Missed hospital appointments and transport...missed hospital appointments were due to transport or transport related factors. • Face to face interviews were also carried out with

Missed hospital appointmentsand transport

byProfessor Kerry Hamilton

and Marion GourlayTransport Studies

University of East London

December 2002

Missed hospital appointments____________________________________________________________________________

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Table of Contents

Page number

Executive Summary 3

Chapter 1 Introduction 4

Chapter 2 Methodology 6

Chapter 3 Background 8 Organisation of antenatal care in the UK Position of Women in the Social Structure Women’s travel patterns Gender roles

Selected Literature Review Cost of Did Not Attends (DNAs)

Transport and Social Exclusion DNAs and Transport

Location Factors

Chapter 4 Case studies 12 IntroductionThe Newham case study

The Richmond case study A Comparison of Newham and Richmond

Chapter 5 Study Findings 17 Comments from Health Sector Professionals Interviews with women attending antenatal clinics

Chapter 6 Conclusions and Recommendations 31 Comparison of Newham and Richmond Transport arrangements Internal NHS Administration and Antenatal Care in the UK Hospital Location

Bibliography 36


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Executive Summary

• This research investigated whether there was a link between missed hospitalappointments and transport. It focused upon maternity care appointments at theNewham General Hospital antenatal clinic.

• An extensive literature review was undertaken which revealed that very few studieshad investigated the link between transport and missed appointments.

• Face-to-face surveys were carried out with women who have missed appointments inthe past. Reasons for missed appointments were ascertained. Approximately 20% ofmissed hospital appointments were due to transport or transport related factors.

• Face to face interviews were also carried out with healthcare and maternity careprofessionals to investigate if, in their opinion, transport was a factor in missedappointments. Transport was not referred to by the professionals as the main reasonfor missing appointments, but issues such as the location of clinics and certain healthservice organisational and institutional factors were alluded to and these were seenas having a bearing on the decision to attend appointments.

• Missed hospital appointments or DNAs (Did Not Attends) are a problem costing theNHS million of pounds each year. Missed appointments are evident across all areas.Health professionals consider that patient apathy is the main cause of missedappointments. Further investigation into the reason behind missed appointments,revealed that transport rather than apathy was a significant factor. Furthermore,transport related factors, such as travelling with children, were also cited as a reasonfor failing to attend appointments.

• Responsibility for the provision of transport to hospitals is a grey area. There doesnot seem to be a clear demarcation between the Department for Transport (DfT) andthe Department of Health (DoH). In practice the DfT does not have a distinct policyor minimum standards for transport access to hospitals, but would advice localauthorities to make adequate transport available for places that generate manyjourneys in their area such as hospitals. Whereas the DoH would not consider theirrole to involve the journey to hospital, but rather the provision of adequate buildingaccess such as ramps for wheelchair users. However, there are several goodexamples in the UK of forward-looking local transport authorities working closely withtheir Health Authority to progress better transport access to hospital sites.

• Antenatal care can generate unnecessary and sometimes difficult journeys, as thecurrent system appears to be over complicated. The Changing Childbirth Report, nowalmost 10 years old has apparently had an impact as some maternity units havemoved to outreach clinics or home visits. The location and accessibility by all modesof transport to hospitals is crucial to making it more convenient for people to attendappointments. Many more women would be able to keep antenatal appointments ifthese were nearer to their home or place of employment.

• There appears to be a dearth of understanding within the Health Sector that theyhave an active role to play within the sustainable transport debate. The trendtowards ‘out of town’ locations for Hospitals may exacerbate existing transportproblems if the public transport links are not adequate.


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Chapter 1 Introduction

Poor transport can restrict an individual’s ability to participate in day-to-day activities such aseducation, employment and healthcare. Currently in the UK, we are suffering from decades ofunder-investment in transport. The ‘predict and provide’ approach adopted over the past halfcentury meant that if car use was predicted to grow, then roads would be provided. Demandfor road space was therefore not managed and an entrenched belief that the majority ofpeople’s travel needs would be met by car use was not successfully challenged. As aconsequence, investment in public transport was allowed to decline sharply. Transport in theUK is in need of radical overhaul, it has one of the highest levels of road congestion in Europeand public transport is seriously deficient.

The need to travel for everyday activities has become a necessity as society has largely beenorganised around the car. Successive planning policy has led to new facilities such as shopsand hospitals being sited in ‘out of town’ and edge of town locations. These locationsexacerbate access problems, as they are often inadequately served by public transport. Wenow travel 42% further for the same services, than we did in 1975.

Car use has continued to rise, with 71% of households having access to at least one car andthe fastest rise in car ownership is amongst women. However, for the remainder of peoplewho do not have day-to-day access to a car, because another household member has firstcall on the family car or because they belong to a household with no car, they are largelyreliant upon public transport provision.

The intention of this new research is to contribute to the debate on the progression towardsa more inclusive society, one in which individuals have a choice of how or even if they needto travel, with fewer people excluded from participating fully in day-to-day activities includingattending hospital appointments.

For this research, the journey to hospital was selected in order to investigate whethertransport or transport related factors were a reason behind missed appointments. Existingresearch points to the main reasons for missed appointments as ‘apathy’ ‘simply forgot’ or‘couldn’t take the time off work’ 1 and these reasons vary from inner city areas to rural areas2.However, the extent to which these reasons mask transport or transport related factors wasconsidered worthy of deeper investigation.

Transport research has rarely focused upon the journey to hospital as a barometer for socialinclusion. The reasons for choosing this particular journey included:

• Hospitals are large trip attractors, most people at some point in their life will findthemselves making a trip to a hospital as an inpatient or outpatient, accompanying arelative or visiting a friend or family;

• Staff need access to the hospital site. Full time, part time and shift working staffmake daily trips; emergency and delivery vehicles require access 24 hours a day;

• Every hospital in the UK experiences ‘missed appointments’ on a daily basis, peoplefailing to turn up for medical appointments. These cost the NHS in the region of£300m3 per year in England alone4;

1 Failure of patients to attend a medical outpatient clinic. A.V. Simmons, K. Atkinson, P. Atkinson, B. Crosse. Journalof the Royal College of Physicians of London Vol. 31 No. 1 January/February 19972 Socio-economic and demographic factors in patient non-attendance. Sid Beauchant, Rodney Jones. British Journalof Health Care Management, 1997, Vol. 3, No. 103 Patient apathy costing millions, Belfast. BBC News website May 20024 Health Service Professionals refer to these as ‘DNAs’ (Did Not Attends).


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• 89% of health professionals felt that missed appointments are a problem and over87% felt that a reduction in missed appointments would lead to shorter waitingtimes5;

• Transport had been cited in existing research as a contributory factor for Did NotAttends (DNAs), but had never been quantified; and,

• No study encountered by the study team has investigated the reasons for apathy. Itwas considered worth researching to see if there was more to missed appointmentsthan apathy.

AimThe aim of the study is to ascertain to what extent transport or the lack of it contributes tomissed hospital appointments. Maternity appointments were chosen, as these are typical,easily identifiable throughout the UK and involve successive appointments. Maternityappointments meant women were the main focus.

5 Patient apathy costing millions, Belfast. BBC News website May 2002


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Chapter 2 Methodology

This research focused upon the extent to which ‘Did Not Attends’ (DNAs) for hospitalappointments were a result of transport or transport related problems. Women attendingantenatal appointments at Newham General Hospital, East London were chosen for thisstudy. Antenatal appointments were chosen because they involved several appointmentscovering an extended period of time.

The methodology undertaken consisted of four main parts. Firstly, a literature review ofrelevant work in the area, secondly, contact with healthcare and transport professionals,thirdly face-to-face interviews with women attending antenatal clinics at Newham GeneralHospital and finally analysis of the findings and setting out recommendations.

Literature ReviewA literature review was undertaken to discover what had been done in this area. Despite ourbest endeavours, little existing work came to light on transport as a contributory factor tomissed hospital appointments. However, evidence was found to suggest that transport couldbe a factor6. No studies were found which linked maternity care specifically with missedappointments.

In general, studies undertaken by the health sector conclude that transport may be onecontributory factor to non-attendance and those studies in the transport sector conclude thathospitals and other health facilities are often located in destinations difficult to access bypublic transport. This suggests that both sectors are in agreement that transport cancontribute to non-attendance.

Health Sector ProfessionalsKey player opinions were sought during the course of this study. It was consideredprofessionals in the field of maternity care would provide information on the internaladministration of antenatal clinics as well as provide experience of their day-to-day contactwith women attending for antenatal appointments and share any anecdotal evidence of whywomen missed appointments. Members of the following organisations and professions wereconsulted:

• The Royal College of Midwives• Community Transport Organisation• Health Academic• Manager of Transport Services• Local Government Women’s Services representatives• Health Promotion Professionals• Midwives

Face-to-face interviews with women attending antenatal clinicsThe aims of these interviews were to find out how women travel to their appointments, theduration of the journey, and the cost. They were asked whether they perceived anydifficulties, and if so, what the difficulties were and asked whether they have ever missed anyappointments, and if they had, they were asked for the reasons. Care was taken not to leadrespondents towards answering in a particular way. When transport was mentioned as areason, follow up questions were used to gain insight into the problem encountered with thejourney to hospital.

