Texts or emails to patients, e.g. confirming appointments, referrals etc

[sarawilcox]

What

Content designers are increasingly writing content for a range of channels including texts or emails. It would be good to collect tested examples to understand better what works for users.

Update February 2024

There is a piece of work underway to produce guidance or a toolkit on effective messaging for primary care. This may be published in the service manual content guide.

[laura-hajba]

Notes from work on NBS appointment confirmation and reminder texts and emails:

• 1 SMS = 160 characters, so if any longer than that you're sending 2 SMS - something to factor in for cost
• On smart phones it would come through as a longer message, so the user might not be aware, but we tried to limit sending out too many messages
• Email doesn't have the same restrictions

Research insights from 6 remote interviews in March 2021 about appointment reminder notifications:

• users would prefer to receive appointment reminder notifications 48 hrs before the appointment
• users would look at emails/text in the daytime
• users expected emails to have more information that text reminders and would refer back to emails for information
• when changing/cancelling an appointment users expected a link in both the email and SMS
• some users expected to be able to reply to emails/SMSs
• in the NBS notification users expected to see venue address including postcode, advice on what to do if you have covid-19

Business rules for sending:

• send 3 days before appointment is due, between 8 and 11am
• email and SMS to include link to cancel and rebook
• SMS will be longer than 160 chars (2 x SMS) because of content needed in the message

[sarawilcox]

• Behavioural Insights Team - Using behavioural insights to create a COVID-19 text service for the NHS, Blog 8th Apr 2020
• Behavioural Insights Team - Why text, 2018
• DHSC - A zero cost way to reduce missed hospital appointments, 2016
• Mobile phone messaging reminders for attendance at healthcare appointments, 2013
• NHS Digital - Creating the COVID-19 text service for vulnerable people, 2020
• NHS population screening: effective text message use, 2020
• NHSX - Email and text message communications, 2021
• PHE Screening - Guidance on sending screening text message reminders now available, 2020
• Text message reminders increase attendance at NHS health checks, 2019

[sarawilcox]

Some screenshots from NBS user research show and tell, March 2021

[kathrynbingham]

Rules and tips for writing SMS/email messages on Gov.Notify (used by Test and Trace eg for coronavirus test results messages).

Length:

Maximum of 918 characters including blank/white spaces. For coronavirus test result messages, 50 characters must be left for full name to be inserted. Birth date and Test taken need 18 characters each. So in total there is 806 characters for the main body.

Formatting:

Formatting is limited on SMS. It's fine to use bullets but we cannot use bold.

Links:

NCSC guidance is to avoid long and deep links in SMS/email because they are easier to spoof and open the message to malicious intent. Links must be given as urls and in full eg https://covid/19.nhs.uk

Cost:

SMS pricing increases with message length. Every 153 characters costs 1 text message. For the longest messages, they therefore cost 6 messages worth - in effect 9.5p per message. They will still appear as a single large message on the device, but will cost more to send. As such a reduction in size, down to say 450 characters would halve costs.

All characters, including spaces and line breaks count towards the message length.

Email doesn't attract a cost as it's very cheap. For info it's around £80 per million emails sent by Notify regardless of length.

International telephone numbers:

For the telephone number field there is a maximum of 14 digits. Most international numbers are allowed, but there are some that are not – this is mandated by Gov.Notify.

[henocookie]

In the NHS App, 71% of iOS and Android users are choosing to opt-in to receive push notifications. Every user who opts in for push notifications gives the NHS an opportunity to avoid SMS (1.55p+VAT each) and paper letter (up to £1+VAT each) costs in the future.

[sarawilcox]

A few content design fail stories from the content channel in the GOV.UK Slack instance.

I had a blood test scheduled for today and my doctor’s office had sent me a text message confirmation with the appointment details. It said: Phlebotomy X Community Centre Blood Test - Y Hospital Wed 16-Mar-2022 10:40 So off I went to the hospital, about 40 minutes away. On arrival they couldn’t see my appointment and told me it was actually at the X Community Centre on Z Street - a 5 minute walk from my flat. :neutral_face:

I took my mum to the hospital yesterday. The clinic letter said one entrance, I got there and was told it was the other entrance up the road. Went there, was told it was past that first entrance to the left of where it said on the letter. Finally, we got the right place! When we left, the place I needed to be was actually accessible by two entrances including the first one we were turned away from. I was lucky my mum was in a wheelchair - if it was my dad, he'd have struggled with walking with his cane a metre up the road. It's a nightmare isn't it?

I am a patient at Guy’s and St Thomas hospital trust who constantly have people turn up at the wrong hospital as their letters can be unclear to people who don't fully realise there are two.

My GP sends texts for appointments that do not make it clear it's a phone appointment. My mum has been phoned by the GP for her appointment as she's walked into the GP's reception.

[sarawilcox]

And another example from NHS.UK:

I was late for a hospital appointment last week as there are 2 departments - 1 for pre-assessment and 1 for the actual clinic - at opposite ends of the hospital. Some of the signs are obsolete as departments have moved into temporary buildings so people can easily get mis-directed. I was told that I needed to go to an entrance near Car Park 2. Car Park 2 no longer exists because of rebuilding/modernisation.

