More than four million people are waiting for specialist care in the NHS. At worst, people can wait more than a year for treatment. In many cases people have the option to choose an alternative, nearby service with shorter waiting times—but do not do so.
Why is this? Sometimes people have a strong preference for where they want to go, regardless of wait times. But patient choice surveys consistently show that shorter waiting times are a top concern for patients. Many would travel a little further for speedier treatment.
After talking to doctors, we found that they often struggled to compare the available options quickly. For example, the national patient referrals system (the “e-Referrals System” or eRS), used by half of local doctors, automatically generates 99 clinic options for each search. In the face of this complexity, some doctors were just referring to their local hospital as standard, even if their patient could wait a very long time.
In response, BIT worked with NHS England and NHS Digital to redesign how information is presented in the nationwide patient referral system. We worked with an excellent team at NHS Digital to create two main changes:
- Adding a small red ‘Limited Capacity’ flag to clinics where waiting times were very long. If doctors shortlisted one of these services, a pop-up box appeared that prompted GPs to discuss long waiting times at these services with their patients (but did not stop them making this choice).
- Creating a green box, at the top of the screen, listing three local clinics that offered the same services – but had good capacity.
In 2016, BIT ran a randomised controlled trial in East London to test the impact of these changes in the real world. At the time, Barking, Havering & Redbridge University Hospitals Trust (BHRUT) was in “special measures”, party due to waiting list mismanagement. One thousand patients had waited longer than a year for treatment; thousands more had waited longer than the national standard of 18 weeks. BHRUT also had a deficit of £32 million.
NHS England set us a target of reducing new referrals to clinics with long waiting times by 5-10 per cent, whilst boosting informed patient choice. In fact, the changes resulted in a 38 per cent reduction in referrals to clinics with long waiting times. Green alerts seemed to increase referrals, but the result was not statistically significant. GPs told their commissioners that they appreciated the changes.
The following year, we rolled out the alert system to another area of London, and repeated the evaluation. This time, patients also saw the colour coding via a patient booking app created by NHS Digital.
In this evaluation, we confirmed the effect of the red limited capacity alerts (this time, a 20% reduction in referrals), but also saw a 14% increase in referrals to services with green alerts (p<0.1).
This is not just a story about pilots. Because the changes were embedded in a national digital system, they can instantly be scaled up nationally. This is exactly what NHS England is doing now: it is rolling out the alert system as a tool that NHS England regional teams can use to quickly address problems in their local health systems. If these alerts also reduce referrals by 20-38% when scaled nationwide, they could redirect up to 40,000 referrals a month to shorter waiting lists.
We think that this is a good example of how a simple, cheap nudge can have a widespread impact on issues that really matter to patients, professionals, and policy makers.