The questions were designed for a semi-structured interview. Some questions were notrelated specifically to transport, but included to ensure that our information could be applied

6 Too much like school: social class, age, martial status and attendance/ non attendance at antenatal classes. DallasCliff and Ruth Deery in Midwifery (1997) 13, p139 – 145.


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in a wider context. Often the interviewer found it easier to ask the questions as part of a‘discussion’ which led to a more relaxed and valuable exchange.

AnalysisTransport had rarely been investigated as a key component of missed appointments amongthe surveys and research literature analysed. Consequently, the literature review uncoveredvery little evidence on transport as a major factor of missed appointments. For this studyinterviews with health sector employees and with women attending antenatal clinics wereundertaken to act as a counterbalance to the approach in the literature reviewed. This projectwas specifically designed to investigate the transport link with DNAs in relation to antenatalappointments. To do this, women waiting in antenatal clinics were interviewed, the primaryinterest was in women who had missed appointments recently and their reasons for non-attendance at these missed appointments. Key people were interviewed in the maternityservices and an analysis of findings from these three stages enabled conclusions to be drawnand recommendations made.


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Chapter 3 Background

Organisation of antenatal care in the UKThe table below sets out the key elements and the current minimum requirements forantenatal care in the UK7. It was not the intention of this study to deal with organisationalissues within NHS Antenatal Care structures, however a consistent view from professionals inthe maternity sector that ‘organisational reform is necessary to meet antenatal care needs’was encountered.

Research8 undertaken by Susan Jackson in the 1990s revealed the absence of a ‘customer-oriented culture’ in the health service. Rather than the patient being the main focus for theprovision of a service, the patient is considered secondary to the service. The application ofthe guidelines (table below) would go some way to improve the experience of antenatal carefor women.

During the course of our research the view that the person seeking the service is ‘theproblem’ rather than ‘the system’ being the problem was expressed by several maternity careprofessionals interviewed. In Jackson’s work many health professionals considered that‘patient apathy’ was the root cause of missed appointments. Of the 17 DNAs surveyed inJackson’s study, all had received details of their appointment, 3 had difficulties with transport,3 tried to cancel by phone but could not get through and 12 knew they could not attend butdid not contact the hospital. Although Jackson’s research was not transport focused, itrevealed that transport was a key factor for some missed appointments. Perhaps if more in-depth questioning had been undertaken on individuals that missed appointments, it ispossible that their reason for non-attendance was transport related.

An extract from the Toolkit for Primary Care Groups and Trusts set outs the key elements ofmaternity care7 below:

KEY ELEMENT MINIMUM REQUIREMENTSRoutineantenatal care

Every appointment should be with a named individual, provided at alocation convenient to the woman. Women should not have to attendhospitals other than for specific tests and scans. The majority of careshould be provided by the identified lead professional. Providers will beexpected to develop policies for antenatal care in collaboration with GPs,midwives, obstetricians and other stakeholders, in order to preventduplication and ensure effective use of professional resources.

Antenatalscreening andtesting

All women should be offered informed choice over, and access to,screening/testing for rubella, blood group, full blood count, rhesus,diabetes, STIs, HIV, hepatitis B, plus maternal serum screening and scanfor approximate birth date. Mothers of Mediterranean, Asian, African orAfro-Caribbean origin should be offered testing for haemaglobinopathies.All screening and testing should be guided by multi-disciplinary protocols,developed with user involvement.

Pre-testcounselling

All women should be offered pre-test counselling before deciding whetherto proceed with any tests for genetic abnormalities, including anomalyscanning. Written information should be given, and the services of aninterpreter should be available as required. Detection rates forabnormalities and any complication rates for the hospital should be

7 Maternity Care: A toolkit for Primary Care Groups and Primary Care Trusts. By the Maternity Care Working PartySupported by: The Royal College of Midwives The Royal College of Obstetricians and Gynaecologists The NationalChildbirth Trust, 2001.8 Does organisational culture affect outpatient DNA rates? Susan Jackson, Health Manpower Management, Volume23 Number 6, 1997, pp 233-236


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available.

Ultrasoundscanning

All women should be offered informed choice over, and access to,anomaly scanning. Facilities for pre-scan counselling should be available.

Parentingeducation

A range of locations and times should be provided to meet the needs ofwomen and their partners, including day and evening classes, a range oflocations including primary care settings, update sessions for multiparouswomen, classes for women only, and classes for teenagers. Womenshould also be informed about non-NHS providers of parenting educationand antenatal support.

Healthpromotionadvice

All women should be provided with information and advice to help themmaximise their own well being in pregnancy. This should includebreastfeeding, smoking cessation, substance misuse, incontinence, sex,and healthy eating.

Hospitalattendance

Women experiencing complicated or high-risk pregnancy should receivethe maximum possible continuity of both medical and midwifery care.There should be an easy access to early pregnancy units, day assessmentservices and fetal assessment units for women thought to be at risk.

Hospital tour All women should be offered the opportunity to visit the delivery suite andwards.

IT services To help achieve these aims, good information technology services arerequired, linking the PCG/T to the midwifery and obstetric services andallowing for easy compilation of outcome measures.

Position of Women in the Social Structure

As already mentioned, the main focus of this research is woman’s physical access toantenatal care. This needs to be considered within the wider context of women’s position inthe social structure and the impact this has on issues of accessibility.

Even after many years of Equal Pay Legislation women’s pay lags far behind that of men.This economic inferiority has much to do with women’s labour being less highly valued thanmen’s. Women’s jobs tend to be concentrated in the poorly paid service sector, and the scaleof inequality runs deep. The dramatic increase in women in paid employment, especiallywomen with young children, has been one of the most important structural changes in thelabour market over the last twenty-five years. But while women comprise over half of allemployees, almost half work part-time. Part-time workers’ earnings tend to be low, not onlybecause of the pro-rata reduction, but also because part-time workers generally are in avulnerable position in the labour market, having fewer employment rights than full timeemployees.

Apart from the low valuation of women’s labour, and the domestic responsibilities whichheavily restrict women’s choice of employment, what is often overlooked is that transportoptions also have a strong bearing on whether a women can take up a job or not. Wherewomen live, is often determined by the workplace of the male partner, who is routinelydefined as the main breadwinner. Such are the restrictions on employment opportunities forwomen it is common for a woman returning to work after a period of full-time child care totake a less skilled and more poorly paid job than she originally had. Home-working, mainlydone by women and one of the lowest paid of all types of employment, is probably theclearest and most extreme example of the way in which women’s bargaining position in thelabour market is reduced by transport and child-care constraints.


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Despite the movement of women into the paid employment market, the sexual division oflabour within the household persists. The result has been an expansion of women’s rolesrather than the achievement of gender role equality. Women’s activities may reflect anycombination of role, as for example, paid employee, student, unpaid domestic labourer, carerof children, or of sick or elderly adults. There are now more old people who need to belooked after, and the carers, whether paid or unpaid, are almost exclusively women.

Women’s travelAs it is for everyone, transport is an essential aspect of women’s lives. It determines theiraccess to society, for example, to employment, childcare, education, health and the politicalprocess. Women’s travel needs are as significant as men’s, although they are in manyrespects radically different. Women make as many journeys as men, but they are differentjourneys, they are shorter, on average, and they tend to be for different purposes.

This is best illustrated by considering how men and women use public transport. Publictransport typically provides for people travelling to nine-to-five jobs in population centres;provision outside this pattern is often poor. Not only are off-peak journeys neglected but alsojourneys which do not follow a radial route, (e.g. suburb to centre) or which link rural areas,may be ignored altogether.

Women travel more than they have ever done before. This is partly a reflection of risingincome and employment levels and increasing access to a car. The National Travel Surveyestimates that 82% of men and 59% of women hold driving licences, however women haveless primary access to a car. Where a household owns a car, only 25% of women have itsprimary use. Licence holding for women has doubled over the past 20 years whereas theproportion of men holding licences has changed little since the late 1980s. Overall thenumber of trips made per person per year has increased 25% since the mid-eighties. At allages, men make more car driver trips per year than women.

Despite the growth in women’s use of cars, men and women still have different travelpatterns. Women travel shorter distances than men. This is partly a reflection of the differentpurposes for which women travel. For example, in 1991 women made 64% of all shoppingtrips and 71% of trips for the sole purpose of ‘escorting’ (mainly children) using all modes oftransport in London.

Moreover, discounted travel, such as season tickets, is typically available only to regular andfrequent travellers. The clear effect of this tendency is to discriminate against women infavour of full time employed males. This is because women are less likely to be in full-timeemployment, are less likely to work in the centre of towns and cities, and are more likely,because of their more local jobs and their typical role as carers, to make non-radial trips - toschools, hospitals, shops and friends and family. At the same time, women are less likely tohave a car or to be able to drive, so their dependence on public transport is in fact greaterthan men’s.

