It is not the first time, and it certainly will not be the last time that missed appointments have hit the headlines. Recently published data from NHS Digital shows that over four million GP appointments were missed this year at a rate of over a million missed appointments each month. Missed appointments are costly and effectively block precious appointment time. On the ground, the views of clinicians are sometimes less negative, as missed appointments can be viewed as a chance to catch up on time or work.1
Recent media coverage has focussed on whether patients should be fined for missing appointments. Would a £10 fine change patient behaviour and put an end to this story once and for all?
Why do patients miss appointments?
…the most commonly cited reasons why patients miss appointments were work or family commitments, simply forgetting and transport difficulties.
Several patient and practice factors are at play when a patient misses an appointment. In a recent systematic review published in the BJGP, the most commonly cited reasons why patients miss appointments were work or family commitments, simply forgetting and transport difficulties.2 The authors of this review suggest that one approach to reducing missed appointments is to tailor appointment scheduling to patient behaviours, for instance, avoiding appointments on days when patients have work or family commitments or offering alternative access strategies. Remote consulting has a potential part to play in allowing patients to fit a consultation into their working and family lives. For those who forget to attend, practical reminder systems, such as text reminders, are cost-effective, well accepted by patients and can significantly increase patient attendance.3
In terms of practice characteristics, appointment systems play a role in rates of non-attendance. Practices which offer appointments with a greater than two day delay between booking and appointment time typically have higher rates of non-attendance; this might be explained by patients experiencing self-limiting problems which resolve.4,5 One mooted intervention is to offer patients with serial non-attendance same-day appointments. Changing appointment systems can lead to significant and sustained reductions in missed appointments, however, system change can be frustrating to staff and patients alike.5
The most important factor predicting the likelihood of missing serial appointments is social deprivation; research has highlighted the complex associations between lower socioeconomic status, multimorbidity, mental health diagnoses and being in an ethnic minority with increasing frequency of missed appointments.2,4 Missed appointments may well be a signal that something is not right, and acts as a marker for higher risk of ill health. A retrospective cohort study of GP data from Scotland demonstrated a dose-based response between increasing number of missed appointments and risk of all-cause mortality, especially amongst those with long-term mental health conditions.6 What’s clear from the research is that there is no one reason why patients miss their appointments, and that patterns of missed appointments are not equally distributed across different practices, socioeconomic status and multimorbid patient groups.
What difference could a fine make?
Slapping a ‘fix it all’ solution to a complex problem may be a perilous approach and may not have the intended effect.
It’s worth thinking carefully about what the goal is for fining patients. If the driving factor for fining patients is to raise funds for the NHS, a £10 fine could raise significant amounts of money each year. If the driving factor is to put people off missing their appointments, however, it’s unlikely that a fine will make a difference to the root causes of why people don’t or can’t attend. Imposition of a financial burden upon the socially deprived could further exacerbate the problem. This is where a kind of inverse care law comes into play, as fines could have the most detrimental impact on those who need the care the most.
Some commentators feel that something must be done to penalise people who don’t attend their GP appointments. Slapping a ‘fix it all’ solution to a complex problem may be a perilous approach and may not have the intended effect. In his book ‘What Money Can’t Buy’, Michael Sandel tells the story of an Israeli day-care nursery which introduced fines for parents who turned up late to collect their children.7 Instead of reducing late pick-ups, the imposition of a fine paradoxically increased late pick-ups; parents viewed the fine as a ‘fee’ to collect their children later. The day care went back to the old system, but late pick-ups continued. The act of monetizing the behaviour of lateness had destroyed a sense of collective responsibility of ‘doing the right thing’ by attending on time. This almost allegorical tale perhaps serves as a warning; once a behaviour is marketized, the impacts on patient behaviour might not be as expected. The introduction of a fine might indeed have unintended outcomes especially amongst the most vulnerable. Instead, as suggested by the research, interventions should be patient focussed, and aim to support attendance, rather than penalise those who cannot attend.
References
- Martin C, Perfect T, Mantle G. Non-attendance in primary care: the views of patients and practices on its causes, impact and solutions. Fam Pract. 2005;22(6):638-43.
