Andrea Elizabeth Williamson

Tackling missed appointments has become a prominent part of conversations about the ‘recovery’ of the UK NHS from the COVID-19 pandemic. With long waiting lists, delays in access to primary care, and overburdened staff, it seems logical that efforts should be made to reduce the time lost to unused appointment slots. Yet care needs to be taken to reflect on how and why missed appointments have become an area of focus, and to be transparent about what this means for patient care and health inequalities. This article provides a critical perspective on the current mainstream approach to missed appointments in policy, research and practice. The study applies Bacchi’s “what is the problem represented to be” method of policy analysis to provide critical commentary on findings from a realist review of 253 documents; interviews with 61 ‘key informants’ whose personal and professional experiences relate to missingness; and a series of co-design workshops with a Stakeholder Advisory Group of 16 professionals and experts-by-experience. It also includes an informal analysis of national news media and NHS news pieces covering missed appointments since 2015. Analysis identified a consistent approach to missed appointments across research, practice and media and policy statements. This approach focuses on the impacts of missed appointments for services; places responsibility on the shoulders of patients; and limits interventions to things that seek to alter their behaviours in pursuit of a service-wide reduction in missed appointments. The hegemony of this approach is sustained by research that has failed to adequately engage with the most marginalised patients; failed to explore causes in depth; and failed to include an inequalities lens in its approach to interventions. We propose an alternative viewpoint – applying a missingness lens – built from an alternative evidence base that combines critical literature review, qualitative interviews, and participatory methods with those experiencing missingness and with key professionals. Embedding an alternative perspective in practice and in research has significant potential as a non-stigmatising, inequalities-based and effective approach to understanding and addressing missed appointments.

Background: People experiencing homelessness face up to 12 times higher mortality rates than the general population. People experiencing homelessness have multiple, unmet health and care needs, including poor physical and mental health, substance use disorder and lack of stable and safe housing, yet they do not find services accessible or tailored to their needs. Aim: The aim of this study was to assess the feasibility of conducting a larger, definitive trial evaluating an integrated clinical pharmacist/homeless third-sector support (Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx) for people experiencing homelessness, in a community pharmacy setting. Design: Randomised, multicentre, open, parallel group external pilot trial with parallel economic and qualitative process evaluation. Methods: People experiencing homelessness ≥ 18 years were recruited from community pharmacies in Glasgow and Birmingham, United Kingdom. Participants were randomised 1 : 1 to receive Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention in addition to usual care or usual care only. The Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention is a collaboration between National Health Service pharmacist independent prescribers and third-sector homelessness charity workers offering weekly community pharmacy and/or outreach-based consultations for people experiencing homelessness to address health (e.g. health screening, treatment and prescribing), housing and social needs (e.g. welfare benefits, housing support). A range of health, social and care outcomes were evaluated at baseline, 3 and 6 months from both usual-care and intervention participants. The primary outcome was to evaluate the feasibility of a subsequent definitive randomised controlled trial according to pre-specified progression criteria classified as green (go ahead), amber (minor amendment in procedures required for definitive trial) and red (substantial changes needed). These related to recruitment; retention; intervention adherence; and collection of clinical and social outcomes data, including emergency department visits, rough sleeping and criminal justice encounters. Results: Progression criteria were met (4 green and 1 amber) as follows: (1) recruitment (target 55% conversion rate): 100 people experiencing homelessness were recruited as planned from 5 community pharmacies, 100/183, that is, 55% eligible consented to participate – green; (2) retention (target 60%): 72 (72%) participants remained in the study at 6 months – green; (3) collection of routine healthcare utilisation data (target 60%): 91 (91%) had emergency department visit and mortality data available at 6 months – green; (4) completion of questionnaire booklet (target 60%): 72 (72%) completed the booklet at 6 months – green; (5) intervention adherence (target 60%). Twenty-six (53%) participants had over half of the planned weekly contacts with the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx team – amber. Signals of improvements were observed, as there were fewer ambulance call-outs, fewer emergency department visits and hospitalisations; fewer nights slept rough; and improved health-related quality of life in Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx participants compared to the usual-care group at 6 months’ follow-up. Qualitative interviews conducted with participants and stakeholders. Participants suggested the Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx intervention was characterised by holistic approach, comprehensiveness, consistency and care. Challenges identified included resource constraints, integration with existing services and concerns about long-term sustainability. Conclusions: Pharmacy Homeless Outreach Engagement Non-medical Independent prescribing Rx community pharmacy pilot randomised controlled trial successfully achieved key progression criteria. If found to be effective and cost-effective in a subsequent definitive randomised controlled trial, it offers promise as an adaptable (United Kingdom and internationally) model of integrated care provision for people experiencing homelessness. Limitations: While small sample size limits generalisability of the, it fulfils the purpose of a pilot study. Temporary absence of intervention worker in one of the study settings constrained intervention delivery. Future trials should plan for contingency measures. Future work: Future research should seek to test and evaluate care models integrating health and voluntary sector care for people experiencing homelessness in various settings, including community pharmacy, street outreach and temporary accommodations. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR133060.

