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Missed patient appointments - frustrating or fatal?

Carole O'Connor
Practice Nurse
Harold Road Surgery

I love my practice nurse job, but sometimes it's frustrating, especially when patients do not attend (DNA) their appointments. Worse still, when they demand an urgent appointment and fail to attend. Thankfully the latter are only a small minority.

To date we have had over 1,000 of DNAs for practice nurse and GP appointments at our surgery. Figures from the Developing Patient Partnership (DPP) state that almost 13.5 million GP appointments and around 6.5 million practice nurse appointments were missed last year. It is a complete waste of our resources, and blocks appointments for genuine patients.

The DPP asked health professionals why there are so many DNAs. The overwhelming majority, 69%, felt patients usually forgot and 22% believed the patients felt better and did not need the appointment.

We all have targets to meet and some patients have been invited to attend by the surgery for reasons including asthma, epilepsy, diabetes and general updating of our systems. These are sometimes the worst offenders. "No, they didn't book the appointment," I hear you say. True, but we have invited them for a medical update for their benefit, and the letter they were sent clearly states: "If you are unable to attend this appointment, or if it is not convenient, please inform the surgery to rebook a more suitable time."

Patients do forget, but the matter should be dealt with if it is a regular occurrence. Some patients have argued that the reason they did not attend their appointment was that "we are booking appointments just to reach the government targets". Not always true. As a nurse I have a duty of care to look after my patients. I would be failing in my profession if I didn't undertake annual check-ups.

If a patient does not arrive for an appointment you could try one or several of the following:

  • A reminder phone call to alert them to the fact they have missed it.
  • Find out why and explain how important it is to inform the surgery if they cannot attend.
  • If unavailable to speak to, leave a message for them to phone you back. Give no details. If they have genuinely forgotten, they will be mystified why you have phoned, then explain when they phone.
  • Some surgeries leave text/voicemail messages on patients' phones before appointments, and even send email messages. This may engage another member of staff in these procedures.
  • If you hear "I didn't receive your letter/phone call with appointment time/date", double check even if you know details are correct. If this happens regularly, maybe suggest they check with the Post Office!
  • "I couldn't get through on the phone!" is another excuse, which is genuinely sometimes a problem. Most surgery phones are not as busy from 11am until lunch. Suggest it may be best to phone at these times.
  • Frequent DNA patients could set an email reminder or a reminder on their mobile phone of the date.
  • Patients who don't attend their appointments more than three times can be sent a letter reminding them that the professional's time is valuable, and the surgery must be informed if they cannot attend, otherwise they may have to find an alternative GP.

Suggestions for patient awareness of the DNA problems:

  • A poster (available from DPP) stating how many missed appointments your surgery has had to date. The poster could read that the cost of a missed GP appointment is approximately £18. DPP statistics state nearly 65% of the public and 685 of practices surveyed would support charging people £10 or less for missing appointments. They have produced a leaflet titled "A Guide to Managing Missed Appointments in General Practice", and postcards to insert into your surgery leaflet quoting "Keep it, or cancel it".
  • When sending appointment letters, type in bold, or highlight a sentence: "if this appointment is not convenient, please phone the surgery to rebook."
  • Before specific nurse clinic, a member of admin can give the patient a reminder call.

Nurse/staff awareness:

  • Consider the age of the patient you are inviting. There is no point asking a child to attend an asthma appointment inside school hours, or elderly patients to attend evening appointments in dark winter months, or working patients appointments in the middle of the day. Use common sense when making the initial booking; this may cut down the DNAs.

Missing appointments can be fatal. I sent several letters and phoned a patient to attend for blood pressure and lipid check. He kept ignoring me, saying he "would look at his busy diary and make an appointment". Sadly he didn't attend and died of a myocardial infarction aged 49. If he had attended, would he still be here today? We shall never know. Maybe patients need further education on why it is important they attend, because missed appointments could, as in this man's case, be fatal.

Developing Patient Partnerships (DPP)

Are missed and cancelled appointments a problem at your practice? Your comments: (Terms and conditions apply)

"Yes! Sad reading this as another nonattender failed yet again to turn up for his diabetic check. I've now sent him another appointment for next week after trying to phone him. Mobile switched off and no answer machine on at home. He's 48yrs old has a HBa1C of 14%! There are only so many times I can chase up people, without handing the repsonsibility back to them." - Christine, Suffolk 

"Yes have tried various options with little success." - Sally Harrison, Margate Kent

"This was a problem for us too, until we adopted an 'opt in' system rather than sending patients predetermined appointments for chronic disease clinics. We send a letter reminding them they are due a check and ask them to ring and arrange it. We are able to search for the people who haven't responded after a month and they are sent another reminder. We send a total of four letters until giving up the chase until next year! This also means we have a clear computerised record of our attempts to reach the patient. Our DNA rates for our chronic disease clinics have reduced dramatically with this method." - Janet, Gateshead

"Please remember that how ever clearly your letter states, appointments can be changed. If the person receiving the letter cannot read, the appointment will not happen. An accompanying phone call when the letter goes out as well as a reminder just before the date increases the likelihood of attendence." - Name and address supplied