tom: That's what most organisations do, it's worth saying. Normally when people implement a choice booking process, they do do the mass cancellation route. And I've always wondered why, and I think there's a better way.
Mel: Yeah, because we're doing phased onboarding. We are just about - in March - planning for at least 90% of all follow-ups to be live with digital booking. So what we did is just stopped booking patients. We knew we would not enable all capacity. But we were happy to live with that. It was enough for us to start changing the process. And now we have caught up.
What we have seen - we started with, and I'm very much focused on the overdue follow-ups because that's where your risk lies - there are two backlogs. You have your waiting list - you need to be seen in 2028, I'm not worrying about you, I will talk to you in 2028. But we have a patient who needs to be booked now. And those are the ones - and I consider that a backlog, not the overall trust follow-up waiting list. We're a big organisation. We have a lot of patients. Our waiting lists are quite significant. So we were focusing on the overdues specifically. We started with around 15,000 to 16,000 - without a clear plan for how we were going to approach it. And with this process, it's very, very simple because you're just going through the system. You text, you book patients. Doesn't engage with us - we do the automatic phone calls. The patient doesn't engage with us - there is a letter: please call us within 21 days. If not, potentially your record will be reviewed for discharge. We give that ownership to the patients. If you need this appointment, please do call us. Because for some of our specialties, we have made exceptions to that - they're a complicated cohort, very important for them to have that appointment because then the clinicians can follow it up. And for them, we have decided - after all of that, if they still don't engage with us - we will book the appointments anyway and send the letter.
Tom: So the process can be adapted to meet the need. It should be nuanced based on the service, right?
Mel: Correct. Because it is healthcare. It's not aeroplanes.
Tom: So we've got a really robust process here. You've obviously thought about it a lot. You've been through your five whys. You've engaged your clinicians. Let's talk about go live. What went well? What didn't go so well?
Mel: Well, it was a little bit of chaos when we went live. I was very anxious. And when I'm very anxious, I can be quite a lot for my team. They were very kind to me - big shout out to the teams I work with. But in terms of administration, we were concerned about the labour-intensive work that needs to be done, because we didn't have everything automated in a way that you can just pick up the waiting list, drop it, and it goes. There had to be quite a lot of administration input.
But we managed to get it live. Our patients - we didn't send them text messages explaining the new process, and we didn't do that on purpose because we didn't want to cause concern. We should have done it. It would have been much better for all of us. But it's one of those things you learn. We should have just said we're changing our booking process, this is how it's going to go, this is the link. We didn't do that. So that caused a little bit of anxiety. It also caused anxiety for our clinicians because we didn't have leaflets prepared for them so that they can give something to patients in the clinics. We didn't put the posters up - but we weren't sure how it was going to work. So we didn't want to publicly announce something so heavily and then have to backtrack. We thought that would be a higher risk. So we were struggling with our consultants seeing their clinics unbooked. That was a cultural change. And it's a real one.
Not everybody is happy still, but we designed dashboards to show them how many overdue follow-up orders they have on the lists per month, so that they're able to see - OK, in August my clinics, I have 100% capacity, but I have 100 slots and 100 orders overdue. So you know they're going to be booked in.
Tom: I'm really interested in this. This is a way of giving everybody in the organisation visibility and confidence.
Mel: Yes - confidence that the patients are going to be booked. And there were quite a lot of conversations we had to have with them - listen, if you're concerned, we will just book the patient. Please don't worry. This is not you have to do it and if you don't, you're out. That's not how we work at Imperial. We're very collaborative and we try to address those things in a fair way. And I appreciate my clinical colleagues and their concerns. They're the ones at the end who have to deal with it. They're on the front line. If the patient is missed, if something happens.
Tom: Completely.
Mel: So we designed those dashboards to try to help them. And then with the cultural change, things start getting better. What didn't go so well? There was quite a lot of anxiety. A lot of energy went from myself, from the teams, from our consultants. Our patients were OK. We didn't get complaints or concerns. The pulse - we were following the pulse - did not go up. But it's just the habits. And I'm not so sure that you can ever be ready.
Tom: I think this is right - you can never be ready, but you have to cross that line at some point.
Mel: At some point, you just need to believe and jump. The biggest problem is that visibility for our consultants in terms of the process. The process was fine.
Tom: And then tell me about the results. Tell me what it did to your metrics and your numbers.
Mel: We did see some great results. We saw the DNA reduction drop down. So for the specialties where patients are doing their own bookings, DNAs went down to six percent. Amazing, right? And they were 11 percent to start with.