Background: Non-communicable diseases (NCDs) represent a significant cause of morbidity and mortality globally. Despite a strong evidence base outlining increased risk of communicable diseases and poor mental health in people who have experienced imprisonment, the risk of NCDs has not been quantified in previous reviews. This study aimed to describe the incidence of morbidity and mortality of physical NCDs in people who have experienced imprisonment compared with the general population in high-income countries. Methods: We searched MEDLINE, Embase, CINAHL and SocINDEX (PROSPERO CRD42024540173) for comparative studies of morbidity or mortality from NCDs. Articles were assessed against predefined criteria to select studies that included people with experience of imprisonment; measured NCD incidence; compared incidence to a general population; and were conducted in a high-income country. Two reviewers conducted independent risk of bias assessment using an adapted version of the Newcastle-Ottawa Scale. Data were synthesised using random-effects meta-analyses and vote counting based on effect direction. Meta-regression and subgroup analysis investigated heterogeneity. Results: Of 3085 articles screened, 32 were included providing 341 datapoints. Meta-analysis showed a higher risk of mortality from several diseases, including respiratory disease (risk ratio (RR) 2.38 (95% CI 1.18 to 4.80), I ² =97%), cardiovascular disease (RR 1.80 (95% CI 1.32 to 2.46), I ² =99%), liver disease and cirrhosis (RR 2.50 (95% CI 1.08 to 5.77), I ² =99%), digestive disease (RR 2.92 (95% CI 1.09 to 7.78), I ² =99%), neurological disease (RR 1.94 (95% CI 1.09 to 3.44), I ² =92%), head and neck cancer (RR 21.31 (95% CI 4.32 to 105.14), I ² =97%), liver cancer (RR 4.07 (95% CI 2.34 to 7.08), I ² =94%), cervical cancer (RR 3.95 (95% CI 3.11 to 5.01), I ² =0%) and lung cancer (RR 1.95 (95% CI 1.34 to 2.85), I ² =0%). Synthesis without meta-analysis also indicated imprisonment was associated with increased morbidity from multiple NCDs. Conclusions: Several NCDs, including multiple cancers, cardiovascular disease, respiratory disease and liver disease, are substantially more common in people who have experienced imprisonment compared with the general population, highlighting a need for primary prevention and NCD management.

