Missed appointments in general practice should be regarded as an “inevitable outcome” of the appointment system, rather than a patient problem, according to a new evaluation published. A range of techniques for non-attendances are suggested by the authors.

The conclusion comes following analysis of a quality improvement (QI) programme involving 25 GP practices in the NHS Tower Hamlets Clinical Commissioning Group (CCG), with an ethnically diverse and socially deprived population. This QI programme, which took place between April 2014 and March 2019, included sharing data on appointment systems and Did Not Attend (DNA) rates, with 14 practices implementing DNA reduction projects, supported by practice-based coaching.

Monthly appointment data, including number and type of appointments booked, DNAs, and length of time between booking and appointment, were collected from EMIS Web during the study period.

At the beginning of the study, the mean DNA rate was 7% (range 2–12%) and the variation in DNA rates between practices was found to be unrelated to practice size. While two years later the generic intervention DNA rates were 5.2%, equating to a reduction of 4,030 missed appointments, based on 762,851 booked appointments in the practices in 2018.

Writing in the latest edition of the British Journal of General Practice, the study authors found that baseline data for all practices in the CCG showed a positive association between the DNA rate and the length of time, in days, between booking the appointment and the appointment date. When the authors analysed specific DNA reduction projects at 14 of the practices, they found that those engaging with DNA reduction projects had a modest additional drop in DNA rates compared with practices undertaking other projects. It looked at one, which introduced a systematic change to its appointment system after experiencing a DNA rate of 9.5% for GP appointments, equivalent to just over six hours per GP each week.

The practice team established that more than 70% of its DNAs occurred when the gap between the date of the booking and that of the appointment was more than two days. For most of its patients, it reduced the advance appointment booking period from 28 days to one working day. Following the intervention, DNAs rapidly fell to between 3% and 4% and this level was maintained until the end of the study period in March 2019.

Lead author Sally Hull, from the Institute of Population Health Sciences, Barts and the London School of Medicine and Dentistry, said: “DNAs should be viewed as an inevitable outcome of an appointment system, rather than a patient problem; to meaningfully reduce non-attendance, it is the appointment system itself that needs to be altered.”

The authors say that when viewed from a systems perspective, the percentage of DNAs is a useful indicator of the ‘health’ of an appointment system and that addressing DNA rates is important if the primary care sector is to be efficient.

However, they say that it is important to recognise that GP surgeries run two systems in parallel: reactive care and planned or proactive care for long-term conditions, which is provided by the nursing and healthcare assistant workforce.