1. ADRP 2009: SNBTS 1 Short Term Deferral - Long term Effect! Moira Carter Katherine Moir Vincent Mooney Scottish National Blood Transfusion Service May 2009

2. ADRP 2009: SNBTS 2 The Virtual Moira Carter Not Convinced? Oh, OK Then! Let’s be Honest! Wish I was there!!

3. ADRP 2009: SNBTS 3 Short Term Deferrals – Long Term Impact on Donor Base  This presentation will aim to explore how true this statement is  Consider what influences our deferral rates  Present Research findings on the impacts of Donor deferrals  Consider whether it is possible to refuse a gift well?  Explore options for intervention to minimise the long-term impacts  Inspire you to think about how you can minimise these impacts on Blood Donors and your Blood Centre

4. ADRP 2009: SNBTS 4 Where were we? Donor Deferral Rate Trends 21% increase in new donor deferral rate since 2003-04 24% increase deferral rate overall for donors since 2003-04 PDI or New & Lapsed Tick Box DHC PTD Exclusion BSQR

5. ADRP 2009: SNBTS 5 Impacts of Increased Deferral  Reduced Donor Availability  Reduced Collection Program Reliability  Reduction in available Supply  Reduced Operational Productivity & Efficiency  By summer 2007 SNBTS were experiencing difficulties in maintaining the 5 day minimum target blood stock levels  Frequent need to restrict issues of O negative despite achieving>12% of total collection as O neg

6. ADRP 2009: SNBTS 6 Where were we?- Donor Base Shortfall  By Dec 07 -Lowest Number of Donors since our national records began  Donor Base Shortfall of 10,500 Donors  6% and a decline of 10% since 2004/05  Additionally, we anticipated the need to implement a test for vCJD in the next 2-3 years  estimated losses of 10% of donors Active Donor Base = Number of Donors Attending in previous 10 months

7. ADRP 2009: SNBTS 7 Impact of Exclusion of Previously Transfused Donors ( vCJD risk reduction measure April 2004 )  Cumulative Previously Transfused Donor losses (PTD’s)  losses of ~22K donations per annum (  9.4% of 2009/10 target )  Cumulatively > 8% of of current Active donor base permanently deferred for this reason  Continuing losses of 1400 donors each year  0.8% of Active Donor Base

8. ADRP 2009: SNBTS 8 Deferral Rates: Trends post Blood Safety & Quality Regulations  Increase in Hb deferral results in the loss of up to 10,700 donations/year  4.2% of supply plus an increase in Medical Deferral Rate results in a minimum loss of a further ~5300  2% of supply  Permanent deferrals also increased by a further 50% since BSQR implemented in 2006 over an above the losses incurred by PTDs  Combined BSQR & PTD losses  38,000 donation (16% of this years Target) BSQR: The European & UK Law with which all Blood Establishments must comply

9. ADRP 2009: SNBTS 9 What Affects Deferral Rate?  Method of Donor Selection Detailed Tick Boxes rather than list of exclusions Confidential Personal Donor Interviews for New & Returning Donors Touchscreen/Online technology  Stringency of the Selection Criteria Exclusion of Previously Transfused Donors Blood Safety & Quality Regulations/ FDA criteria Evidenced based selection criteria  Quality of Staff training in donor Selection Regional variations in practice Historical differences in operational practice Different staff groups making deferral decisions  Donor Population Donor Lifestyle Choices Donor Demographics Health and deprivation indexes Differences in these issues must be considered when reviewing benchmarking data

10. ADRP 2009: SNBTS 10 Where/When are Donors Deferred ? Donor Call Up Self Deferral Less Accurate Between Donations Self Deferral Inaccurate Resulting from Changes in Circumstances e.g. Travel/ Medication etc On Session Most Accurate Offers more chance to explain Call Centre Enquiry More Controlled More accurate Avoids Deferrals on session NB: Operation practices vary between services and this can account for some of the apparent differences Post Donation Inaccurate reporting Donors less aware of need to report Adverse event may lead to decision to self defer

11. ADRP 2009: SNBTS 11 Donor Or Patient Safety: Review of Donor Health Check Questionnaire What should our focus be? Need to get the balance right between donor and recipient safety Deferral must be accurate and ensure that only those who need to be deferred are indeed deferred

