Addressing the causes of 'missingness' in healthcare: a co-designed suite of interventions

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.

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.'

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.