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Children's missed health care appointments: an initial scoping review
1. Children’s missed health care appointments:
an initial scoping review
Dr Catherine Powell, Dr Jane Appleton,
Lindsey Coombes
BASPCAN Congress Presentation
April 2015
2. 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)
3. Research Question
How do health care organisations
respond when children do not
attend/were not brought to their health
care appointments?
4. 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.
6. 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)
7. 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.
9. 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.
10. 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)
12. 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.
13. 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.
.
14. 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?
15. 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.
16. 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;
17. 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);
18. 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.
19. 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;
20. 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.
22. 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
23. For further information please contact:
•Jane Appleton - jvappleton@brookes.ac.uk
•Catherine Powell – catherine.powell@soton.ac.uk
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