12. ADRP 2009: SNBTS 12 Benchmarking Deferrals  SNBTS measure Donor Exclusions at Sessions  When Comparing Data with other services we need to make sure that we are measuring like for like  Need to consider differences in Data Capture and Process

13. ADRP 2009: SNBTS 13 Is it Possible to Refuse a Gift Well? Qualitative Research  Qualitative Research: Caffrey Consultants  Conducted July 2007  The objectives of the research were: 1. To establish the reasons why temporarily deferred donors do not return to give blood 2. To gauge how deferred donors felt their deferral was handled and to establish degree of rejection, if any, they experienced 3. To investigate any differences between how longer term and shorter term donors respond to deferral 4. To establish which incentives/triggers would entice donors to attempt to give blood again – specifically to test a range of propositions

14. ADRP 2009: SNBTS 14 Method and Sample  Sample identified and sourced by SNBTS  20 in depth interviews were recruited by SNBTS 4 no-shows 3 replaced Currently deferred donors most difficult to replace like for like Total of 19 in depth interviews achieved Caffrey Consultants conducted the 45 minute long interviews 8 in depth interviews Deferred donors who have not returned after the deferral period 6 in depth interviews Deferred donors who are within the deferral period and are undecided 6 in depth interviews Deferred donors who did return after the deferral period 8 achieved 4 achieved 7 achieved

15. ADRP 2009: SNBTS 15 Results: Deferral Experience: The Deferral Event  SNBTS staff well regarded  Very few criticisms of the manner in which deferrals were handled  SNBTS staff were repeatedly referred to in exceptionally positive light  At a top line level deferrals handled in a consistent manner:  Staff described as professional, friendly, reassuring  Deferral often described as delivered in a factual, matter of fact, or professional manner  Evidence of some deferrals being offered a leaflet Recall of dietary advice in Hb leaflet They were upset themselves because they were having to refuse people They were very nice…I wasn’t the only one there were others too

16. ADRP 2009: SNBTS 16 The Deferral Event : One or two criticisms  Most common shortcoming is that SNBTS did not make clear to donor when they could return  Doubt  assumptions that may not be correct Can cause confusion Particularly amongst repeat Hb cases who assume 12 months Also for short term deferrals – e.g. ‘come back when you feel better’  Some concern expressed over how obvious it was that donor was being deferred Particularly New donors – this may just be a perception If I wanted to and if I was able I might want to come back sooner

17. ADRP 2009: SNBTS 17 Post deferral emotions?  Generally a mostly rational reaction to being deferred  No great feeling of rejection  Disappointment prevails  Anger, annoyance and irritation more common amongst Regular donors  Particularly for Hb deferrals where EU regulations / changes were cited  Seen as something that is impeding the donor and is very de- motivating  2 regular donors (males) ‘failed’ the Hb test due to EU regulations and both questioned whether they would ever be able to give blood again  Disappointment seems most acute for New Donors  Relief too for New donors but also embarrassment And within that, new donors who had gone with a group of people Feeling of being in one door and out the other

18. ADRP 2009: SNBTS 18 Post deferral: Not top of mind for long  Very little navel gazing about deferral At most thought about for the rest of the day  Reminded when encounter SNBTS advertising or media coverage of blood shortage At these times annoyance at being deferred can emerge amongst some donors e.g. O negative blood type donors who are aware of the utility of their blood  Most common mind-set is to wait to hear from SNBTS re: a return date  These donors did not recognise being called to donate as signalling the end of their deferral period  Need to be explicit

19. ADRP 2009: SNBTS 19 The deferral visit: Some lack of understanding  Depth of understanding around reason for deferral differed depending on donor previous experiences  Uncertainty over whether deferral was due to risk to donor’s or patient’s health  Second time Hb deferrals may benefit from more time from SNBTS staff to explain why this has happened again I think you would have felt happier if you had been a bit more explained

20. ADRP 2009: SNBTS 20 Why did some donors tell us they had not returned? Of the 8 non-returners 4 were regular and 4 new  Regular donors all cited not being told how long they were deferred for as the main reason for not returning All claimed that they would definitely be going back once they were told they could – they were simply waiting to be invited 1 also suggested that having had a reminder she was not sure whether she was still within the deferral period and had not been able to attend to check this  The New Donors cited not getting round to going back, not knowing when to go back, not having had as much contact from SNBTS as they thought they might, not feeling sufficiently ‘wanted’ by SNBTS 1 returned as a result of being invited to participate in the research (and was deferred again)