For a long time, the conventional solution was to encourage women to equip themselves witha car. As women’s financial power has increased, and because of the failure of publictransport to meet their needs, that is precisely what has occurred. The net increase in car-use in London over the last decade is attributable to the rise in numbers of women-drivers.There has been a consequent loss of revenue to public transport operators throughout theUK, which makes it harder to cater for people who depend on public transport, and increasestheir isolation. But despite the recent rise in car-use by women, the majority of women donot have access to a car.

A development linked to rising car-use has been the locating of facilities such as large retailoutlets, leisure centres and hospitals on the edge of cities and towns, to the detriment of


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existing town-centres and local neighbourhood facilities. When out-of-town facilities open,local facilities often close. More out-of-town locations have meant that cars have becomemore and more necessary for journeys to facilities that would otherwise be inaccessible. Theaverage distance travelled by individuals has increased dramatically over the last ten years,most of it accounted for by cars.


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Chapter 4 Case Studies

IntroductionIn order to gain an insight into the public and private transport experiences of womenattending the antenatal clinic at Newham General Hospital it is important to place these incontext with other factors.

The London Borough of Newham was chosen for investigation because Newham is a deprivedinner city area with low car ownership and high dependency on public transport. In theserespects it has similarities with other inner cities in the UK such as Glasgow, Birmingham andManchester. For comparison, analysis of trends was undertaken with the more affluentLondon Borough of Richmond. Newham and Richmond differ greatly in terms of socio-demographic characteristics. No face-to-face interviews were undertaken in Richmond.

To gain a general profile of Newham and Richmond, this chapter will focus on the population,economy, health and transport characteristics of the borough. It will also consider futuretrends and council strategies for the coming years.

NewhamThe current borough of Newham owes its existence to the amalgamation of the formerboroughs of East Ham and West Ham in 1965. The borough lies north of the Thames in EastLondon and borders with Barking and Dagenham to the East and Tower Hamlets to the West.Newham Borough is only a few miles from the City of London and as such constitutes part ofInner London. The size of the borough is 3,855 hectares9. Newham Borough is broken downinto 24 wards. Newham is the highest-ranking Local Authority in England on the LocalConditions Index, a Government set of deprivation indicators, which essentially means that itis an area of “severe urban deprivation”10.

However it is important to note that Newham is undergoing many changes. The majorindustries, formerly the main employers for the borough, are now in decline. There are stillestablished industrial employers in the Thameside Belt and the Lower Lea Valley and there isgrowth in the office and service sectors around Stratford and the Royal Docks. An extensiveprogramme of regeneration is currently taking place.

PopulationAt the last published census in 1991, the population of Newham was identified as 212,170.Population projections suggest that this figure will have increased to over 230,000 by 200111.There is a great deal of ethnic and culture diversity within Newham. Indeed, the Borough’sUDP (Unitary Development Plan) states that the borough is the most ethnically diverse in theUK. This level of diversity is best reflected in a comparison of ethnicity across Newham,Greater London and the UK as recorded in the 1991 census. In Newham 57.7% of thepopulation are classed ‘White’, this compares to 80% in London and 94% in the UK.

The average household size in projected to be decreasing. This proportion of single personand sole parent households is increasing whilst the predominant household type of marriedcouple is becoming less common. These trends are consistent with London as a whole.

EconomyUnemployment in Newham is high. Statistics from the UDP highlight that in June 1998,Newham had an unemployment rate of 11.9%, the fifth highest in Greater London. However,this rate has declined along national trends, for example in 1993 the unemployment rate was20.8%. The 1991 census shows that one third of economically active residents wereemployed in the low paid manual sector. Compared to Greater London as a whole, there werefewer employees in the professional and employers/managers socio-economic categories. It 9 Newham Interim Transport Plan - 2001/200210 Griffiths 1994, p711 From break down of 1991 Census Statistics


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is not surprising to note that in terms of income, many of the borough’s residents are poor.The UDP states that in 1996, 33% of the borough’s residents aged 16 and over wererecipients of Income Support whilst 47% of households were receiving Housing Benefit.

HealthIndicators of deprivation can be provided through health statistics collated from the 1991census. A National Health target for 2010 is to reduce by at least 10% the gap in infantmortality between manual groups and the population as a whole12. Although infant mortalityrepresents only a small proportion of total deaths, it is an important measure of public health.The infant mortality rate for Newham between 1993 and 2000 was 7.2 deaths per 1000 livebirths, for London the overall rate was 6.1 and the rate for England and Wales was 6.0 for1993 to 1998. Within Newham itself there is a wide variance in the rates, one area, ManorPark, has 12 deaths per 1000 live births.

Contributing factors to higher infantmortality rates include:

• Babies born with low birth weight• Babies born to mothers under the age

of 20• Babies born to mothers who

themselves were born outside Englandand Wales

• Births registered by the mother alone13

Newham is characterised by high levels in most of these factors. The proportion of low birthweight (less than 2500g) between 1993 and 2000 was 9.8 births per 100 live and still births.In 2000, the proportion of low birth weights in Newham was higher than all other Londonboroughs with the exception of Hackney. Teenage pregnancies are also more common,Newham has a higher rate than in England as whole. As Newham has high numbers ofimmigrants and refugees, a higher proportion of births in the borough will be to women bornoutside the UK. However the rate for sole birth or births outside marriage is not as frequentas in many other boroughs.

Health in Newham is poor compared to national and London averages. Using long term illnessas an example, one in seven residents has a long-term illness that limits their daily activities.The Newham Health for All Survey (1991) reports that 6% of residents are registereddisabled and that 27% of households have a dependent with a limiting long-term illness; theGreater London average is 22%. It is also interesting to note that Newham’s StandardisedMortality Ratio is 14% worse than for England and Wales14.

Future trendsA population of 231,000 has been projected for 2001. However, growth is anticipated tooccur most substantially in the 35 – 54 year age group, from 46,500 in 1991 to approximately62,000 by 2001. Factors such as birth and future migration rates are difficult to predict andtherefore projections are to be treated with caution. However, the Newham UDP suggeststhat the population could be between 236,000 and 249,000 by 2006, depending on theavailability of housing

It is anticipated that the ethnic minority community made up mainly of Black Caribbean andIndian will become the majority, accounting for 55% of the population by 200615. Thegreatest demographic shift is likely to occur in the elderly population. There are also likely to

12 Department of Health, 200113 London Health Observatory, 200114 Vital Statistics’, ONS 1998, cited by Newham Unitary Development Plan15 LRC 1998, cited by the Newham UDP


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be changes relating to housing issues with the number of single person and sole parenthouseholds anticipated to increase substantially by 200616. Finally, changes are alsoanticipated amongst the working population, the proportion of those in work may notexperience great change but the age of workers is predicted to change, with a decrease inthe numbers of 16 – 34 year olds in employment.

Transport in NewhamIn terms of quantity, there is comparatively high public transport provision within Newham,providing transport locally, to the City of London four miles away and also to Outer Londonand Essex. London City Airport and the Jubilee Line Extension, with a new station inStratford, are tangible signs that the extensive regeneration programme is underway in theborough.

Public transport is essential for the local population, while 47% of the population have accessto a car, 53% of residents do not. The average for Greater London is 43%. Newham is wellserved by the London Underground. The Central Line, District Line, Hammersmith and CityLine and Jubilee Line all run through it. The Docklands Light Railway (DLR) also serves theborough and there are a number of National train lines that go through Stratford. However,still the most common method of getting to work in Newham is by car at 33% andapproximately 25% use the underground to get to work, the rest use the bus or walk and asmall percentage cycle to work. These figures highlight that in order for people to beeconomically and socially active, effective public transport and accessible routes for walkingare essential.

Access to Newham General HospitalBus, underground, taxis and cars are all used to get to the hospital. The nearest undergroundstation is a 15 minutes walk away for a fit adult. Public transport to Newham General Hospitalis mainly by bus. Cars are used, but car parking at the hospital site is limited. Some patientschoose to be dropped off by the driver who later returns to pick them up. Taxis are alsofrequently used. The bus provides the main means of access for our study group. Six buseshave Newham General Hospital on their route these include numbers 272, 376, 147, 262, 300and 473.

RichmondThe London Borough of Richmond upon Thames is one of the richest boroughs in London. Itis situated in outer West London. The borough is also home to the highest percentage ofOuter London’s total number of listed buildings and home to four ancient monuments.

PopulationAccording to the 1991 Census, the resident population in Richmond was 160,7632 (thiscompared to 212,170 for Newham). An estimated mid-year resident population for 199817

suggests that 186,700 people reside in the Borough. This makes it the fourth smallest out of19 boroughs in Outer London. A breakdown by gender reveals that 49% are male and 51.1%are female16.

There are 83,000 households in the borough of which 4% belong to sole parents withdependent children, making it the lowest sole parent population of all London Boroughs(jointly with the City of London, Redbridge and Kingston upon Thames).

37% of households are one-person households. A breakdown of housing stock by tenurereveals that 14% of the housing stock is in the public sector and 86% is in the private sector.The average price for privately renting the above was £269 per week and is the most

16 Newham UDP17 Focus on London 2000, GLA 2000


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expensive in Outer London whilst local authority rent was £57 per week making it the 8th

most expensive in Outer London.

