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Debate: Should patients be charged for missing appointments?

Is it guilt or annoyance that stops attendance or cancellation?


Kirsty Armstrong: Missed appointments are costing practices thousands
of pounds

When I first read about the idea of charging patients for missed GP appointments, I immediately conducted a straw poll on social media and, for comparison, among my healthcare colleagues at work. This was not a piece of in-depth research, but more a canvassing of opinions.

The results were surprisingly similar to each other.

Around 80-90% of respondents thought that patients should be charged £10-20 for each missed GP or practice nurse appointment, but only if they were persistent non-attenders or did not have a very good reason for not attending, such as hospital admission or an excellent alibi. 

From my ow d or those with long-term conditions receiving medication or care regularly.

One of the many excellent observations from the straw poll was that if we charge patients they would instead use non-charging services more – such as the urgent care centre or walk-in clinic – and create an administrative nightmare. Other comments included that the charge was the ‘thin end of the wedge’, and my favourite, ‘I pay my taxes so why should I pay more?’.

If missed GP appointments can cost clinical commissioning groups £250,000 each month, surely there must be a way to claw that money back.

Would it be possible to weed out the non-attenders and charge them? And where would the money go? To the GPs? Into our Christmas dinner kitty? And who are the persistent non-attenders — a vulnerable group in need of better management? Is their non-attendance a cry for help?

We have a wealth of technology that is more often than not used to remind us of events. Have you received a text  recently by your doctor, dentist or podiatrist to remind you of your appointment? Did you attend? Did your best friend text, Facebook or WhatsApp you about that film you are seeing together on Friday night? Did you reply, cancel or attend?

If these text reminders are not working for persistent non-attenders then perhaps we should charge them.

We have given them an appointment card and reminded them by text — surely it is impolite not to cancel if you cannot make it?

Or do we not care about other people’s feelings enough in today’s society? Or maybe the nurse told a patient to stop smoking and lose weight, and they didn’t like what they heard or simply haven’t done it. Is it guilt or annoyance that stops attendance or cancellation?

If it’s annoyance, maybe this manifests in a ‘serves her right’ attitude towards the practice nurse where patients feel justified in not attending because they were asked to do something they didn’t agree with.

Is this the thin edge of the wedge? There is a general agreement that today we have more patients with complex conditions, more elderly people, more expensive medications and more need for a ‘different’ way of working. 

If only we could wave a magic wand to find that ‘different’ way. Maybe it’s possible in a land where patients are so happy, informed and involved that they would never miss appointments. Where healthcare staff are so enthralled with their jobs that patients are queueing up to see them and hear their words of wisdom. Where endless resources and pots of money exist so that postcode lotteries of surgery, care packages and medications are a thing of the past.

Charging for missed appointments is a great idea in theory but when we talk to people about it, the adminstration of such a system is complex. 

When it comes down to it we need to decide if we have the technology to practically implement charging.


Michele Olphonce: We need to educate our patients on cancelling appointments

We have all seen it – the prolific DNAer. A patient’s appointment turns to ‘D’ on your screen and then you might look at their notes and see three, four, maybe five did not attends (DNAs). What’s going on here?

When I see the patient (eventually) I am always curious, so I ask: ‘I noticed you did not attend the last appointment. Was there a reason why?’

The responses range from: 

  • The appointment was booked so far in advance and the symptoms had resolved.
  • They forgot.
  • There was an emergency.
  • They were late so it went to DNA, but they had attended but were told that they could not be seen. 
  • They didn’t receive a text, letter or call to remind them, so they did not know the details of the appointment.
  • Alternatively, they may have booked multiple appointments, attempting to see different clinicians on the same day and there may have been clashes, so some appointments were inadvertently cancelled.

The main and most interesting reason I found was that they had been calling the surgery and couldn’t get through. 

So I started to think of possible solutions. We could encourage our patients to embrace technology, offer options to cancel online or by text. My personal favourite is giving the patient a receipt of each booking. The receipt would have costings on it and say how much the appointment would cost if they had to pay. 

DNA figures with the time and money lost are already displayed in waiting areas – but DNAers won’t see them, just the people attending their appointments.

Some surgeries may have their own policies and procedures for offenders, for example, three DNAs and
you cannot book advanced appointments. 

A surgery I worked in had a policy to send a letter saying ‘We are sorry you missed your appointment. Please cancel it in future to make appointments available for others’. 

I know some surgeries have a policy of three DNAs and you are removed from the list. But what happens to the vulnerable patients? Will they end up using A&E by default?

Communication is key. When educated, patients will understand and they will cancel the appointments they cannot make.

A recent headline about the money lost through DNAs provoked debate with my colleagues. Valid points were made about charges but I questioned who would police and enforce a charging system? If the patient doesn’t or can’t pay, what then? Also, can we charge for NHS care that would have potentially been given if they had turned up? After all, one of the founding principles of the NHS is it should be free at the point of delivery.

As for the proposed deterrent – how much would the charge be? If it is too little it’s tokenistic, but if it’s too large it will never be paid. Would it have to be a national charge? A flat fee?

Just imagine the reception staff when taking bookings for appointments: ‘So that’s an appointment on the 30th with Dr X. Can I take your card details to confirm the booking?’

A colleague suggested incentivising appointments. I scoffed and retorted ‘attend two appointments get the third one free.’ He said he’d give them £5.

Could incentivising health be maintained? Then there’s the potential issue of the surgery being perceived
as ‘profiteering’.

Resources and capacity are sparse but we need to be savvy and educate our service users on cancelling their appointments instead of having our sessions marked with the dreaded ‘D’.