Calum Lindsay

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: 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. Results: 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.

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 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.

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.

Migration policy in the United Kingdom continues to distinguish between acceptable and unacceptable forms of migration, using increasingly punitive policy provisions designed to make life unliveable for those outside narrowing frames of acceptability. Part of this policy involves broadening and deepening precarious forms of status while denying routes to permanence to those considered less desirable. This includes many families with children. Although existing quantitative studies have established links between precarious immigration status, post‐migration stressors and poor mental health outcomes for children and for parents, these studies lack insight into everyday life within a hostile immigration environment, including how people actively encounter and navigate life in precarity. This paper presents new qualitative research exploring the impacts of precarious and uncertain immigration status on the wellbeing of children in the United Kingdom. It uses a novel theoretical framework combining the concept of ontological security with Bourdieu's theory of practice to determine how policies of precaritisation result in the denial of access to resources that contribute to crucial elements of wellbeing. It also provides insight into how people actively navigate these challenges to resist the pressures of exclusionary policy.

Background This protocol describes a realist review exploring the problem of “missingness” in healthcare, defined as the repeated tendency not to take up offers of care that has a negative impact on the person and their life chances. More specifically, the review looks at the phenomenon of patients missing multiple appointments in primary care in the UK – at the causal factors that influence how patients come to be “missing” in this way, and what interventions might support uptake and “presence” in healthcare. Background research informing this project suggests that a high rate of missed appointments predicted high premature death rates, and patients were more likely to have multiple long-term health conditions and experience significant socioeconomic disadvantage. Most research in this field focuses on population- or service-level characteristics of patients who miss appointments, often making no distinction between causes of single missed appointments and of multiple missed appointments. There have therefore been no interventions for ‘missingness’, accounting for the complex life circumstances or common mechanisms that cause people to repeatedly miss appointments. Methods We use a realist review approach to explore what causes missingness - and what might prevent or address it - for whom, and in what circumstances. The review uses an iterative approach of database searching, citation-tracking and sourcing grey literature, with selected articles providing insight into the causal dynamics underpinning missed appointments and the interventions designed to address them. Discussion The findings of this review will be combined with the findings of a qualitative empirical study and the contributions of a Stakeholder Advisory Group (STAG) to inform the development of a programme theory that seeks to explain how missingness occurs, whom it affects and under what circumstances. This will be used to develop a complex intervention to address multiple missed appointments in primary care. PROSPERO registration CRD42022346006

Background: Although missed appointments in healthcare have been an area of concern for policy, practice and research, the primary focus has been on reducing single ‘situational’ missed appointments to the benefit of services. Little attention has been paid to the causes and consequences of more ‘enduring’ multiple missed appointments in primary care and the role this has in producing health inequalities. Methods: We conducted a realist review of the literature on multiple missed appointments to identify the causes of ‘missingness.’ We searched multiple databases, carried out iterative citation-tracking on key papers on the topic of missed appointments and identified papers through searches of grey literature. We synthesised evidence from 197 papers, drawing on the theoretical frameworks of candidacy and fundamental causation. Results: Missingness is caused by an overlapping set of complex factors, including patients not identifying a need for an appointment or feeling it is ‘for them’; appointments as sites of poor communication, power imbalance and relational threat; patients being exposed to competing demands, priorities and urgencies; issues of travel and mobility; and an absence of choice or flexibility in when, where and with whom appointments take place. Conclusions: Interventions to address missingness at policy and practice levels should be theoretically informed, tailored to patients experiencing missingness and their identified needs and barriers; be cognisant of causal domains at multiple levels and address as many as practical; and be designed to increase safety for those seeking care.

Background This protocol describes a realist review exploring the problem of “missingness” in healthcare, defined as the repeated tendency not to take up offers of care that has a negative impact on the person and their life chances. More specifically, the review looks at the phenomenon of patients missing multiple appointments in primary care in the UK – at the causal factors that influence how patients come to be “missing” in this way, and what interventions might support uptake and “presence” in healthcare. Background research informing this project suggests that a high rate of missed appointments predicted high premature death rates, and patients were more likely to have multiple long-term health conditions and experience significant socioeconomic disadvantage. Most research in this field focuses on population- or service-level characteristics of patients who miss appointments, often making no distinction between causes of single missed appointments and of multiple missed appointments. There have therefore been no interventions for ‘missingness’, accounting for the complex life circumstances or common mechanisms that cause people to repeatedly miss appointments. Methods We use a realist review approach to explore what causes missingness - and what might prevent or address it - for whom, and in what circumstances. The review uses an iterative approach of database searching, citation-tracking and sourcing grey literature, with selected articles providing insight into the causal dynamics underpinning missed appointments and the interventions designed to address them. Discussion The findings of this review will be combined with the findings of a qualitative empirical study and the contributions of a Stakeholder Advisory Group (STAG) to inform the development of a programme theory that seeks to explain how missingness occurs, whom it affects and under what circumstances. This will be used to develop a complex intervention to address multiple missed appointments in primary care. PROSPERO registration CRD42022346006