The missing appointment

There is an appointment in healthcare that never appears in the diary.

There is no waiting room, no ten-minute slot, no clinician sitting opposite the patient. No letter is sent afterwards and no one records whether it happened.

Yet this may be the moment when healthcare advice either becomes useful or quietly disappears.

It begins when the consultation ends.

A doctor has explained what needs to happen next. Perhaps a patient has been advised to become more active, change their diet, lose weight, stop smoking or make changes that could reduce their risk of future illness. Perhaps they have been given medication alongside those recommendations. They leave the appointment understanding what they have been told.

Then they go home.

And that is where the real work starts.

The consultation is not the difficult part

We often talk about health behaviour as though the main challenge is getting people to understand what they should do but understanding is rarely the whole problem.

A person can know that exercise is good for them and still struggle to exercise. They can understand that smoking is damaging their health and still reach for a cigarette when stress hits. They can know that their diet needs to change and still find themselves eating differently at the end of a long, difficult day.

The information is there. The intention may be there too.

What is missing is everything that sits between the intention and the behaviour.

Healthcare happens within a system of appointments, investigations, diagnoses and treatments. Behaviour happens somewhere else entirely. It happens in kitchens and supermarkets, on Monday mornings and Friday nights, during arguments, deadlines, sleepless nights and family holidays. It happens when someone is exhausted and when motivation has disappeared.

The World Health Organization has long recognised that adherence to treatment is not a simple matter of whether a patient chooses to follow instructions. It is influenced by the person, the treatment itself, the healthcare system and the environment around them. The older idea that non-adherence is simply a failure of the patient misses much of what is actually happening.

That distinction matters.

Because once we stop seeing behaviour as a test of character, we can start looking at what is actually getting in the way.

There is a lot of life between two appointments

One of my clients is someone who has just been told that their blood sugar is becoming a problem. In the consultation, the advice might sound straightforward: improve the diet, increase physical activity, lose some weight.

She asked me so many questions, starting with what does that mean on a Wednesday?

Does breakfast need to change? What happens when I am travelling for work? What if my partner doesn't want to eat differently? What happens at the weekend? What if, like in the past when I have tried before, I regain the weight? What happens when I have a stressful week and the plan falls apart?

None of those questions necessarily belong in a ten-minute clinical consultation.

But they are precisely the questions that determine whether the recommendation survives contact with everyday life.

This is the implementation gap: the distance between knowing what would be beneficial and being able to consistently make it happen and it isn't a gap created by a lack of intelligence or a lack of caring.

People need to be listened to! They often trying to change something in the middle of lives that haven't stopped happening and thoughts that haven’t stopped driving to the unwanted habit.

Thera a lots of book that have made behaviour sound easier than it is

There is a persistent tendency to reduce behaviour change to motivation.

If someone really wants to change, the thinking goes, they will.

As a matter of fact, motivation fluctuates. It is affected by circumstances, confidence, stress, previous experiences and whether a person believes they are actually capable of succeeding. Research into behaviour change consistently points towards a much more complicated picture than simply giving people information and expecting motivation to do the rest. I would argue that giving them “proven” protocols instead, it’s also a big risk.

This is one reason the language doctors use around patients matters.

Words such as non-compliant can make a complicated situation sound remarkably simple. They imply that the patient was given the right instruction and simply failed to obey it.

I believe they understood it perfectly.

Perhaps they were overwhelmed. Perhaps the recommendation was too large a change to sustain. Perhaps previous attempts had ended badly. Perhaps nobody had helped them work out what the advice looked like in the context of their particular life.

That is a very different conversation from asking why they didn't comply.

The missing piece is translation

Good healthcare advice is not necessarily difficult to understand.

It can be difficult to translate in the exact “language” of that particular pain-sufferer.

“Exercise more” has to become something that fits around a person's pain, work, family and energy.

“Eat a healthier diet” has to become food they enjoy, can afford, can prepare and can continue eating when life becomes inconvenient.

“Stop smoking” has to become a way of navigating cravings, routines, social situations and the moments when smoking has become part of how someone manages difficult emotions.

The clinical recommendation and the science behind pain perception & sensations remain important. The coaching does not replace it.

It helps translate it.

That distinction is particularly important as healthcare increasingly recognises the role of lifestyle and behaviour in long-term health. The WHO's work on behavioural and cultural insights makes the point clearly: behaviour is shaped not only by knowledge and individual choice, but also by social, cultural and environmental circumstances.

The question, therefore, is not simply whether someone has been told what to do.

It is whether they have enough support to work out how to do it.

This isn't about asking doctors to become coaches

There is an obvious objection here.

