Surprises Revealed by Recent Research for the NHS


Appointment By Bobette Gorden

Recently, the result of a fascinating set of studies sponsored by INFLUENCE AT WORK, BDO and the National Health Services UK (NHS)was released.  Steve Martin, CMCT and director of the INFLUENCE AT WORK UK office led this research with Dr. Suraj Bassi and Dr. Rupert Dunbar Rees of BDO.

This research examined DNAs (Did Not Attend/No-Shows) in doctor’s offices.  DNAs are a significant and costly problem all over.  But according to The King’s Fund, a health think tank based in the UK, there is an estimated direct loss of ÂŁ700m annually due to patients failing to come to their appointments or failing to cancel in time. 

The goal of this study was to find simple and cheap approaches to reduce DNAs.  This pilot study is now being peer reviewed by the Journal of the Royal Society of Medicine.

In one condition patients making their appointment were asked to verbally repeat the date and time for their next appointment before hanging up the phone.  This simple and virtually costless change used the Principle of Consistency an led to an immediate reduction in DNAs by 6.7%

In a second condition, which again employed the Principle of Consistency, nurses and receptionists, when making the patient’s next appointment in person, instead of filling out the small white appointment card asked the patient to fill out this card themselves. This small change produced an 18% reduction in DNAs. 

A common practice in UK medical offices is to have a very visible sign in waiting areas that highlights the number of DNAs that previous month.  This is not only wrongheaded, but encourages exactly the opposite behavior that these medical offices are trying to extinguish. Because the Principle of Social Proof is so powerful, instead of discouraging DNAs, this poster was actually encouraging DNAs by insinuating that it was a very common practice to not show up for medical appointments.  Such use of the Principle of Social Proof can work to help or hurt desired activities.

In an attempt to reduce DNAs, the researchers replaced these signs with alternate signs that simply stated the truth…in another way.  The changed sign read that 95% of patients at (the name of the office) turn up for their appointments or call (insert phone number) if they have to cancel. 

This strategy (using Social Proof correctly) combined with the appointment card intervention examined above (using the Consistency Principle)  produced a 31.4% reduction in DNAs. 

A health economist working within the NHS calculated that if the simple changes tested in this study were employed across the NHS the savings would be the equivalent to the cost of hiring an extra 472 physicians each year.

Now, what can YOU do with these same easy and nearly costless approaches?

For more information about these studies, see this article from The Guardian.

  • RudeGirl

    Terrible writing. Took forever to get to the point, the recommendations. Look at this complicated, involuted sentence:
    “In a second condition, which again employed the Principle of Consistency, nurses and receptionists, when making the patient’s next appointment in person, instead of filling out the small white appointment card asked the patient to fill out this card themselves.”
    How about, “Having the patients fill out the appointment cards themselves resulted in an 18% decrease in no-shows”???
    Get writers who can write.

  • Bobette

    Thanks RudeGirl. I should have made this one concept into more than one sentence. Translating scientific research into layman’s terms can sometimes be challenging. I appreciate the advice and will work on it for next time.

  • Ryan Nagy

    Brilliant! Thanks. This is a wonderful way of putting the persuasion principles into context in a way that makes them easy to use and remember. – Ryan

  • Dale

    This is a marvelous example of simple changes making a huge impact — this is just the sort of thing that make the Influence principles so powerful. Nicely done. Thanks for an excellent piece.

  • Andy Smith

    Rudegirl is living up to her name, so illustrating the Consistency principle. Bobette, I thought the article was fine – it would be a slow reader indeed who could find a one-page article ‘taking forever’ to get to something.

  • Curtis

    Relax. This isn’t an english composition.
    It’s a blog. It’s a good one too.
    Try taking a deep breath and have a nice day.

  • Peggy Garvey McMahon

    After the first time I hear Dr Cialdini speak (in 1986 !!) I implemented several of his principles in my practice as a Diabetes Educator. One change was having the patients write their own action plans and next appointment time, instead of writing them myself. It worked then and it looks like it still works now! I also started by asking them to test their blood sugar 6 times a day, then “retreated” to saying 3 times would work, too, which increased compliance significantly. Timeless wisdom….
    Thank you!

  • Paul

    Great article. Worth testing myself.

  • Barbara Paz

    Very good article. Thank you for bringing this interesting concept to our attention.
    I work in the field of investments. People who show interest in our investment make appointments with me to get further info, but I have about 20% no shows. I always call the same morning to make sure they are coming, and in some cases, I get something like, “I wanted to call you. I am so busy; I really can’t make it. I’ll call you when I’m under less pressure from work.”
    Does anyone in the forum or at “Influence” know of a study done which can help in this matter?
    Thank you very much for your time.

  • Norma

    I live in the UK. As soon as I read Yes! and the chapter on hotel towels it seemed to me that the research applied to NHS waiting lists. So I’m partly pleased that the research proves what I had thought and partly annoyed that I thought of it and others proved it. Since then I’ve puzzled why no hospital psychologist has made the connection and I fantasised about sending them the chapter from the book; now I can send them this article.
    Can I point out that what is particularly annoying about these posters is that they place the reader i.e. the person who HAS turned up, in the wrong? Usually they have some such heading as “We were here, where were you?” when it is clear that the majority of people do in fact attend their appointments.

  • Bobette

    Hi Barbara. I would suggest that you read Dr. Cialdini’s chapter on Consistency. There are a number of ethical applications you can effectively use to engage this principle. I hope you find this helpful.

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