21. ADRP 2009: SNBTS 21 How deferral length can influence returning  For some the issue is not whether they return but WHEN they return and how to get them to return sooner to maximise donations  This is most acute in short deferrals (1 day – c 4 weeks) Key to an early return is to: Make a Date Try to arrange next visit within the current cycle where possible Encourage donor to share the view that the deferral is short term That deferral is a brief separation and not Divorce! Deferral periods also need to be reinforced at each communication to heighten awareness of return date

22. ADRP 2009: SNBTS 22 Donor typologies: Three Key Cohorts Donors who were deferred on their first visit No frame of reference re: the donor experience and in need of most management Most likely to feel unmotivated Passive New = most vulnerable Donors who have given regularly when the mobile unit has visited place of work / local area / when feel like they have been asked to Opportunistic donors & Deferral something that happens to them Risk that can get lost in the system due to lack of opportunities to donate By their nature need more targeted encouragement to return Donors who have given regularly by actively visiting a donor centre or mobile unit More likely to actively manage donations / visits to minimise potential deferrals / maximise potential donations More likely to return of own volition / with limited encouragement Potential to further maximise donations through communication New Reg Passive Reg Active

23. ADRP 2009: SNBTS 23 How emotional impact of deferral can affect returning Feel-good factor Something that is the norm for them to do Returning was more of an internal motivation Intrinsic in their nature to continue to try to give Part of the original motivation for giving No fundamental reliance on external stimulus However the functional reminder card is invaluable Even donors who were repeatedly deferred, repeatedly returned Indefatigable spirit Regular Active Donors Donors: Why did they return?

24. ADRP 2009: SNBTS 24 Intervention required to restore emotional well-being and maintain motivation to donate Feel good factor How emotional impact of deferral can affect returning New donors enter at a quite high level Already feel that they have made a positive decision to give blood Expecting to give blood and for feel-good to increase as a result New donors can end up down here when deferred Nothing to show for their effort Effectively like a crash Need something relatively immediate to get back up the scale

25. ADRP 2009: SNBTS 25 Qualitative Research: Conclusions  New donors seem most at risk of not returning. Greatest need to be made to feel special  Regular passive donors may return but could be encouraged to return sooner by demonstrating where opportunities exist and encouraging to seek opportunities to donate  Regular active donors likely to return relatively quickly after deferral period if they know when to come back  Short term deferrals would benefit greatly from an appointment being made on the day of the deferral where practical  Long term deferrals do not need constant reminders, only at critical points

26. ADRP 2009: SNBTS 26 Desk Top Research: SNBTS  Desk Top Analysis of 565 Donors who had attended during Dec 2005  Two Cohorts compared  283 Donors who had returned to give during next 12 months  282 Donors who had not returned  Donors were selected at random from all donors who had attended during December Analysis Conducted by Carol Garnett & Lynn Whitelaw

27. ADRP 2009: SNBTS 27 Desk Top Research: Results ?? Regular Active ?? Regular Passive

28. ADRP 2009: SNBTS 28  Revise Donor Selection Criteria  Improve Training on Donor Selection Criteria  Improve monitoring system and conduct trend analysis  Implement ‘Sample Only Donation’ and accreditation of Deferred New Donors to reduce impact of deferral and promote ‘Club Membership’  Develop Welcome Pack with Temp Membership Card for On Session Use  Develop Specific Deferred New Donor letters to accompany Donor Card  Extend range of materials for Deferred Donors on Session Possible Interventions

29. ADRP 2009: SNBTS 29 Possible Interventions  Clearly Identify the date the donor can next donate and identify the next donation opportunity. Provide Donor with written confirmation on day  Develop Intervention Models For New and Regular Donor who have been Deferred  Conduct Further Research on the Characteristics of Regular Passive Donors  Develop an end of deferral mailing or tele-recruitment strategy

30. ADRP 2009: SNBTS 30 End of Deferral Mail shot: Pilot  Why did we do it? Research indicated donors were unclear on when to return Routine Donor Call up did not seem to trigger return Therefore, needed to send clear signal  How did we do it? Limitations of current IT system did not permit automation Manual system required to record deferral end date  What Did we do? Targeted mailing for next session post deferral end date Generic letter reminding donor to return with session details