- Parsons J, Bryce C, Atherton H. Which patients miss appointments with general practice and the reasons why: a systematic review. Br J Gen Pract. 2021;71(707):e406-e12.
- Junod Perron N, Dao MD, Righini NC, Humair JP, Broers B, Narring F, et al. Text-messaging versus telephone reminders to reduce missed appointments in an academic primary care clinic: a randomized controlled trial. BMC Health Serv Res. 2013;13:125.
- Ellis DA, McQueenie R, McConnachie A, Wilson P, Williamson AE. Demographic and practice factors predicting repeated non-attendance in primary care: a national retrospective cohort analysis. Lancet Public Health. 2017;2(12):e551-e9.
- Margham T, Williams C, Steadman J, Hull S. Reducing missed appointments in general practice: evaluation of a quality improvement programme in East London. Br J Gen Pract. 2021;71(702):e31-e8.
- McQueenie R, Ellis DA, McConnachie A, Wilson P, Williamson AE. Morbidity, mortality and missed appointments in healthcare: a national retrospective data linkage study. BMC Med. 2019;17(1):2.
- Sandel MJ. What Money Can’t Buy: the moral limits of markets. New York: Farrar, Straus and Giroux; 2012.
Featured image: Exit sign from The Story Museum (Oxford). Photograph taken by Andrew Papanikitas, 2021
Joel Brown is a portfolio GP with interests in digital health and global health, multi-instrumentalist and singer-songwriter. He is on Twitter: @JoelBrownMD
Rishi Sunak’s campaign offer (as a potential future prime minister) to rescue the NHS by charging £10 to patients who miss GP appointments is unlikely to treat any real malfunctions under the bonnet of our health service’s smoking engine despite the presumed nobility of his intentions. I think it will only exacerbate strained relationships between primary care staff and the patients who need our care the most.
Missed appointments are a problem, but as clinicians we are trained to treat problems as signs and symptoms to investigate and mitigate and not something to stigmatise and punish.
Many patients are progressively finding it even more difficult to get GP appointments, This is not primarily due to missed appointments but due to the fact we often don’t have enough appointments to meet the rising demands of a chronically underfunded national health service.1 That’s right, we don’t have enough GPs and those that are left are increasingly disillusioned with the conditions they are expected to work in while still delivering high quality patient care.
Given this disproportionate demand on our diminishing human resources, the last thing we need is to punish the relatively fewer proportion of patients who fail to turn up with fines, only for practices to have to deal with the fall out from the conflict that arises from them refusing/being unable to pay.
In a BJGP systematic review called “Which patients miss appointments with general practice and the reasons why,” Parsons et al described twelve studies reporting a reason that appointments were missed, with work or family/childcare commitments, forgetting the appointment, and transportation difficulties most commonly reported. It was also interesting to note that all 20 studies reported characteristics of people likely to miss appointments as those from minority ethnicity, low sociodemographic status, and younger patients.2
It is abundantly clear that those who are more likely to have cultural, socio-economic and communication barriers to healthcare access and health care vulnerabilities, are those more likely to be penalised by this intervention. It seems to me that the problem of missed appointments requires real investment in improving access to care for the vulnerable, easier ability to postpone or cancel existing appointments and more intelligent appointment booking to take into account the various challenges of different groups who struggle.
Most GPs might also not readily admit that while we recognise the significant cost of missed appointments, in a system bursting at the seams with unrealistic and unsustainable demands, an unexpected ‘DNA’ (Did Not Attend) can feel like well needed respite in a busy overrun clinic.
We must get to the deeper root issues to effectively solve the NHS’s economic and human resource crisis and not give into the path of least resistance by punishing our most vulnerable populations who too often are already failed by the state.
References
Khan N, Fining patients who miss GP appointments – will this strategy work? https://bjgplife.com/fining-patients-who-miss-gp-appointments-will-this-strategy-work/ (accessed 2/8/22)
Parsons J, Bryce C, Atherton H. Which patients miss appointments with general practice and the reasons why: a systematic review. Br J Gen Pract. 2021;71(707):e406-e12.
Featured image: Tenner on the road, by Andrew Papanikitas, 2022