In comparison to the ethnic diversity found in Newham, Richmond is relatively homogenous.Statistics from the 1991 Census state that 95% of the population are white, 0.3% are Black(Caribbean), 0.2% are Black (African), 0.2 are Black (Other), 1.6% are Indian, 0.2% arePakistani, 0.2% are Bangladeshi, 0.6% are Chinese, 1% are Asian (Other Groups) and 1.2%belong to other groups.

EconomyBetween March 1998 and February 1999, 74% of those of working age were in employment.The sample size in the 1991 Census for Richmond was too small to provide a reliableestimate of those unemployed. However, 2,000 people were classed as ‘claimants’ or onincome support benefits in the quarter ending October 1999.

Only 5% of the Borough’s population aged 16 and over received income support in 1999, thelowest figure for the whole of London. A ranking from the Index of local Deprivation (1998)places Richmond at 156 making it the fourth least deprived borough by this indicator inLondon.

HealthRichmond has a crude birth rate of 13 per 1,000 population. Only 5.2% of all live birthsweighed under 2,500g (considered to be low birth weight), this is the lowest percentage forthe whole of London and compares with the Newham rate of 10.8%. The crude death rate is8.4 per 1,000 population and the standardised mortality ratio is 79, which comparesfavourably against the UK figure and is the lowest in London.

Unlike Newham, Richmond has fewer of the factors which contribute to high infant mortalityrates such as babies born with low birth weight, babies born to mothers under the age of 20,babies born to mothers who themselves were born outside England and Wales and birthsregistered by the mother alone.

Transport in RichmondRichmond is well served by good transport. The Borough has heavy rail, underground andgood bus links to the surrounding areas, direct routes to the West and into central London.Data from the 1991 Census shows that 46% of households have 1 car; 22% have two carswhilst nearly 4% have three or more cars. There are more cars in the Borough thanhouseholds, a trend reflected in 8 other London Boroughs. Compared with Newham,Richmond residents have far greater access to cars.

By examining modes of travel to work, the most common method, as with Newham, is bycar. However the proportion of residents who go to work by car is 48% (compared withNewham’s 33%). More than half (52.7%) of Richmond’s economically active residentsworking outside the borough travel to work by car. All other travel modes to work, except bytrain, (which increased slightly by 0.5%) have fallen.


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A Comparison of Newham and Richmond

Indicator Newham Richmond% of DNAs, 2002 23% 1.8%

Estimated mid year resident population, 1997 183,800 228,500

Estimated number of females between 15 and 44 70,000 62,600

Live births 4,607 2,379

Crude birth rate per 100 population 20.2 13

Income support as % of 16+ age population 21 4

Number of prescriptions per head of population East London andCity HealthAuthority

10.9

Kingston andRichmond

8.7

Unemployment rate 1998 as % of population ofworking age in the labour force 15.3 6.5

% of population from ethnic minority groups Between 40-50% Between 7-8%

Household car ownership 46.5% 72%

In Newham in 2000, there were 4,927 live births and 1,713 deaths18. The total fertility rate 19

for women in Newham in 2000 was 2.7, which was considerably higher than the InnerLondon rate of 1.73, (Newham had the highest birth rate of all London boroughs) and therate for England and Wales was 1.65.

18 ONS Vital Statistics, 200019 The average number of children that would be born to a woman if she experiences the current age-specific fertilityrates throughout her child baring years


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Chapter 5 Findings

Selected Literature ReviewA comprehensive literature review was undertaken. Despite the sheer volume of literaturereviewed, existing work on 'Did Not Attends' (DNAs) have failed to capture the majorinterests of this research. Of the studies reviewed, few if any had a transport focus. Manystudies concluded that ‘apathy’ was the main reason of DNAs, however one intention of thisstudy was to discover if apathy masked other problems such as transport.

The literature review focused upon what is already known about ‘DNAs’ (Did Not Attends).This research was largely concerned with the reasons for non-attendance and outlined someof the initiatives that have been made to try to improve attendance. Literature relatingspecifically to maternity care/antenatal clinics was sparse.

It appears that where appointments were missed, several methods were used to try andascertain the reasons for non-attendance. Methods used in these studies to uncover thereasons for DNAs ranged from postal questionnaires, telephone surveys and socio-economicanalysis of patient records. Qualitative survey techniques such as those involving questioningparticipants through postal and telephone surveys are generally less reliable that face-to-facequestioning. Furthermore, socio-economic analysis of patient records rely upon an overreliance of ‘assumed observations’ based on existing research only.

The literature reflects investigation and research in several different types of clinics rangingfrom plastic surgery20, gastrointestinal21, periodontics, ear nose and throat (ENT)22, andgeneral practice23.

The most common reason given for non-attendance in the literature was that the ‘patientforgot’ or what is often termed ‘patient apathy’. Some evidence related to the use of variousad-hoc postal and telephone reminder techniques to try to solve the ‘apathy’ aspect of theproblem24. However these have proved unsuccessful and are viewed by maternity careprofessionals as too costly.

Transport, or transport related factors, although not necessarily given any major attention inconnection with DNAs, did appear as a contributory factor25. The few studies where transportfactors were analysed tended to be initiated from a transport rather than integrated transportand health sector perspective. However, Government Transport Policy has recently26 shiftedfocus towards tackling certain journeys such as the ‘journey to school’ and the ‘journey towork’ as key elements of its transport strategy. In the transport studies, cost, timing andconvenience tend to be the main problems associated with attending hospital appointments.Significantly, the questions asked relate to the ‘difficulties of getting to hospitals’ rather thandirectly to the reasons for ‘non-attendance’.

In general terms, in studies undertaken by the health sector, transport is described as acontributory factor for non-attendance, and studies undertaken by the transport sectorindicate that hospitals and other health related facilities are frequently located in areasdifficult to access by public transport. It appears from the research reviewed that bothsectors concur that transport can be a contributory factor to non-attendance.

20 Reducing non-attendance at outpatient clinics" CA Stone JH Palmer, PJ Saxby VS Devaraj. Journal of the RoyalSociety of Medicine Vol. 92 Marc 1999 p 114-118.21 Failure of patients to attend a medical outpatient clinic. A.V. Simmons, K. Atkinson, P. Atkinson, B. Crosse.Journal of the Royal College of Physicians of London Vol. 31 No. 1 January/February 199722 Improving Attendance at ENT Clinics. IMPACT, NHS Learning Network, 2000. www.ebando.com/ImpAct23 Did Not Attends. Who are they and what can we do about them? Centre for Innovation in Primary Care, January 199924 Patient apathy costing millions, Belfast. BBC News website May 200225 Too much like school: social class, age, marital status and attendance/ non-attendance at antenatal classes. DallasCliff and Ruth Deery, Midwifery (1997) 13, p139-145.26 Transport White Paper, 1998


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The following four sections provide an overview from the literature reviewed; conclusionshave been drawn at the end of each section.

• Cost of DNAs• Transport and Social Exclusion• DNAs and Transport• Location Factors

Cost of DNAsResearch carried out in Belfast, in 2002 and published by the Royal Society of Medicine foundthat 14% of patients did not keep their clinic appointment. This same study estimated that itcosts the NHS £65 per missed appointment. This meant that if the same absenteeism ratewas recorded across the NHS it would cost the health service £300m per year in Englandalone. The survey found that a quarter of those who missed an appointment during the pastseven months had missed at least one other appointment in the past. The researchsuggested that apathy was the main reason for 62% of missed NHS outpatient appointments.The authors of the report suggest that solutions such as telephone reminders or gettingpeople to confirm their own appointments are unlikely to work long-term across all kinds ofoutpatient clinics. The authors believe that reminding people to attend appointments will be adrain on resources27.

However, dedicated staff purely responsible for reminding patients by telephone or by postmay be one solution, but it would be unlikely to work if transport problems were a majorfactor affecting non-attendance.

The appointment system allows for a certain amount of overbooking to take non-attendanceinto account. The Belfast research also showed that over 89% of health professionals felt thatmissed appointments were a problem and 87% felt a reduction in missed appointmentswould lead to shorter waiting times.

In 2000, the Guardian Newspaper reported that absent patients are costing the NHS £18mper year. Evidence taken from a report for the ‘Doctor Patient Partnership’ and the Instituteof Healthcare Management suggested that 10 million GP appointments are missed per yearwith an average cost of £18.7 per appointment. In 1996/7 the Department of Healthestimated that 6 million appointments were missed, at an average cost of £61 each28.

The Belfast study and the Department of Health Study in 1997 indicate that the cost ofmissed appointments to the NHS is between £300 and £366 million per year and give theaverage cost of each missed appointment at between £61 and £65, but there is variationbetween the average numbers of missed appointments. The Belfast Study suggests 4.5million and the earlier DoH study puts the number at 6 million.

Furthermore the DoH study, mentioned above, also estimated that the cost per non-attendance at GP surgeries is lower than for hospitals. This suggests that different types ofnon-attendance, have differing costs.