31. ADRP 2009: SNBTS 31  These results indicate a 17% increase in the likelihood of return within one month of deferral end date  7% increase of return within the next year End of Deferral Mail shot: Pilot: Results

32. ADRP 2009: SNBTS 32  Automation via e-Progesa or Data extraction, Ultimately CRM  More specific to deferral reason Pregnancy Body Piercing & Tattoo Travel –Malaria/Chagas Hb  End of deferral telephone call to build relationship  Combined impact of on session improvements and letter/call End of Deferral Mail shot Pilot: Next Steps

33. ADRP 2009: SNBTS 33  Why did we do it? Research indicated donors were unclear on when to return Donors did not share the view that deferral was temporary No matter what we tell the donors when they are deferred, many do not take the information on board. This results in donor complaints or failure to return To avoid distress / annoyance at being deferred The “walk of shame” – donors are often in a hurry to leave and therefore do not listen  How did we do it? Designed card for on session use  What Did we do? Conducted pilot for all deferred donors for 1 month Provided simple written information on whether they can return, and if so when, or how they will be told – the “Deferral Card Conducted donor satisfaction survey Session Deferral Card: Pilot

34. ADRP 2009: SNBTS 34 The On Session Deferral Card Starts off with a “Thank you” Session date recorded so donor can relate from this point. Tick-box list of options Blood Centre contact number provided

35. ADRP 2009: SNBTS 35 A few regular deferral items listed overleaf – otherwise space to record free text. The On Session Deferral Card

36. ADRP 2009: SNBTS 36 15 7 08 Sample Card: Failed haemoglobin The Deferral Card – Examples of Use (3) 3

37. ADRP 2009: SNBTS 37 15 7 08 GP investigating upper GI symptoms The Deferral Card – Examples of Use (9) All investigations must be negative, and you must have no further planned follow up.

38. ADRP 2009: SNBTS 38  One month pilot conducted August 2008  234 Donors Deferred  193 Questionnaires Sent (82% sample)  48% Response Rate  93 responses  100% said they understood the information  97% said they found the information useful  82% thought donors who got a card would be more likely to return Session Deferral Card: Pilot: Results

39. ADRP 2009: SNBTS 39  13 free text comments of relevance  9 were positive – e.g. “good idea”/ “excellent idea”.  2 were “negative” – “would have returned even if I didn’t receive a card”/ verbal information was good enough.  2 were practical issues – “heavier card”/ “more wallet-sized”  One particularly enthusiastic comment was “Being told when you can donate is a really good idea as opposed to being told to “try again next time”, especially for the first time donors”. Session Deferral Card: Pilot: Results

40. ADRP 2009: SNBTS 40  Implement nationally alongside Sample Donation  Encourage Donors to visit website to find an alternative donation opportunity for short deferrals  Provide dates of future sessions  Extend the range of deferral information on session  Monitor return rates Session Deferral Card: Pilot:Next Steps

41. ADRP 2009: SNBTS 41 Other Initiatives  Launched major marketing strategy to reverse the decline in blood donors and prepare for vCJD test  Revised Donor Selection at UK Level High Blood Pressure Medication Removed Upper Age limit for regular Donors Accept non insulin dependent diabetics  Implementation of Capillary Hemocue to improve accuracy of Hb screening  Revise donor selection methods for lapsed donors returning after more than two years  Implemented national training for all donor selection staff

42. ADRP 2009: SNBTS 42

43. ADRP 2009: SNBTS 43 Where are we now?  Over all improvement in donor deferral resulting in 6000 extra donations per annum  Significant reduction in New Donor Deferral rates despite the high profile marketing campaign

44. ADRP 2009: SNBTS 44 Where are we now?  Decline reversed, rebuild commenced  Donor base increased by 6.2% (10,749) since December 2007

45. ADRP 2009: SNBTS 45 Where are we now?  Throughout 2008/09 blood stocks have remained extremely healthy  Only Negative has not maintained the target five day minimum stock level but still very healthy Stock level expressed in Number of Days Supply to meet Average Daily Issue Requirement

46. ADRP 2009: SNBTS 46 Your Action Plan No matter what your role is- You can make a difference to mimimise the impact of Deferrals on Blood Donors and Tour Blood Centre. ACT NOW!

47. ADRP 2009: SNBTS 47 Thank You - Any Questions? Contacts: moira.carter@nhs.net k.moir@nhs.net vincent.mooney@nhs.net