Tom: Yeah. So the stats I've got - and Mel's being very modest - hospital cancellations went down 59%. Patient-initiated cancellations went down 45% and the DNA rate dropped by 38%. Which is phenomenal, right?
Mel: It's unbelievable for me how I track it. So the trust DNAs - we were on around 10.5% and Imperial was struggling to get them down for years. 2019 it was 10.5%. Then it went to 12, thereabouts. Now we are managing to reduce it down. And what I have seen is that we managed to reduce it to under 10% for Imperial. That's the first time in a very long time. We lost a little bit in January for some reason -
Tom: I can see the pain on your face.
Mel: I was not happy. I'm not going to lie to you. Poor my general manager. He was not happy either. But we figured out what was happening. In November it was 9.4%, which was the lowest that Imperial ever managed to hit. And this is definitely contributing. And when you break it down per news and follow-ups, you can see the picture - our news is sitting on around 12% and our follow-ups are under nine.
Tom: And that's particularly impressive because follow-ups tend to be higher than news for DNA rate. So for people that aren't NHS booking nerds, that's a double win.
Mel: Yeah. We have moved to the manual version of choice booking for one specific specialty - oncology. And we have seen a significant drop of the new DNA rates. So now we're in a process of moving all of that. We were at 11%, we're down to 6.6%. And we're also seeing in cohorts where we're using fully digital booking that it drops again.
Tom: Right. So we're at three or four percent in some of those cohorts. It just goes to show that DNA rates don't need to be ten or eleven percent. We can get them down to three, four, five, six percent.
Mel: Hitting three percent is tough. Really hard.
Tom: Yeah. You'd be like the number one performing trust in the country.
Mel: I mean, I would be expecting some awards. HSJ, if you're listening. But where I'm going - for us to hit seven percent, that's the target I have set us.
Tom: That's phenomenal. And some of the stats I've got here - 94.5% of patients engage with choice booking. 94.5% of patients engage with this system, which I think is a huge statistic.
Mel: The first patient that digitally booked was 78 years old. So one of the things which is an actually interesting point was the digital exclusion - which is something that we really need to think about because it does exist. It's a real thing. But the digital exclusion concern is, I think, overstated based on our case.
Tom: I think the digital exclusion thing is far more nuanced than people realise. It's not that the elderly don't use these tools at all - it's really variable based on the specifics of that individual.
Mel: Correct. And that takes me back to the point we made earlier - because we know that 94% of people engage with these tools and it's better for them, it allows the humans in the booking centre to spend time with the humans that don't like to use the digital.
Tom: Yes, exactly. By improving it for the majority, you improve it for those people too.
Mel: Yeah. So as a parallel - we have a quite ambitious outpatient transformation programme. And my colleague Rachel is doing the preference work. Our idea is that we will know for every patient at Imperial what their preferences are. I do not call me. I never pick up my phone. There is absolutely no point of calling me. If you're not my mum or dad, the likelihood of me picking up the phone is very, very low. And I'm sure there are people like me out there. And there are also people who want to receive the letter. There are people who want to be called. And this work that we are doing will give us that - so that then we can completely digitalise the process. If we know that Mel only wants to receive the text message, because it's structured data, you can extract it, you can digitalise it. And that's my goal. Create the structured data.
Tom: Amazing. And personalise the experience for everybody.
Mel: Correct. And the other stat I wanted to call out - after you went to choice booking, your cancellation rate dropped from 28% to 16%. That's phenomenal. And that's sustained, right?
Tom: Yes, it's sustained. We had the industrial actions - so the cancellations did go up a little bit. But if we exclude that, the cancellations went down significantly.
Mel: And what did the team feel about this?
Tom: The administration, the central booking - I think they love it. When I ask them, they're happy. But of course, that's what they're going to tell me.
No, I think we have some incredible people who work with us for a very long time. And I was interested to see their perspective now that we are changing things, because yes, I sit here and I represent the change, but I did not deliver the change. I was maybe a driver, but I was not the person who was doing it. They did it. The patient service centre at Imperial did all the hard work. To be honest, it was five people when we started. Only five people when we went live with the pilot services. Now we have restructured the full team so that we can support digitalisation. And they absolutely agree with this process and they can see the benefits - because the calls went down. Patients' frustrations went down. Patients were showing up. So when we show them the results and they are the key in that result.