Transport and Social ExclusionA report by the Social Exclusion Unit29 for the Cabinet Office30 highlights that transport is asignificant barrier to social inclusion (this research looked at exclusion in terms of access topublic services and facilities as well as access to jobs). It demonstrates that an individual’s fullparticipation in society, which includes access to healthcare, can be restricted by poortransport. The report states that overemphasis on cars can result in social exclusion as

27 Patient apathy costing millions, Belfast. BBC News website May 200228 P. Davies, Health Social Survey Journal, 1984, 886-7.29 The Social Exclusion Unit was set up by the Government in 1997 and is part of the Cabinet Office.30 Making the Connections: Transport and Social Exclusion. Interim findings from the Social Exclusion Unit, 2002.www.cabinet-office.gov.uk


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individuals on low incomes can not afford the cost of motoring and their use of publictransport may be far from ideal because of poor transport networks, unaffordable fares andunreliability. It also suggests people with disabilities and the young and old are restrictedfrom much of the transport system due to over emphasis placed upon motorised transport.

The report also explains how poor transport can reinforce social exclusion. For example, asole parent may be unable to take up employment because of travel costs and the complexityof trips required for those with childcare responsibilities. It also points to the possibility ofcreating special transport arrangements for patients attending hospital appointments. Othersuggestions include:

• Better advice on how to get to hospital using transport;• Greater publicity for the Hospital Travel Costs Scheme;• Greater Choice over the timing of hospital appointments to fit in with travel needs;• Better integration of support available from non-emergency patient transport, the

Hospital Travel Costs Scheme and the Social Fund; and,• Local authorities should identify and promote key sites for facilities such as hospitals

in accessible locations and this should happen within a process which actively takesaccount of local people.

A study by the political think tank Demos31 explains the effects of an individual’s ability toparticipate fully in day-to-day activities. Demos suggests that there may be connectionsbetween ‘poverty and non-attendance for hospital appointments’ and concludes that anindividual would be more likely to travel if accompanied with someone else. However, formany, finding an escort is yet a further hurdle, such that two people could have to find timeoff work and both would have to pay for the cost of getting there. Being escorted to thehospital is unlikely to be an option for many people.

The ‘Journal of Health and Social Care’32 explored the relationship between transportavailability to employment opportunities and to health services, in Merseyside. It found thatattendance for healthcare always involved complex scheduling or getting help. Althoughindividuals questioned had many more problems than transport, it was clear that attending ahospital appointment would involve a great deal of organisation.

In many ways, poor transport provision can exacerbate existing organisational problems. Thiscan be seen in one study involving a woman who had caring commitments at home for herelderly mother. Attending her outpatient appointment would take her almost four hourstravelling time to and from the hospital and therefore she would have to seek temporary carefor her mother. Apathy could be taken as the reason for non-attendance masking caringcommitments, the duration of the journey and time away from home. Patients who aredependent upon public transport, which can be unreliable, coupled by an appointment systemwhich often runs late, would have to rearrange a considerable part of their day to attendtheir 20 minute hospital appointment.

This is just one of many examples which illustrate that poor transport and waiting times canlead to major inconvenience and upheaval. Better integration of public services such ashealth and transport is a very necessary step towards including people in society.

Meeting the cost of travel for some patients involves using the Hospital Travel Cost Scheme.This scheme provides financial help through reimbursing travel costs for those on lowincomes, but is an inflexible system as it only pays out after the money has been spent.

31 Escaping Poverty. Perri 6. Demos, London September 199732 Health on borrowed time? Prioritising and meeting needs in low-income households. Maggie Pearson, ChrisDawson, Hannah Moore and Sue Spencer. Journal of Health and Social Care 1 pp. 45-54


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The Hospital Travel Costs Scheme (HTCS)Currently patients who do not have a medical need for ambulance transport and who cannotmeet the cost of travel to hospital can claim for travel expenses. It is available to recipientsof Income Support or Family Credit and also others on the basis of low income or if they haveto make frequent, long and difficult journeys.

Patients can reclaim the cost of their travel and receive an immediate cash payment onpresentation of travel tickets and evidence of ‘benefit’. Costs are calculated on the basis ofthe cheapest form of public transport, including any concessionary fares available to thepatient. Patients travelling by private car may claim the cheapest estimated cost of petrolactually used. The scheme operates under the provisions of the ‘National Health ServiceTravelling Expenses and Remission of Charges’ Regulations 1988.

A research project which examined the socio-economic and demographic issues of patientnon-attendance33 centred on a hospital near the centre of Reading and within a 15-minutebus ride of the farthest part of the town centre. Analysis of the DNA rate by postcoderevealed a range in non-attendance of between 6% in rural areas to 15% in town centreareas. Most urban areas average an 8% DNA rate, however the Reading study suggests thatdistance to the hospital has a weak effect on DNA rates. However, the accessibility of thehospital by all modes of transport was shown to be much more important. For example, ifthe journey to the hospital involved changing buses and a long walk from the bus stop, thenthis may have the effect of putting people off making the journey. However, non-attendancerates are lower for those having to travel greater distances such as in rural areas. This canpartly be explained by higher car ownership in rural areas.

In general this Reading study demonstrated that all measures of deprivation or lack of familysupport, correlate with a higher disposition to non-attendance. The highest DNA rates wereamong the parents of young children; females and males aged 16-51 and people living insocio-economically disadvantaged inner city and urban areas (younger and older peoplebeing more likely to attend).

These social exclusion focused studies demonstrate that poverty is a factor in an individual’sability to keep a hospital appointment. Additionally, people living in urban areas andespecially those with caring responsibilities are more at risk of missing their hospitalappointments. Inadequate transport provision can have a detrimental effect on an individual’sability to organise their day-to-day activities.

Did Not Attends and TransportAn Integrated Transport Study by Sandwell HAZ34 highlighted several connections betweenDNA rates and transport. It appeared that about 10% of DNAs were caused directly bytransport difficulties such as “non-urgent ambulance did not arrive”, “friend with car wasunable to provide lift”, “bus service inappropriate” and about 10% indirectly “hanging aboutfor a bus is the last straw when you don't feel 100%”.

A Leaflet by The Association of Community Health Conference (ACHC) England and Wales35

states that the main reasons for non-attendance are:• People forget/ apathy• People get better and may not feel they have to attend, especially in GP surgeries.• Patients are discharged to GP• Too ill to attend

33 Socio-economic and demographic factors in patient non-attendance. Sid Beauchant, Rodney Jones. BritishJournal of Health Care Management, 1997, Vol. 3, No. 1034 Sandwell HAZ Integrated Transport Study, Richard Armitage, April 2000.35 ‘Did Not Attend - Whose fault is it anyway?’ Health Perspective, (leaflet) ACHC England and Wales, June 1997


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• Overbooking; some patients are aware of the overbooking policy and consider it willhelp the NHS if they do not attend their appointment.

• No notification or reminder given• Sometimes postal details are wrong; the communication and administration system

often fails.• Some individuals do not understand appointment letters, and the system can be

difficult to access, perhaps due to language barriers• The unavailability of female health professions for those wishing to avoid contact with

male doctors and nurses as is the case for Muslim women.• Transport or other location difficulties• Administration mistakes; the booking and rebooking system can often lead to

mistakes

An audit of plastic surgery outpatient clinics published in the Journal of the Royal Society ofMedicine36 determined the clinical and demographic profile of non-attendees and discoveredthat 16% of patients missed appointments. The main reasons included “forgetting 35%”,“illness 10%”, “work commitments of patients 14%”, “transport difficulties, 10%” and “poorweather making the journey difficult 16%”.

A report by the Department of Environment Transport and Regions on ‘Social Exclusion andthe Provision and Availability of Public Transport’37 specifically mentioned the difficulty ofgetting to hospitals and local surgeries and health centres. The difficulties were found to bearound the complexity of some journeys, which may require changing from one mode oftransport to another, (for example bus to rail); the costs of travel; the possibility of notarriving on time; the location of bus stops; and, the physical accessibility of the bus.

Another report indicated that efforts to improve attendance at Ear, Nose and Throat (ENT)Clinics at the North Riding Infirmary38 met with limited success. The ENT Department is nowexploring ways of tackling non-attendance, which include improving access for publictransport into the hospital site and improving car parking for visitors and outpatients. OtherHospitals such as the Addenbrooks in Cambridge have appointed an officer to set up aHospital Travel Plan, which has started to make tangible improvements for those travelling tothe site by public transport, by bike or on foot. Employees at Addenbrooks are beingencouraged to leave their cars at home and allow the reduced amount of car parking spacesto be allocated for ‘short stay’ visitors.

Clearly there is a strong link between transport and the non-attendance of hospitalappointments. Actual volumes of DNAs vary from sector to sector and from hospital tohospital. Additionally, problems with transport are often masked by other reasons such aschildcare responsibilities and poor weather. There is clear evidence to suggest transport andtransport related reasons are a significant factor of DNAs. The centralisation of patientservices in large unfriendly bureaucratic places could be another factor, The governmentsuggested this in The NHS modern and Dependable (1998) and stated that services shouldbe delivered closer to communities.