[sarawilcox]

May be of interest: NHS App messaging - a better way to talk to patients

[sarawilcox]

A question about the term SMS. Looks like preferred usage among content designers is: text message (SMS).

From conversations on NHS.UK Slack:

• On pages about mental health we say "text "SHOUT" to 85258" so I imagine just "text message" is fine. There are examples here - https://www.nhs.uk/mental-health/feelings-symptoms-behaviours/behaviours/help-for-suicidal-thoughts
• On 111OL we say text message (SMS) when offering options for means of contact

[Emmygraham]

As part of our study into usability of GP websites, we asked participants what they thought the term 'Secure message' meant. No one mentioned SMS and 4 participants used the term 'text'.

The individual responses from 31 participants with low digital and written English confidence are here:

1. Is that a text message? (From wife: 'maybe password protected")
2. Whoever you message will stay confidential.
3. Like when you do an OC its secure, going to the doctor, it's confidential.
4. Safe message - she needs to be careful who she sends it to.
5. send messages securely that no one else can see. Contact between them and their GP.
6. Texting
7. how they contact backwards and forwards - secure
8. Something that is private and safe - via forms/chat/phone calls, text
9. Some sort of messenger service
10. Encrypted, only she and her doctor can see it. protects her privacy
11. private and no one can get into it.
12. Only the other person, or you can see it.
13. He isn't sure - encrypted messages.
14. "Somewhere she can write a message, on the site, like an email and it would go straight to the surgey and would only be read by the people who are supposed to read it, like the doctor, or perhaps the receptionists.
15. It's all security protected."
16. Messaging that is not going to be shared (Data would be secure)
17. Send a message
18. Somewhere where nobody else to get hands - very secure
19. Somewhere you can message your GP
20. No
21. talking to your doctor about something private that you don't want other people to know about.
22. Personal message
23. Looking after the message.
24. Something that is private - no-one else can see it
25. Not sure
26. Messaging
27. Encrypted - no reply - can’t text back
28. Messaging that no 3rd party have access to(Encrypted)
29. Email
30. Privacy protected
31. Safe

[sarawilcox]

A proposal from the Digital First Primary Care team:

Secure message

We found that people didn’t understand ‘secure message’. We found using ‘text or email’ was understood by patients.

I think we could combine this with recent discussions in NHS.UK that recommend not using SMS on its own. Instead we propose "text message (SMS)".

For next Style Council meeting.

[stefanNHSdigital]

I've been working on the Notifications and Messaging area of the NHS App. Though we don't write messages ourselves, we tested viewing and responding message samples provided by GPs.

Providing information to help users understand what they need to

If you are asking users to respond with information, messages should be written to cover all possible scenarios. During research, we presented users with an appointment reminder message. Users understood that they should respond ‘Cancel’ to cancel an appointment or take no action to keep the appointment. However, most users expressed that they would expect to be able to confirm an appointment or - if they couldn't make it anymore - reschedule it. The single reply option left them feeling uneasy or dissatisfied.

Let me know if you'd like any more information :)

[sarawilcox]

Thanks @stefanNHSdigital. That's interesting. If you have any screenshots or example wording, that may help other teams.

[sarawilcox]

At Style Council meeting October 2022, we approved the following 2 entries to the style guide A to Z. (Still needs clinical approval.)

Secure message

We've found that people do not understand "secure message".

Use the words "text" or "email" instead.

SMS

Use "text message" instead of "SMS".

Note: user research found that talking about “secure” messages raised questions about security.

[sarawilcox]

Approved by clinicians. Preparing to publish in the New Year.

[sarawilcox]

Published. Moving this back into the backlog while we gather more guidance on texts and emails.

[sarawilcox]

Feedback from the NHS App Notifications and Messaging team - we may want to give the entry a bit more clarify and cover in-app messaging. E.g. we could amend it to.

We’ve found that people do not understand “secure message” and the word “secure” raised concerns about security. Instead, make it clear how people will get a message. Use the words “text” or “email” or, for example, “messages through the NHS App”.

[sarawilcox]

Existing style guide entry on “secure message”:

secure message

We've found that people do not understand "secure message".

Use the words "text" or "email" instead.

At the June Style Council meeting, the NHS App team proposed a minor change:

Proposed entry

We’ve found that people do not understand “secure message”. Also, the word “secure” makes some users question security.

Instead, make it clear how people will get a message. Use the words “text” or “email” or, for example, “messages through the NHS App”.

Action: approved highlighted text. To be added to the style guide, subject to clinical approval.

Note the sentence about the word "secure" raising questions about security came from the research by NHSE's Digital First Primary Care team.

[sarawilcox]

An example I posted on Twitter: https://x.com/S_Wilcox/status/1547677082896912393?s=20. The letter turned out to be a message about a triaging date - a note of when the consultant and team would review the case, but the letter was worded such that we thought it was a telephone/video appointment.

@AndyLongContent - this may be of interest. We're uploading a few other anecdotes here.