Background Tackling missed appointments has become a prominent part of conversations about the ‘recovery’ of the UK NHS from the COVID-19 pandemic. With long waiting lists, delays in access to primary care, and overburdened staff, it seems logical that efforts should be made to reduce the time lost to unused appointment slots. Yet care needs to be taken to reflect on how and why missed appointments have become an area of focus, and to be transparent about what this means for patient care and health inequalities. This article provides a critical perspective on the current mainstream approach to missed appointments in policy, research and practice. Methods The study applies Bacchi’s “what is the problem represented to be” method of policy analysis to provide critical commentary on findings from a realist review of 253 documents; interviews with 61 ‘key informants’ whose personal and professional experiences relate to missingness; and a series of co-design workshops with a Stakeholder Advisory Group of 16 professionals and experts-by-experience. It also includes an informal analysis of national news media and NHS news pieces covering missed appointments since 2015. Results Analysis identified a consistent approach to missed appointments across research, practice and media and policy statements. This approach focuses on the impacts of missed appointments for services; places responsibility on the shoulders of patients; and limits interventions to things that seek alter their behaviours in pursuit of a service-wide reduction in missed appointments. The hegemony of this approach is sustained by research that has failed to adequately engage with the most marginalised patients; failed to explore causes in depth; and failed to include an inequalities lens in its approach to interventions. We propose an alternative viewpoint – applying a missingness lens – built from an alternative evidence base that combines critical literature review, qualitative interviews, and participatory methods with those experiencing missingness and with key professionals. Conclusions Embedding an alternative perspective in practice and in research has significant potential as a non-stigmatising, inequalities-based and effective approach to understanding and addressing missed appointments.

Recent years have seen the development of conceptualisations of stigma which have moved beyond individual-level analyses towards exploring how stigma operates across multiple levels. While empirical research has examined the impact of stigma across various domains, there remains scant research exploring the lived experience of structural stigma . In this article, we examine structural stigma as a driver of multiple missed appointments, or ‘missingness’, in health care. We draw on qualitative data from 61 interviews with health and social care professionals and experts-by-experience of missingness in the United Kingdom, focusing on three stigmatised statuses: people from marginalised racial and ethnic groups, including those in the asylum system; people with mental health conditions; and people experiencing problem substance use. We adapt Link and colleagues’ schema of stigma outcomes—keeping people down , in, and away —to explore how structural stigma shapes access to and experiences of health care. Our findings demonstrate a range of such processes through which barriers to effective engagement occur, and suggest that a focus on structural stigma will benefit policy, practice, and future research in this area.

Introduction People experiencing severe and multiple disadvantage (SMD: homelessness, substance use and criminal offending) have multiple intersecting unmet health and social care needs and high mortality rates, often due to street-drug overdose. Pilot randomised controlled trials (RCTs) suggest an integrated, holistic, collaborative outreach intervention (Pharmacy Homeless Outreach Engagement Non-medical Independent Prescribing Rx (PHOENIx)) involving generalist-trained pharmacists, nurses or General Practitioners accompanied by staff from third sector homeless organisations may improve outcomes, including reducing overdose. Methods Multicentre, parallel group, prospective RCT with parallel economic and process evaluation. Set in six areas of Scotland, UK, 378 adults with SMD will be recruited and randomised (stratified by setting and previous non-fatal overdoses) to PHOENIx intervention in addition to usual care (UC) or UC. Aiming to meet participants weekly for 9–15 months, PHOENIx teams assess and address health and social care needs while referring onwards as necessary, co-ordinating care with wider health and third sector teams. During a person-centred consultation, in the participants’ choice of venue, and taking account of the participant’s priorities, the NHS clinician may prescribe, de-prescribe and treat, for example, wound care, and refer to other health services as necessary. The third sector worker may help with welfare benefit applications, social prescribing or advocacy, for example, securing stable housing. Pairings of clinicians and third sector workers support the same participants. The primary outcome is time to first fatal/non-fatal street-drug overdose at nine months. Secondary endpoints include health-related quality of life, healthcare use and criminal justice encounters. A health economic evaluation will assess cost per quality adjusted life year of PHOENIx relative to standard care. A parallel qualitative process evaluation will explore the perceptions and experiences of PHOENIx, by participants, stakeholders and PHOENIx staff. Analysis The primary and other time-to-event secondary outcomes will be analysed by Cox proportional hazards regression. Ethics and dissemination IRAS number 345246, approved 23/10/2024 by North of Scotland Research Ethics Service. Results will be shared with participants, third sector homelessness organisations, health and social care partnerships, then peer-reviewed journals and conferences worldwide, from the first quarter of 2027. Trial registration number ISRCTN12234059 registered on 20/2/2025 (ISRCTN).

