adds post for invite UR findings (#329)

Author: mattlucht

app/screening-invite/2025/12/invite-breast-screening-private-beta-user-research/index.md

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+---
+title: User research findings from digital-first breast screening invitations
+description: What we learnt from user research of digital-first breast screening invitations, and what we planned to do next
+date: 2025-12-19
+author: Katy Cooper
+tags:
+  - private beta
+  - user research
+  - screening
+---
+
+The work to rollout digital comms in breast using data from NBSS has been paused. Instead, digital comms will be rolled out along with our new Manage breast screening service. This design history documents what we have learned so far, and what we would have done next, to support the new team looking at this.
+
+## Problem we were solving 
+
+Breast screening invitations are paper-based. This can be slow, costly and inflexible, and does not always meet user expectations in an increasingly digital NHS. We explored how digital invitations could improve clarity, timeliness and experience, while ensuring the service remains inclusive for people with varying levels of digital access, language skills and health confidence. 
+
+## What we would have done next 
+
+### Fill known research gaps at point of pause  
+
+Research conducted to date lacked in the following areas: 
+
+* full journey/ prototype testing with people with low English proficiency, very low digital skills and users of assistive technology 
+* full journey/ prototype testing with people with disabilities  
+* generalised research with trans participants and those with severe health anxiety/ body confidence issues 
+
+We had planned to address these gaps in the upcoming months. 
+
+### Private beta testing approach 
+
+We planned a private beta to safely test digital invitations with one breast screening office (BSO), combining quantitative monitoring with in-depth qualitative research, then scaling up the number of BSOs participating. 
+
+We had planned to monitor success in the following ways: 
+
+#### Analytics 
+
+* Track screening uptake and ‘Did Not Attend’ (DNA) rates through BSO data.
+* Monitor digital communication performance on our side, including:
+    * messages sent and opened across channels
+    * link clicks and basic engagement metrics 
+
+#### BSO staff research 
+
+* Conduct pre and post-beta research with BSO staff including shadowing and depth interviews
+* Use paper diary tasks to capture common questions, issues, and incidents such as people arriving at the wrong time or place – sent back to us on a weekly basis by the following people:
+    * staff handling phone calls
+    * staff handling sending of invitations
+    * mammographers working on mobile units / or reception staff
+* Regular catch ups and progress reports throughout  
+
+#### Participant research 
+
+* Pop-up research with participants at the point of screening to capture experience of people being invited in new way 
+* Short always-on survey (available in units via QR code or paper survey to include less digitally enabled) to capture experience, awareness of changes to invitations, understanding etc.  
+
+#### Inclusion monitoring 
+
+* Work with health inequalities/ health promotion leads at BSOs to actively monitor the impact of digital-first changes on participants with:
+    * low digital confidence
+    * low English proficiency
+    * access needs/disabilities  
+
+#### Research reporting  
+
+* Research reporting was planned to be condensed in a weekly one- slide report of KPIs (key performance indicators), key themes/ quotes etc. highlighting impact, risks and decisions to be made
+* Followed by a more comprehensive report and playback at the end of the period  
+
+![A zoomed out view of the Invite private beta journey mapped out on a Mural board.](invite-private-beta-process.png 'Zoomed out view of the private beta journey')
+
+## Further recommendations 
+
+To ensure a safe and well-rounded service, we recommended releasing the digital-first invitation alongside, or quickly followed by, digital versions of other types of letter. 
+
+### Pre-launch communications
+
+We recommend working with GPs and wider NHS communications channels to clearly inform participants that invitation communications are changing. This is intended to: 
+
+* reduce fear and confusion
+* build trust and legitimacy around digital messages
+* reassure people that messages are genuine NHS communications 
+
+### Rescheduling clarity 
+
+We identified a strong need for clear data and messaging around rescheduled appointments. Participants need to understand: 
+
+* that their appointment has changed
+* what the new appointment details are
+* whether any previous appointment details are still valid 
+
+### Reminders 
+
+We recommended consistent text reminders across participating BSOs as an extra safety layer to help in the following situations: 
+
+* someone no longer has a physical letter as a reminder to refer back to, for example on their fridge/ notice board
+* someone has opened an app message but hasn’t fully processed it at the time or has issues navigating the app 
+* someone hasn’t read or hasn't trusted an initial digital invitation
+* someone hasn't made a note of the appointment
+* the paper invitation letter has been delayed or lost in post  
+
+This multi-channel approach was strongly supported by users, who are used to it in other services such as banking or making restaurant reservations. 
+
+Based on initial research, we suggest a reminder around one week before the appointment and a second reminder 48–24 hours before, to allow participants to act on them. Exact content and timing would require further research, with frequency and wording optimised over time. 
+
