“Tenner tantrums” — An opinion on fining patients

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.

I think it will only exacerbate strained relationships between primary care staff and the patients who need our care the most.

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.


  1. Khan N, Fining patients who miss GP appointments – will this strategy work? (accessed 2/8/22)
  2. 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

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You’ll possibly get tantrums from the limited few who are fined.

But you might also improve NPS from patients overall if DNA fines reduce DNAs and improve overall accessibility (or if DNA fees are reinvested to improve care at that practice).

An observation: when it comes to possible solutions / ideas in NHS primary care, it seems there is a temptation to focus on the possible downsides for the “few” not the upsides for the “many”. Maybe this approach is right…but maybe not…

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