Background Missingness refers to a repeated tendency not to take up offers of care that has a negative impact on the person and their life chances, visible in patterns of missed health appointments. Epidemiological work has shown that patients experiencing ‘missingness’ are more likely to have multiple physical and mental health conditions, to live in adverse or precarious circumstances, and experience a range of negative health outcomes. Yet existing approaches designed to address missed appointments rarely focus on these patients; when they do, it is often through a punitive lens rather than one that engages meaningfully with the causes of missingness. As a result, existing interventions are often ineffective for these patients and may instead worsen access inequalities. This study addresses this gap by outlining a co-produced ‘suite’ of interventions aimed at addressing the specific, complex causes of missingness. Methods and Findings The study synthesised findings from three co-occurring workstreams: an extensive realist review of 253 documents including peer-reviewed and grey literature; interviews with 61 ‘key informants’ whose personal and professional experiences provided insight into causes and possible solutions; and a series of co-design workshops with a Stakeholder Advisory Group of 16 professionals and experts-by-experience aimed at designing and refining an intervention. The intervention consists of activities across several key domains: embedding a change of perspective around missed appointments; identification; relationships and communication; missingness coordinators; transport and logistics; flexibility; and contact around appointments. Unifying these activities, and crucial to their success, is a paradigm shift towards missed appointments that we term a ‘missingness lens.’ Conclusions This intervention presented here is an evidence-informed, realistic and meaningful set of actions with the potential to address the complex causes of missingness and, by extension, access inequalities and wider health inequalities. Future interventional research into missed appointments should actively focus on or include ‘missing’ patients in design, implementation and the measurement of outcomes.

Objectives An Inclusion Health movement has gained momentum over the past decade, aiming to address the extreme health inequities faced by socially excluded groups (including people experiencing homelessness, problem substance use, Gypsy, Roma and Traveller communities, vulnerable migrants, sex workers, people in contact with the justice system and victims of modern slavery). Despite this progress, there is a lack of understanding of how the issues are being taught by medical schools. We conducted a scoping review to identify and analyse existing research about Inclusion Health content and pedagogy in undergraduate medical education. Design A stepwise scoping review methodology was followed in accordance with the latest manual for evidence synthesis from Joanna Briggs Institute and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews guidelines. Data sources A search was undertaken across six bibliographic databases, and additional articles were found through citation and grey literature searching. Eligibility criteria Primary research studies and evidence reviews from 2013 onwards were included. There were no restrictions on language. Data extraction and synthesis Standardised methods were used to screen possible papers. A charting table was developed to record key information from the 74 papers included. Quantitative steps of the analysis included frequency counts of the extent, nature and distribution of the studies; this was followed by basic qualitative content analysis. Results Most educational interventions were optional, or student led, with no longitudinal integration across curricula. There was little evidence of co-production with people with lived experience. Challenges included limited curricula time and faculty expertise, being an emotionally challenging subject, limitations of the biomedical model and informal learning perpetuating stigma. Key enablers included structured reflection, support, positive role models, interaction and co-production with people with lived experience, community partnerships and faculty commitment. Conclusions Developments in undergraduate medical education are required to produce doctors equipped to meet the needs of socially excluded groups. We have summarised key aspects of the literature that will be useful to clinicians and educators in this endeavour. Trial registration number A review protocol was preregistered in the Open Science Framework on 11 May 2023 and can be accessed at https://osf.io/6c2rk/.