+It’s worth noting that reminders are implemented in an inconsistent way across 77 BSOs in England. Both timings and content may differ among BSOs. Therefore, more thorough testing and consultations with the services and the programme might be necessary. 
+
+### Did not attend (DNA) process 
+
+We recommended keeping DNA communications as a letter initially, even if invitations and reminders have been sent digitally, because little research has been conducted into this area. If digital comms prove to be a barrier to attendance for some people, a paper letter after a missed appointment could act as a safety net. 
+
+Moving forward, we recommend looking more closely at this type of comms because DNAs are a complex area and addressing these can be particularly important to maintain uptake targets. It would be beneficial to test various content and channel options and their effectiveness, especially among non-attenders. 
+
+## Opportunities to further improve the service 
+
+### Appointment management
+
+**View appointments in the NHS App** - Usability testing showed that participants strongly expect to be able to view screening appointments in the appointments section of the app, particularly if the invitation itself comes through it. This would: 
+
+* help people manage reschedules
+* reduce confusion for those who receive multiple messages about screening or have busy inboxes to manage
+* make it easier to check details close to the appointment 
+
+**Add to calendar functionality** - Many participants reported manually adding appointments to their personal calendars. Providing this functionality would likely: 
+
+* reduce errors when entering dates, times or locations
+* be especially helpful when appointments are rescheduled to easily update calendar entries (which are used as source of truth for some rather than referring back to invitations) 
+
+**Online rescheduling** - Receiving digital communications increased expectations that appointments could also be managed digitally. Online rescheduling was supported by: 
+
+* BSOs, as it could reduce manual workload, especially if linked to automated clinics management in the back-office system
+* participants, who viewed it as quicker, easier and more inclusive. This was seen as particularly beneficial for people who may struggle with phone calls or written English 
+
+If online rescheduling were introduced, non-digital rescheduling options would need to stay in place for those who wouldn’t use NHS App or web-based services. It could be worth considering adding text message rescheduling or cancellations. 
+
+**Location-specific information** - A common reason for contacting BSOs was to ask about practical issues such as: 
+
+* parking availability and cost
+* Blue Badge parking
+* public transport links
+* how to access mobile units 
+
+Providing this information upfront could reduce participants’ anxiety and the need to get in touch, allowing staff to save time and use it for other ways of supporting delivery of the service. 
+
+### Data and inclusion 
+
+**Access needs data** - The service currently relies on participants self-identifying access needs, GPs responding to information requests (which is inconsistent) and mammographers recording details about previous appointments. For first-time screening participants, NBSS does not hold any accessibility data. This can lead to units not being prepared for specific needs. Participants may arrive at units they cannot physically access or are not suitable for the type of screening appointment they need.  
+
+Improving the availability and flow of access needs data would help prevent these issues and ensure people are more likely to be booked an appropriate location and appointment length from the beginning. 
+
+**Translations and alternative formats** - Translations and alternative formats remain a complex area requiring further discovery. Initial research suggests those with very little English would prefer to be communicated to in their own language. Key considerations include: 
+
+* data availability to support the need for alternative formats
+* understanding the link between translation and alternative format needs
+* written translations might not always be suitable, for example if people don’t read well in the language they speak
+* further testing of GOV.UK-linked invitations with people who have low English proficiency
+* ensuring support continues beyond the invitation and into the appointment itself, for example through translated or accessible information on site 
+
+### Other comms/ larger pathway issues 
+
+All need much more research, but initial findings suggest these opportunities:  
+
+**For potential participants who are over 70:** Research has shown pain points for people over 70 who are unaware of the process to self-refer and/or likely to forget without a reminder. Meanwhile there is messaging that the risk of breast cancer increases with age, so there is an opportunity to explore people’s understanding of why screening stops at 71 and what their options are. 
+
+**Opt-out:** Research has shown that those who do not want to take part in breast screening are unhappy with the current process because they don’t find it easy to learn how to opt out.  
+
+**Results:** Research to date suggests people are willing to receive normal results through digital channels but this raises issues around how best to communicate if a follow-up assessment is needed  
+
+**Did not attend (DNA):** Limited research has been conducted in this area but BSO research suggests the process could be optimised to increase uptake further.  
+
+## Next steps for future teams 
+
+When this work is restarted, we recommend that the new team should: 
+
+* bridge the research gaps identified above
+* run a tightly monitored private beta
+* prioritise inclusion and safety measures for any digital release
+* treat digital-first invitations as part of a wider screening journey, not a standalone communication