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Using behavioural insights to increase patient engagement with validation of hospital waiting lists

Administrative validation of waiting list is where patients are contacted by hospitals in writing to confirm if they still require hospital care or wish to be removed from a waiting list. Many patients do not reply to validation letters. This innovation involved a collaborative redesign of the validation letter, the application of a range of behavioural insights to letter design and testing through a randomised control trial.

Innovation Summary

Innovation Overview

It is good practice for hospitals to undertake validation of waiting lists. In Ireland, the National Treatment Purchase Fund (NTPF) published a national protocol to support the management of waiting lists, The National Inpatient, Day Case, Planned Procedure (IDDP) Waiting List Management Protocol (2017). It states that:

“the purpose of waiting list validation is to: maintain hospital-patient communication during the patient’s waiting list journey,
update the patient record, reduce DNA and patient cancellation rates, provide clean, accurate, up to date waiting list data which reflects the true demand for hospital services.”

Administrative validation is the process whereby hospital administration contacts patients on inpatient and day case waiting lists at pre-planned intervals during the year to ensure that patients are ready, willing, suitable and available to attend a hospital appointment or wish to be removed. The Protocol states that it is compulsory that a formal bi-annual hospital validation is carried out on all inpatient and day case waiting lists over six months. Following publication of the protocol, the NTPF consulted across the HSE on requirements to help its implementation. One of the priority areas identified in this consultation was the need to develop a suite of consistent and effective patient correspondence for use with patients across the health service when managing waiting lists.

The Research Services and Policy Unit, Department of Health engaged with the Process Innovation Director Unit in the NTPF to discuss the possibility of taking a behaviourally-informed and tested approach to developing patient correspondence. It was decided the first project should focus on waiting validation. Because many patients do not reply to validation letters the purpose of this project was to explore whether using behavioural insights in the redesign of the validation letter would help more patients to engage with the validation process. This outcome was measured by lower non-responses from patients.

Innovation Description

What Makes Your Project Innovative?

This is the first test internationally of the application of behavioural insights to a waiting list validation letter.

Innovative aspects include:

1. Simplified the process and language in letters to patients.
2. Used behavioural design elements in letters to patients.
3. Tested redesigned letters against existing letters using a RCT so the Department can attribute improvements to the redesign (i.e. they can assign causation).
4. Worked collaboration between units in a central government department, two agencies, eight hospitals, and an advisory group (voluntary and research community).

What is the current status of your innovation?

Following the positive tests results (improved patient engagement by 20%) the redesigned letter was adopted as the national template letter for use in the validation of inpatient and day case waiting lists. The design was also adapted for use in the validation of outpatient waiting lists and recommended as the national template. The innovation was scaled up. So much so that during 2019 the innovative letters were issued to over a quarter of a million patients.

The project learning has resulted in new projects, namely: a redesign and test of appointment offer letters for inpatient and day cases is nearing completion. The project team is also diffusing understanding how the innovation can be applied in other ways and has undertaken more than 10 presentations on the project in the last two years at civil and public sector staff seminars and at national and international open conferences.

Innovation Development

Collaborations & Partnerships

This project involved government officials in two Units in the Department of Health, public servants in two state agencies (the Health Service Executive and the National Treatment Purchase Fund), a patient advocacy group, and advisory group consisting of the National Adult Literacy Agency along with behavioural scientists from a think-tank and four universities. The input from all parities was key to the redesign. Ultimately, the responses of 2,800 citizens decided which letter works best.

Users, Stakeholders & Beneficiaries

The redesigned validation letter improved engagement. The Department suspect this is because it makes clearer the importance of the validation process and what the patient is asked to do.

Improved two-way communication between patient and hospital.
Improved system efficiencies, with better use of administrative time.

Other participating organisations
It has been very rewarding to be able to generate an improvement.
It has stimulated demand for applications of the innovation to other

Innovation Reflections

Results, Outcomes & Impacts

The Department could only know with confidence if the innovation was effective if they made the change, measured its impact, and compared it with a group and process identical in every way except for the new element introduced. They used the scientific technique of a randomised control trial (the gold standard) to assess the impact. Half of the 2,800 patients received a letter with the existing format and half received the redesigned letter.

The redesigned letter increased patient engagement. The number of patients who did not reply was lower for the redesigned validation letter (Letter B) than for the control letter (Letter A) as shown in Figure 1. Patients who received the redesigned letter had a statistically significant lower non-response rate of 19% compared to non-responses for patients who received the existing format of 24%, Z = 2.99, p < .01. The redesigned achieved a 19.3% better performance or resulted in one in five non-responders changing their behaviour and responding.

Challenges and Failures

The main challenges were:

1. That the Department were asking already busy people to do more work by testing the redesigned letters.

2. Figuring out how to and going to extra lengths to marry technical aspects of the project with practical considerations, how to ensure rigour testing.

The Department responded to these challenges by focusing on

(a) the objective of better outcomes for patients, and

(b) on the more efficient processes that could arise for staff nationally.

Conditions for Success

The Department believe the following conditions are necessary for the success of an innovation like this:

1. Positive relationships built on trust and open communication.
2. Leadership to create a vision, to allow something different and to take a risk, the willingness of organisations to advocate and to accept a new vision.
3. A pre-existing protocol for the administrative validation of waiting lists.
4. The ability and willingness to draw on existing evidence.
5. Flexibility of task and process.
6. The willingness to do extra.
7. Advice from service providers and managers, and from plain English and behavioural scientists.
8. The courage and determination to act upon results.
9. A commitment to continuous improvement and innovation.


This innovation has been replicated to address a similar problem. The project designed and tested a redesigned letter for use in validation of inpatient and day case hospital waiting lists (where a citizen is typically waiting for a procedure), and the redesigned has been amended to be used as the national template for validation of outpatient hospital waiting lists (where a citizen is typically waiting for an appointment with a consultant).

The innovation has also been applied to new areas. For instance, during 2019 the same team who worked on this project redesigned and tested a new appointment offer letter for inpatient and day case appointments.

There is also potential to apply this projects approach to other public services.

Lessons Learned

Behavioural insights are relevant when outcomes are significantly influenced by behaviour.

It is rewarding to be able to demonstrate an improvement.

It is Important to base innovations on sound understanding of behavioural and related evidence, and avoid a ‘tool’ driven focus.

There are many useful guides to help in the design and testing of behavioural innovations.

There are huge benefits from collaborating across organisations and across multiple disciplines.

There are massive opportunities in the health sector to apply behavioural insights and to innovate – but “apply with care”.

Anything Else?

A full report on the project will be available on the Department's website:

The Better Letter Initiative: An Impact Evaluation of a Redesigned Waiting List Validation Letter

Year: 2017
Level of Government: National/Federal government


  • Diffusing Lessons - using what was learnt to inform other projects and understanding how the innovation can be applied in other ways

Innovation provided by:

Date Published:

22 July 2020

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