Several hospitals are actively encouraging better access to their hospital sites. Further workwill be necessary to find out if DNAs at those hospitals is reducing. Outreach clinics havebeen shown to be successful in reducing DNAs, especially when the services are deliveredcloser to the communities

36 Reducing non-attendance at outpatient clinics" CA Stone JH Palmer, PJ Saxby, VS Devaraj. Journal of the RoyalSociety of Medicine Vol. 92 Marc 1999 p 114-118.37 Social Exclusion and the Provision and Availability of Public Transport. DETR 200038 Improving Attendance at ENT Clinics. IMPACT, NHS Learning Network, 2000. www.ebando.com/ImpAct


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Location factorsThe London Health Strategy39 states that transport is one of its four key priorities. It aims tosupport efforts across the capital to improve health and reduce inequalities. The reportsuggests that integrated transport and land use measures can be used more effectively tohelp people access their services more easily. For example, facilities such as GP surgeriesshould be located conveniently for access by public transport, walking and cycling. It alsocalls for thought to be given to easy access to health facilities within all regeneration plans.The health sector has a substantial transport ‘footprint’ in London with its concentration ofNHS hospitals, primary care facilities and research institutions. The report emphases theimportance of location and how it obviously influences the travel patterns of patients, staffand deliveries.

The Greater London Authority40 claims that, although it has no remit for health care provision,it does however have strategic responsibilities including the development of transport, andspatial development strategies, both of which have major impacts on the health ofLondoners.

A study published in the Health Service Journal41 examined the factors determining non-attendance at health appointments and recommended that more flexible local arrangementsare required to maximise the take-up of services and that some GP fund-holders were alreadypurchasing specialist outpatient clinics in their local practice premises, offering a service forseveral practices in their locality. Here location has been given priority in order to maximiseattendance at key outpatient clinics.

From a transport perspective, location can determines how people travel. An out of townlocation will undoubtedly attract more car based journeys, whereas a city central location willattract more trips made on foot, cycle and public transport.

Healthcare

The antenatal clinicAccording to one midwife interviewed, the antenatal clinic at Newham General Hospital allowsfor 10-minute slots between each pregnant woman. Not everyone is seen in this time andsometimes it can take half an hour “so we get a lot of slippage”. A 10-minute appointment isused to ask how the pregnant woman is doing, and to ask about the baby’s movement,“there is also a check for the heartbeat and blood pressure and to see how the baby is lying .. . we weigh the mother too. It is normal practice for all antenatal hospital appointments tobe late”. There are some instances of people leaving the clinic before being seen, “…somewill come to me and say they have been waiting for over an hour and need to get away tocollect a child or children” (these will be recorded as DNAs).

Notice boards give information about how to reclaim travel expenses, but it is not in alllanguages. And, it is not the nurse’s job to tell patients about travel expenses. Some women,especially refugees, are given tokens for food, but are not entitled to transport fares, whichcan result in some pregnant women walking several miles to attend an appointment.

This research did not consider 'at risk' patients (such as drug addicts or those with mentalhealth problems), which will always account for a degree of missed hospital appointments. Amidwife at Newham General Hospital explained that locating or tracing those 'at risk' peoplecan take approximately 20% of her time.

Provision of careCare is shared between community care and hospital care, but there are insufficientcommunity midwives to provide care. Care could be provided either in GP practices or in

39 On the Move; informing transport health impact assessment in London. NHS Executive October 2000.40 Health Service Bulletin, Issue 2, Spring 2002, Greater London Authority.41 Health Service Journal 15 October 1992. “Outpatients outclassed”


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women's homes particularly in cases where women had already successfully given birth.Apart from antenatal classes, most ‘low risk’ women should receive the majority of theirantenatal care at their local GP practice or in community health centres.

Some of the maternity care professionals we spoke to considered that some women did notneed so many appointments for antenatal care, because they were 'low risk' and having tospend a lot of time in a clinic for a short appointment could be a deterrent to attending.

Face-to-face interviewsThe research undertaken for this study involved collecting new data from antenataloutpatients in order to investigate whether transport was a factor in missed appointments. Ashort questionnaire was developed and face-to-face interviews were conducted. 120structured in-depth interviews were carried out in the antenatal clinic waiting area at theNewham General Hospital. 20 of the 120 interviews were undertaken as pilot interviews. Eachinterview lasted approximately 25 minutes.

Women attending antenatal appointments at Newham General Hospital were keen to takepart in the study. Most of the women approached were willing to talk to the interviewersabout their journey. This was partly a reflection of the long wait and the degree of isolationthat they felt whilst waiting to be seen. Table 1 shows that nearly half of women interviewedhad to wait over 90 minutes for their appointment.

Table 1 Appointment waiting timeTime Frequency15 – 45 minutes 1246 – 60 minutes 2361 – 90 minutes 1491 – 120 minutes 18121 – 180 minutes 23181 + minutes 5Don’t know 3Missing Data 2Total 100**For the 20 pilot surveys, this question was not asked

The number of given appointments varied between women, depending upon the level of careconsidered necessary by the doctor. Table 2(a) shows that more than half of the womeninterviewed have at least 6 hospital appointments during the course of their pregnancy andtable (b) illustrates the number of GP visits, which shows that over 4 appointments werenecessary.

Table 2(a) Number of hospitalappointments during pregnancyNumber ofvisits

Frequency

0 31 – 3 244 – 5 166 – 10 4111 – 20 1121+ 5Total 100**For the 20 pilot surveys, this question was not asked

Table 2(b) Number of GPappointments, during pregnancy

Number ofvisits

Frequency

0 17


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1 – 3 254 – 5 14

6 – 10 3211 – 20 8

21+ 2Missing 2

Total 100**For the 20 pilot surveys, this question was not asked

27% of all respondents had missed at least one appointment in the past six months. Reasonsvaried for those missed appointments included administrative errors, childcare responsibilitiesand transport problems. The main findings and analysis from the interviews are set outbelow.

Getting thereOf those women that had missed appointments, 68.8% considered that transport was themain reason. Table 2 also reveals that other reasons such as “forgot” and illness were notmajor reasons for non-attendance.

“I haven’t missed an appointmentand have been late due tounreliability of the buses”

Table 3 Reason for non- attendanceReason for non attending Frequency Percentage

%Forgot 2 6.2Illness 3 9.4No time off work 2 6.2It seemed too much effort 2 6.2It seemed too much effort + other 1 3.1Transport 22 68.8Total 32 100

6% of the sample were not aware of their entitlement to time off work or found it difficult toask for time to attend their antenatal appointment.

“I’ve missed an appointment dueto an administration error.

Table 4 shows the mode of transport normally used by the pregnant woman to get to thehospital. Approximately 40% normally travelled by car as a driver or as a passenger, nearly40% used public transport, 6% walked to the hospital, 12.5% took a taxi and the remaindertook a combination of either ‘train and bus’, ‘car and bus’ and ‘bus and walk’. Of thosepatients who had missed appointments over half would normally use public transport.

“The car was not available and thebus didn’t come, so I missed myappointment”


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Table 4 Mode of transport used to get to hospitalMode Frequency Percentage

%Drive car / van 20 16.7Passenger in car / van 27 22.5Bus 46 38.3Train / Underground 1 0.8Walk 7 5.8Taxi 15 12.5DLR + Bus 1 0.8Car and Bus 1 0.8Bus and walk 1 0.8Car and Underground 1 0.8Total 120 100

Similar to many inner city locations throughout the UK, Newham General Hospital has asignificant number of outpatients accessing the site by public transport. Currently the hospitalcould be better served by public transport; there are no direct rail or tube connections to thesite, all are at least 15 minutes walk away for a fit person. However several bus routes stopat the site, but do not enter the hospital grounds, therefore a short walk is required from thebus stop into the hospital. The car park at the hospital is reaching capacity; often it is hard toget a place to park on the site. Currently Newham General Hospital does not have a TravelPlan Officer for staff and visitors.

“I’ve missed an appointment as Iwas stuck in traffic”

Car driver

Difficulty in accessing the hospital was citied as an issue by over half of all the respondents.As regular visitors to the hospital, Table 5 shows that nearly 30% of the women interviewedfound the journey difficult. Almost 53% of respondents who normally make the journey bybus found the journey either “rather difficult” or “very difficult”. This differed for those thatnormally travelled by car as a driver or passenger as only 13% found getting there “ratherdifficult” or “very difficult”.

Table 5 The journey to the hospital or to GPLevel of Ease Frequency Percentage

%Very easy 20 16.7Quite easy 64 53.3Neither easy or difficult 2 1.7Rather difficult 25 20.8Very difficult 9 7.5Totals 120 100


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What are considered transport problems by car drivers are often quite different from those ofnon-car drivers. Expectations of a good transport system are much higher amongst cardrivers, who consider it tiresome waiting for a parking space for 10 minutes, whereas waitingthis length of time for the bus is ‘to be expected’ amongst public transport users.

Many women in the sample that drove to appointments said they perceived public transportto be far too unreliable, however those same drivers or passengers also spent time in trafficcongestion and waiting for a parking space at the hospital site.

“I’ve missed an appointment due tonot being able to face publictransport. I usually drive”

Car driver

One third of the sample stated that they had suffered a ‘transport problem’, either on the dayof the interview or when previously attending an appointment. These problems range from“waiting 10 minutes for a car parking space” to “problems with buses that don’t turn up” anddifficulties “travelling with children”.