Clinicians - we still have some work to do. We need to think a little bit about how to enable them to see everything they want to see and also to remove some of the anxieties, specifically around the chronic conditions. That's something that really worries them. Is that a visibility problem?
Mel: Yes. They're concerned that we will not book those patients in the time frame that they need to be booked. And I understand that. So we will now improve that process. The problem we have is that a follow-up order is a follow-up order. You can't differentiate if it's not urgent, if it's not cancerous. So we are going to look into how we can understand which patients are chronic patients so that we can exclude them from this process and just book them.
Tom: And maybe there's something interesting here - because I know the trust has a big push around PIFU. And this is where I think choice booking and some of these patient-initiated models begin to overlap, because if you're doing choice booking, it makes it easier to implement PIFU because you have a different capacity profile - and PIFU is at its most effective in chronic conditions. So actually, a lot of those patients who are potentially going to be excluded will probably come back round through the PIFU process and will be the high-opportunity PIFU areas.
Mel: Yeah, probably. I'm not that involved in PIFU. But I definitely think there is a place for it. I'm also a patient in the hospital. You don't need to book a follow-up. Just give me an option. If I think that I'm not getting better, that my drugs are not working, give me an opportunity to contact somebody and book the appointment. And I think that's what patients need. That's what PIFU is essentially. So we have designed the administrative process around it to enable that. But it is a cultural change. It's not going to be done in a year, irrespective of how much pressure we get. We need our consultants to be comfortable that those patients will be able to access the hospital. There is a trust that needs to be developed between all of us.
Tom: Trust is the word, isn't it? And for PIFU to work, it has to be clinically led.
Mel: Correct. It has to be clinically led and they need to trust administration that they will do what needs to be done. And we cannot blame our clinicians for wanting to get to that point.
Tom: No, completely not. And I think what's interesting is - as we've stepped through today - people still view validation, choice booking, the act of booking, and then some of these PIFU or remote monitoring models as separate things. And actually, the more you look at them, you realise that they're completely connected. It's actually just about providing a really seamless end-to-end journey where patients have control.
Mel: We had one of the leadership forums at Imperial and my co-host asked me to talk a little bit around digitalisation. And I was an athlete in my previous life, so I travelled a lot. I say I finished university at the airport. And what I said was - I can book my own flight, I can order my own lunch, I can order the drink, I can do everything from my phone. So why can't I do that in healthcare? Why is it so bureaucratic? I believe in a full digital experience and I want to help us get there, but there are real things that we need to think through.
And what I said is - our lovely IT colleagues are really good at bringing us all of these new tools, new apps, new products. And what we do is we just try to plug them into the operations that we have now. But we didn't design our processes to enable digitalisation. Not because we didn't want to - it's just that's not how it was done. So it's like - you bought me a Ferrari engine, but I drive a Ford. And now you want me to put the Ferrari engine in my Ford and you think it's a Ferrari. It's not. It's still a Ford. And it probably won't go.
Tom: So true. This stuff often happens on the edge of the organisation and it has to be in the centre. Everybody has their digital transformation strategies, their productivity strategies - which is only going to be more and more of a thing over the next couple of years. It's about clinicians, senior executives and the admin teams working together to design - not a Ferrari or a Ford - but the next generation of what transport looks like.
Mel: And I think it's across the country - other trusts probably have the same problem. We have so much data that is not structured. Loads of free text. Loads of comments. We book patients by comments. But if it's that important, can we just structure it, please, so that I can do something with it rather than having a human who needs to read it? Or we plug it with some RPA solution to read. But that's again introducing unnecessary risk. And that's how it happens. Because like any other digital tool, things stop working. And you're just introducing unnecessary risk and then people lose faith that digitalisation is the right way forward.
Tom: And it's connecting the dots for our colleagues - if we're asking you to select an outcome in a structured way, the reason we're doing it is so that you don't get worried about the patient at the back end. I think perhaps that gets lost sometimes.
Mel: Exactly. But it's a cultural change. It's something that was done forever like this. It's very difficult changing. One of the things you asked me - what didn't go well - I think I didn't appreciate the resistance to change and that it's actually really real. And we need to put time into thinking how to go around that. I did not probably put enough time into it, because I'm a little bit bulldozer. I believe in something, I have demonstrated it, and I'm like - we're going to make it happen, we need to do it. I'm just tired of talking about problems anymore. I have that personality. I get away with it - thank God. But at some point we just need to solve the problems. I'm tired of talking about it. I've worked ten years and we're talking about chronological bookings for ten years. Can we just try?
