A perennial problem for general practice is the issue of missed appointments or ‘did not attends’ (DNAs) – and it’s not getting any better.

A recent study published in the British Journal of General Practice found that rates of missed GP appointments have not changed much at all over the past 20 years.

According to the study by researchers from the University of Warwick, which reviewed 26 suitable studies on the subject, an average of around 15% of GP appointments are missed each year and this rate is similar to that observed in another similar review carried out 20 years ago.

NHS England has estimated that more than 15 million general practice appointments with GPs, nurses, therapists and other practice staff are wasted every year by no-show patients and of these, around 7.2m are GP appointments. Wasting these appointments costs the NHS around £216m annually.

Dr Nikki Kanani, Medical Director of Primary Care for NHS England and NHS Improvement, has spoken about this issue previously, saying: “We know that timely access to general practice appointments are a priority for the public. Patients can do their part by letting the NHS know if they can’t make their slot – freeing up doctors, nurses and other professionals to see those who do need care and attention.”

Value of appointments

The reasons why patients miss appointments are, no doubt, numerous and include childcare, work issues, transport, weather difficulties, simply forgetting the appointment and feeling better by the time it is due – which all thwart their intention to attend, says the Warwick study.

Studies have found that some GPs are not as annoyed by DNAs as the rest of the primary care team and sometimes consider them as time to catch up, but nevertheless, missed appointments can lead to unresolved medical problems and delay treatment for something that may become worse down the line.

Not valuing the appointment is at the heart of the problem, according to Nicola Davies, co-founder of the Institute for General Practice Management and a practice manager in Cornwall.

“It’s about valuing the time of the clinician and because the NHS is free at the point of access for the user, is there any value placed on the appointment?” says Nicola.

Helen, a practice manager from Eltham, London, says: “Why does this happen? Because it’s free. If you haven’t got to pay for something, you’re not invested in it and you have no ownership.

“The vast majority of patients that we see at the moment are preventative appointments rather than acute appointments, therefore it matters less to them because it doesn’t affect their health or they don’t think it does.”

Tara, a practice manager from Greenwich, says: “I don’t know whether the DNAs are due to a lack of respect or that they think it’s not going to cause any problems for them to DNA an appointment, and they don’t think it will cause any hardship to the surgery, but it does obviously.”

Pandemic impact

One of the impacts of the COVID-19 pandemic last year was the dramatic reduction in face-to-face consultations in primary care and that has, to some extent, suspended the problem of DNAs – but only temporarily.

Tara says: “This isn’t such a problem at the moment because we’re telephone triaging first and then the doctors are making the decision to bring the patient in, so we’re not getting DNAs in that respect, although the nurses still are getting DNAs.”

Helen adds: “Most of our appointments just now are nurse appointments because the majority of face-to-faces are with nurses. The number of DNAs has started to creep up. We don’t get that many DNAs for doctor appointments because they’re acute appointments but the ones that don’t attend are the long-term reviews.”

Prior to the pandemic, the practice’s DNA rate was around 10% to 12% and Helen says: “At the moment we haven’t reinstated the text-messaging reminders because we don’t want people to have a reminder that they’ve got an appointment at 3pm when it’s a phone call that could be at 5pm.

“Over the coming months, I imagine the more appointments we offer, the more chance we’re going to have a DNA.”

Penalty charges

Much debate has taken place over the years about whether or not it would be appropriate to charge or fine patients for DNAs in primary care.

Nicola says: “There’s always a correlation between our DNA rates and dentist DNA rates. Dentists can charge for a failed appointment and we can’t.

“There’s an argument that has run on for a very long time about what if primary care could charge patients for failing to attend? My worry is there will be people for whom something happens and there’s an emergency or they forget to phone. I’d prefer not to go down the route of charging and prefer to think maybe we’re just booking those appointments too far in advance.”

On the issue of charging patients who fail to turn up, Helen is not enthusiastic about the idea, saying: “I don’t think we can. The NHS should be free at the point of care. A lot of our patients aren’t wealthy.”

Technology impact 

The use of technology to try and ensure that DNAs are kept to a minimum has helped to some extent, with practices using emails or text messages to remind patients the day before their appointment is due, but it doesn’t seem to have cracked the problem.

Nicola says there was little impact when her practice introduced the text-messaging reminder service.

“I don’t think we noticed a massive change because we have quite a top-heavy elderly population and a number of them don’t have mobile phones, but they will write that appointment religiously in their diaries and are very much led by a calendar.”

When it came to booking COVID vaccination appointments, the practice called those patients who failed to turn up to rebook them, saying ‘this dose of vaccine has your name on it, so please turn up and if you don’t, we’ve got a list of people waiting’.

“By emphasising to patients that they should turn up, it’s impressing upon them the importance of it and how precious that vaccine is,” says Nicola. “Maybe that’s something that we ought to explore for the doctor and nurse appointments.”

Patient list removals

Practices have the option of removing patients from their list as a last resort when it comes to repeated DNAs and this option is used.

Tara says: “Before we went into COVID, we would put up messages in the surgery and on our website about the amount of DNAs that we had per month. We also sent warning letters after the second DNA, advising them that if they had one more, then we would remove them from the practice list. We have removed patients.

“We’ve tried engaging our PPG [Patient Participation Group] to see if there’s anything we can do to make it more appealing for people to come to the surgery. Unfortunately, we’ve got a very migrant population here so people are in and out.”

Her practice has worked on ensuring that patients have access to plenty of appointments and at times deemed to be most useful in another attempt to prevent DNAs – such as the ‘commuter slot’ and extended hours for those people who work.

DNA rates at her practice, as measured before the pandemic at the end of 2019 for the practice’s nurses, were around 28% and many of those were for appointments for specialist clinics for diabetic and asthma reviews, and new patient medicals.

DNA rates for nurse practitioners were around 14%, and 22% for doctors at that time.

Tara says it took a few years after she joined the practice before the then partners listened to her about doing something about DNAs.

“Before we did something, at that point [around 2008], we were at about 40% DNAs for our doctors. Then we started overhauling the appointment system. Some of our doctors would start at later times in the morning… to give more flexibility. We also put up posters to remind patients about the waste of resources.

“It’s about educating patients to know what the impact is on the practice, how it impacts other people, and the financial impact. We started telling them, ‘did you realise that it costs approximately £85 to miss one appointment and how that resource could be spent in the surgery on you’ but it didn’t work.”

DNAs are a stubborn problem that no one seems to have cracked yet, and they’re a problem that will continue to frustrate practices as they increase the number of face-to-face consultations as COVID recedes.

The only answer seems to be to keep trying to educate patients about the cost of what it is they’re getting, and how it’s wasted if they don’t turn up. No easy task.

We have produced a new poster based on the Warwick study to help remind patients of the consequences of missing appointments. Download here [PLUS]. We also offer a useful free course via the HUB on Reducing your DNAs, find out more here