It transpired from the interviews that many women have an expectation that transport to thehospital will be a problem, so many find they ‘build-in’ extra time for their journey to makesure they get to the appointment on time. However it is often the case that once they get tothe hospital, appointments can be running late.

“I have to wait a long time for theno.147 bus”

Table 6 relates to door-to-door journey time, and shows that over 60% took under 20minutes, 17% took about 30 minutes, 12% took about 45 minutes and 8% took one to twohours and 3% took over 2 hours. In-depth investigation revealed that travelling by publictransport to the Newham General Hospital was far slower than getting there by car. 85% ofrespondents who travelled by car or taxi took under 20 minutes to reach the hospitalcompared with 47% of patients who travelled by all other modes including public transport. Itis possible that those travelling by public transport are more likely to be put off making thetrip due to the time constraints.

Table 6 Door-to-door journey timeLength Frequency Percentage %Under 10 minutes 25 2110 – 20 minutes 49 41About 30 minutes 20 17About 45 minutes 14 121 to 2 hours 9 82 hours plus 3 3Total 120 100

Public TransportChanging from one bus to another is often cited by transport professionals as a reason orexcuse for not travelling by public transport. Accessibility by public transport depends notonly on the number and frequency of bus routes and the ease of walking from the bus stop,but also by where the routes are in relation to the users. Amongst the respondents atNewham General Hospital, 10 bus routes were frequently used, most of those involved a


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substantial walk from the bus stop to the hospital site, again this implies that some womenwould rather walk substantial distances than wait for a change of bus.

“I’ve missed an appointment due tothe bus service, I waited in rain forthe first bus and then missed theconnection for the second bus”

Table 7 reveals that nearly half wait 10 minutes or under for a bus, 35% wait between 11and 20 minutes, 10.8% wait between 20 to 30 minutes whilst nearly 2.7% have to wait over30%.

Table 7 Usual waiting time for the busWaiting Time Frequency Percentage

%10 minutes & under 19 51.411 and 20 minutes 13 35.121 and 30 minutes 4 10.830 minutes plus 1 2.7Total 37 100

The interviews revealed that the key factors for non-attendance were that public transportwas inadequate and it made travelling with children uncomfortable and inconvenient. 63%make explicit references to problems with buses such as unreliability of journey time, laterunning buses and traffic congestion. 20% refer to problems with using pushchairs andaccompanying children whilst using public transport.

WalkingAs a nation our walking tolerances has decreased over the past ten years. When asked if theywould use another mode of transport instead of the car, only two respondents said that theywould consider walking. This reluctance to walk is likely to stem from a car dependent cultureand lifestyle and the subsequent creation of an intimidating walking environment. However,as the sample highlighted, several women walk quite a distance than wait for a bus,indicating the inadequacy of the current bus provision to the Newham General Hospital site.

I’ve missed an appointment due tothe bus stop not being close and I felttoo tired to walk”

Caring responsibilitiesWomen in general have more caring responsibilities than men. Responsibility for youngchildren or elderly people can require 24-hour attention, in many instances there are noalternatives to taking the ‘cared for’ to the hospital appointment. Many women interviewedfor a study in 199142 indicated that travelling with children, particularly when public transportis used, is cumbersome and difficult especially when travelling with more than one child. Thiscurrent research repeats the findings of the earlier work in that many women admitted thattaking their child by bus almost put them off make the trip. They complained that it wasdifficult and time-consuming travelling with children on public transport. In short ‘caringresponsibilities’ mean that travel is more complicated, and requires more organisation and

42Women and Transport,Hamilton K et al.


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planning. Childcare responsibilities coupled with a long bus ride may be the reason behind socalled ‘apathy’ for women failing to turn up for antenatal appointments.

Caring for elderly relatives or children brings with it a level of responsibility, which restrictswomen’s ability to undertake certain activities. Getting temporary care may be appropriate forsome women, but for many it is a luxury. Table 8 shows that over half (58.3%) of therespondents already had dependant children, 31.7% had one child and 26.6% had two ormore children.

Table 8 Number of childrenNumber ofChildren

Frequency Percentage%

0 50 41.71 38 31.72 19 15.83 7 5.84 2 1.75 3 2.56 1 0.8

Totals 120 100

“I don’t like taking my children onthe bus as they have nearlycaused me to miss myappointment”

66% of respondents who had missed an appointment had one child or more. Despite morewomen in paid employment, the sexual division of labour within the household persists. Theresult has been an expansion of women’s roles rather than the achievement of gender roleequality. Women’s activities may reflect any combination of roles, for example, paidemployee, unpaid domestic worker, and carer of children or of sick or elderly parents. Thereare now more old people who need to be looked after, and the carers, whether paid orunpaid, are almost exclusively women.

“I find it difficult travelling with achild on the bus, especially whenit rains and the buses do not stop”

Tables 9a and 9b demonstrate that 82% of respondents were not accompanied to theirappointment. Approximately 35% were accompanied by their partner or husband, a further20% accompanied by a family member and nearly 16% were accompanied by their child.


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Table 9(a) Accompanied travel to the hospitalAccompaniedto theappointment?

Frequency Percentage%

No 82 68.3Yes 37 30.8No answer given 1 0.8Totals 120 100

Table 9(b) Accompanied by whomAccompanied by… Frequency Percentage

%Husband 17 20.7Adult Family Member (AFM) 16 19.5Child 13 15.9Friend 2 2.4Husband + AFM 1 1.2Husband + Child 10 12.2Partner 11 13.4Given Lift by Partner 3 3.7Partner + AFM 1 1.2Partner + Child 2 2.4Missing Data 6 7.3Totals 82 100

Table 10a shows that travelling with children was considered a problem by 27% ofrespondents. By correlating the mode of transport with ‘travelling with children’ it can be seenin Table 10b that travelling with children by public transport is considered more of a problem.

Table 10a Travelling with childrenProblem

travellingwith

children?

Frequency

“No” 60“Yes” 26

“Sometimes” 1No answer 13

Total 100(This question was not asked in the pilot study)


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Table 10b Travelling with children(Private transport vs. other Modes)

Problemtravellingwithchildren?

Private%

OtherModes

%

No 76.9% 60.9%Yes 20.5% 39.1%Sometimes 2.6% 0%Totals 100% 100%(‘Private’ refers to car driver or passenger and ‘other modes’ applies to all public transport including taxi and walking.)

When asked if they found it easy to get someone to look after their children when theyattended their appointment at hospital 50% stated they found it difficult and 44.3% statedthey did not find it a problem (Table 11).

Table 11 Ease of seeking alternative ‘Care’Able toseekalternativecare

Frequency %

No 31 44.3Yes 35 50Never tried 1 1.4Missing 3 4.3Totals 70 100

Low incomeAs mentioned previously, women’s pay lags far behind that of men. This economic inferiorityhas much to do with women’s labour being less highly valued than men’s. Women’s jobs tendto be concentrated in the poorly paid service sector. While women comprise over half of allemployees, almost half work part-time. Part-time workers’ earnings tend to be low, not onlybecause of the pro-rata reduction, but also because part-time workers generally are in avulnerable position in the labour market.

Transport options also have a strong bearing on whether women can take up a job or not.The literature review demonstrated a sharp correlation between income level and non-attendance. Many of the respondents in employment were in part-time and low paidemployment and they found it most difficult to take time off work to fit into the fairlyinflexible appointment system.

Table 12 shows that 18.3% of women in the sample were in full-time paid employment,10.8% were part-time employed, 17% were on income support, 28.3% were unpaid homekeepers, the rest were students, self employed, unemployed or asylum seeker.


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Table 12 Employment statusEmployment status Frequency Percentage

%Full-time employment 22 18.3Part-time employment 13 10.8Job Seekers 4 3.3Income Support 17 14.2Maternity Leave 5 4.2Full Time in House 34 28.3Student 5 4.2Self-employed 1 0.8Unemployed 4 3.3Asylum Seeker 1 0.8Other 2 1.7None Paid Work 11 9.2Missing 1 0.8Total 120 100

Languages34 different languages were encountered in the sample of 120 women at Newham GeneralHospital. The literature review findings suggested that language could be a barrier toattending appointments. Further work is necessary to discover the relationship between non-English speakers and attendance rates. Communication problems would appear to be abarrier to participation in the Hospital Travel Cost Scheme, which has been greatlyunderused. The Healthcare system can sometimes be difficult to access due to languagebarriers.

34 different languages and dialects were spoken with the sample group. These are namedbelow.AlbanianArabicAsborBangladeshiBanslayBarahiBengaliChineseDanishEnglishFrenchGallego

GujaratiIndonesianKirundiLithuanianPolishPortuguesePugujerartiPunjabiPushtuRussianSerbianSomalia

SpanishSwahiliTamilTigrinaTurkishTwiUrduVietnameseWoollofYoruba


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Chapter 5 Conclusions and Recommendations

1 Transport not ApathyMissed hospital appointments or DNAs (Did Not Attends) are a problem throughout the entireUK; they cost the NHS million of pounds each year. Missed appointments are not limited to aspecific sector of the health service, but are evident across all areas. Many healthprofessionals consider that patient apathy is the main problem behind missed appointments,and most health professionals consider missed appointments to be a major problem thatrequires action.