Clinicians are already under enormous pressure. They do not need another responsibility added to an already crowded consultation. A GP cannot spend forty minutes exploring someone's relationship with food. A consultant cannot follow every patient through the difficult weeks between appointments. A surgeon cannot personally coach every patient through the behavioural changes required before and after an intervention.

Nor should they.

The answer is not to make clinical appointments longer; it wouldn’t enough anyway.

It is to think differently about what happens around them.

Health coaching can sit alongside clinical care as a behavioural support layer: helping a person understand their own barriers, decide what matters most, translate recommendations into realistic actions and review what happens when things don't go according to plan.

There is growing evidence that health and wellness coaching can improve several patient-important outcomes in people living with chronic illness, although the evidence is heterogeneous and coaching should not be presented as a universal solution.

That is precisely why the role needs to be properly defined.

A coach isn't there to diagnose.

A coach isn't there to prescribe.

A coach isn't there to override the clinician.

The clinician determines the medical direction. The coach helps the person navigate the behaviour required to follow that direction in their specific real life.

Perhaps we need to change the handover

Imagine that the end of a consultation wasn't quite the end.

The clinician gives the medical recommendation. The patient understands the plan. And where behaviour change is going to be central to the outcome, there is somewhere appropriate for the patient to go next.

Not because the clinician has failed to do their job. Quite the opposite.

The forward-thinking clinician has recognised, in fact, that giving good advice and implementing good advice are two different tasks.

That small change in thinking could have considerable implications.

It could mean that a patient who has been told to lose weight doesn't simply leave with a leaflet. Someone helps them identify what has prevented change in the past and build a strategy they can actually sustain.

Someone advised to become more active isn't simply told to exercise. Their barriers are explored and the recommendation is translated into behaviour that makes sense for their current circumstances.

Someone trying to stop smoking isn't treated as though relapse proves they weren't committed. The behaviour is examined, the trigger understood and the next attempt approached with more positive support than the last.

The aim isn't to create another layer of healthcare bureaucracy but to make the existing advice more likely to become meaningful outside the consulting room.

And what happens when it doesn't work?

This may be the most valuable part of the missing appointment, in my opinion, because behaviour change rarely follows a perfectly straight line.

In a traditional model, that can look like failure. In a coaching relationship, it can become information.

What happened?

What made the plan difficult?

What was different this time?

What could be adjusted?

The answer may reveal something that was invisible during the original consultation with the doctor and spending some time weekly with a trusted professional that encourages that self-exploration, and suddenly that information can be useful.

Sustainable behaviour change is about developing the capacity to respond when life inevitably does.

The appointment nobody books

Healthcare will always need consultations.

We need clinicians, diagnosis, medication, investigations, monitoring and specialist treatment. We need surgery when surgery is appropriate. We need medical expertise, thanks God we have them!

Ultimately, though, people have to live their healthcare recommendations. Then ty take them home, into their kitchens, their workplaces, their relationships, their weekends, into the difficult days and inevitably into ordinary Tuesday mornings.

That is where behaviour happens and perhaps that is why the space between appointments deserves more attention.

The missing appointment doesn't need to become another appointment.

It needs to become a recognised part of the journey.

The Ciao Change perspective

At Ciao Change, I don't believe healthcare professionals need to become health coaches.

I believe they need good partners who understand what happens after the consultation ends and they make their workload lighter.

The medical recommendation is the beginning. The work of making it part of someone's life is something different and for many people, it is where the real challenge begins.

Because people don't just need to know what might improve their health.

They have to be able to live it.

Sources and further reading

• World Health Organization. Adherence to Long-Term Therapies: Evidence for Action. Geneva: WHO; 2003.

• Boehmer KR, et al. The impact of health and wellness coaching on patient-important outcomes in chronic illness care: A systematic review and meta-analysis. Patient Education and Counseling. 2023;117:107975. DOI: 10.1016/j.pec.2023.107975.

• Sheeran P, et al. Self-determination theory interventions for health behavior change: Meta-analysis and meta-analytic structural equation modeling of randomized controlled trials. Journal of Consulting and Clinical Psychology. 2020;88(8):701–715. DOI: 10.1037/ccp0000501.

• World Health Organization Regional Office for Europe. Behavioural and cultural insights: How do behaviours impact our health? 2024.

• World Health Organization. Integrated brief interventions for noncommunicable disease risk factors in primary care: The manual: BRIEF project. 2022.

"Disclaimer: This article is for informational purposes only, even if and regardless of whether it features the advice of physicians and medical practitioners. This article is not, nor is it intended to be, a substitute for professional medical advice, diagnosis, or treatment and should never be relied upon for specific medical advice. The views expressed in this article are the views of the expert and do not necessarily represent the views of Ciao Change Ltd unless specified under “The Ciao Change perspective” section."