Clearly there is a strong link between transport and the non-attendance of hospitalappointments. Actual volumes of DNAs vary from sector to sector and from hospital tohospital. Additionally, problems with transport are often masked by other reasons such aschildcare responsibilities and poor weather. There is clear evidence to suggest transport andtransport related reasons are a significant factor of DNAs. However, several hospitals areactively encouraging better access to their hospital sites. Further work will be necessary toestablish if DNAs at those hospitals have reduced in frequency.

It would appear that ‘conventional wisdom’ has led to blame (apathy) being attached to thepregnant woman rather than establishing why apathy occurred in so many instances. An in-depth analysis of missed antenatal appointments at Newham General Hospital found thatnearly 70% of missed appointments were because of transport factors alone and ‘patientapathy’ (or the ‘patient forgot’) was a mere 6%. In most cases, where patients had missedappointments, transport problems were the cause for what would otherwise or previouslyhave been considered ‘apathy’. In addition transport related factors such as problems oftravelling with children was also cited as a reason for not attending a hospital appointment.

Accessing hospitals by public transport, by car and on foot were all seen as problems andlead to missed appointments. Although the research focused upon Newham, these findingsreflect similar problems in other inner cities in UK such as in Glasgow, Manchester, andBirmingham.

Recommendations (A)• Further investigation is necessary to ascertain the level of transport related problems,

which lead to DNAs across the UK.• Further analysis is necessary to estimate the cost to the NHS of missed appointments

in general and in particular those caused by transport.• A comprehensive map is required for each hospital in the UK describing the ease of

access by public transport, by car, by bicycle and on foot.

2 Transport arrangements to hospitalsResponsibility for the provision of transport to hospitals is a grey area. There does not seemto be a clear demarcation between the Department for Transport (DfT) and the Departmentof Health (DoH). In practice the DfT does not have a distinct policy or minimum standards fortransport access to hospitals, but would advice local authorities to make adequate transportprovision available for places that generate many journeys in their area such as hospitals.Whereas the DoH would not consider it within their remit to involve the journey to hospital,but rather the more domestic provision of adequate building access such as ramps forwheelchair users. However, there are several examples throughout the UK where a forward-looking local transport authority will work closely with the Health Authority to progress bettertransport access to their hospital sites. Examples include the Oxford Radcliffe Hospital andAddenbrooks in Cambridge.

The arrangements for the ‘Hospital Travel Costs Scheme’ (HTCS) require reorganisation.Currently few patients know about the scheme or understand how it operates, and healthcarestaff are not required to take a pro-active role in telling patients about the scheme. Publictransport fares have risen at a faster rate than the cost of motoring. The cost of public


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transport is often cited as a barrier for socially excluded groups and many of those individualsreceiving ‘state benefit’ do not realise that the cost of travelling to hospital can be whollyrefunded. The HTCS requires a more responsive and co-ordinated approach to allow patientsto make full use of this potentially valuable initiative.

Recommendations (B)

• The DfT and the DoH should jointly work together to demonstrate the importance ofthe journey to hospital to health and transport professionals. A national initiative isrequired.

• There is a clear need to focus further work upon assessing transport provision tohospitals in general and to antenatal care in particular.

• Local Authorities must create more opportunities to improve public transportreliability and improve journey time, for example by creating a network of bus prioritylanes.

• Good practice from Hospitals such as Addenbrooks in Cambridge which has its ownTravel Plan Officer responsible for improving access to the hospital site for patients,visitors and staff should be emulated nationally.

• An audit of the current Hospital Travel Costs Scheme should be undertaken, with aview to revamping the entire system. This should involve: an audit of the currenttake-up, an examination of the strategies currently available to make legitimate useof the scheme, and an audit of the administration procedures.

Imaginative thinking is required to improve transport access to hospitals such as:A pro-active approach by public transport operators such as supplying better information inthe form of Route maps and timetables specifically for hospital sites.Improvements for car parking on hospital sites should shift in emphasis towards ‘short-stay’rather than for ‘long-stay’ staff employee/ staff parking e.g. Addenbrooks & The Royal Surrey.

3 Internal NHS Administration and Antenatal Care in the UKAntenatal care can generate unnecessary and sometimes difficult journeys, as the currentsystem is over complicated. Currently every healthy pregnant woman must undergo anaverage of 10 appointments during the course of her pregnancy. However, many maternitycare professionals support the suggestion that 10 antenatal visits are not necessary for everywomen, especially those that have had children, and there could be many more home birthswith a midwife present. One healthcare professional suggest that home births are not only forwomen who have had a child, it should be available for first time mothers too.

The Changing Childbirth Report (1993) was considered to have had an impact as somematernity units have moved to outreach clinics or home visits. For more than ten years, inmany parts of the UK, women have had the majority of antenatal appointments in thecommunity or at home at a time convenient for them. Our findings suggest that the hospitalantenatal clinics need to look at good practice elsewhere or women will continue to DNA.

As mentioned above, the location and accessibility by all modes of transport to hospitals iscrucial to making access to antenatal care convenient. Keeping antenatal appointmentswould be much easier if these could take place nearer to home or place of employment.Extended waiting times whilst at the hospital give rise to feelings of frustration and anxietyand also deter women from keeping appointments.

Midwifery is understaffed particularly in London, yet it does not appear to be an unattractivecareer compared to other areas of nursing. On the contrary, it can be said to be veryattractive in that the midwife has a special status of autonomy accountable for her actionsjust like a doctor, which a nurse does not have: this means they are independent practitioner


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in their own right. In addition, the starting salary of a midwife is two grades above that of anurse. Many midwives are trained nurses who become midwives because of that autonomousstatus. The issue of low morale and poor pay and the lack of affordable homes to rent or buyin London runs through the professions, particularly nurses and midwives. Midwives arerecruited in great numbers but they do not stay for a variety of reasons.

Recommendations (C)

• Further work is required to investigate the level of care required during pregnancy.Pregnant women should be asked essential questions about service delivery. Thiswork should also investigate whether imaginative and flexible solutions may be moreproductive such as ‘home visits’ and ‘telephone consultations’. This has already beenrecommended in The Changing Childbirth Report (1993). There are several examplesof good practice throughout the UK and why some units still insist on bringingwomen to the hospital needs to be investigated

• Some women in paid employment find it difficult to ask for time off to attend theirantenatal appointments and there are also women who are unaware of theirentitlement to time off for antenatal care. There is urgent need for further researchto establish the reasons for and extent of this problem and ways of combating it.

• For many pregnant women in paid employment the length of the journey to theappointment and the availability of transport can pose severe problems. There is aneed to think creatively about where antenatal care should take place and howgreater flexibility in antenatal care could reinforces the notion of normality. Thiscould help midwives to work in true partnership with the pregnant woman andempower her to take control of her pregnancy and health.43

The Audit Commission’s First Class Delivery (1997) was the first publication toacknowledge that women are in the main fit and healthy and that pregnancy andbirth is a normal life event. It questions why fit and healthy women are being sentinto hospitals, a place which emphasises pathology, and found that only one in threewomen felt that they had a say in where they had their antenatal care.

• Despite the evidence and guidance from bodies such as the WHO, that antenatal careshould be holistic and be concerned with the intellectual, emotional, social andcultural needs of women and their families and not only their biological care, theissue of the provision and location of antenatal care remain contentious. In thisrespect several factors come into play, for example, with the exception of GPs,doctors working in maternity services are not always ‘community focused’. Theystrive to make childbirth a biomedical event yet maternity does not fit into medicine.The health service causes harm when they fail to recognise that women are not ahomogeneous group and fail to provide care that reflects the realities of their lives.

• There is a need to understand the dynamics of power relationships and consider thevested interests in keeping antenatal care in hospitals. Despite various governmentpolicies on pregnancy care and even joint guidelines with obstetricians and midwives,little has changed. It causes frustration among midwives. The most frequently citedreason in numerous research projects, about why midwives leave is because of thebarriers which prevent them from providing woman-centred care. The NHS mustwork towards ways to improve the status and morale amongst staff working in theantenatal care sector.

43 Sanders J, Somerset M et al; 1999.


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4 Hospital locationThe trend towards ‘out of town’ locations for hospitals such as the new Royal Infirmary inEdinburgh at Little France, has provoke public outcry locally as public transport links are notadequate. There are countless examples throughout the UK to suggest this is happeningelsewhere. There appears to be a dearth of understanding within the Health Sector that theyhave an active role to play to support the sustainable transport agenda.

Recommendations (D)

• Public transport provision to hospitals in the UK must be improved.• New hospitals should only be built in locations easily accessible by public transport

and planning consent must be dependant on an agreement that adequate publictransport provision will be made.

• A national policy for the location of hospitals must be established through a jointagreement between the DfT and DoH.

• The Health Sector needs to engage fully with the transport agenda and contribute tothe creation of a sustainable environment.


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Documents

Missed hospital appointments and transport...missed hospital appointments were due to transport or transport related factors. • Face to face interviews were also carried out with