Patients who fail to turn up waste precious time and money, but there are ways to help reduce the numbers of people who do not attend
One of the many challenges facing general practice today is how to meet the ever-growing patient demand for appointments, whether with doctors, nurses or healthcare assistants. Most practice managers will have received complaints from patients about the difficulty of getting an appointment. If a practice has a large number of missed appointments, often known as ‘DNAs’ (did not attend), this is an especially frustrating situation.
What can a practice do to reduce the number of missed appointments? The first step is to establish the facts by ensuring that DNAs are recorded as such in the clinical system. This can be done by admin staff, with an appropriate read code added to the record of any patients who have missed appointments, and any other information that might be of interest, eg. healthcare professional, appointment length. After just a few weeks it will be possible to run searches to build up a DNA picture.
Questions to ask yourself might include:
- Does one category of healthcare professional experience more missed appointments than others?
- If a practice has multiple sites, are there more DNAs at one or are they spread evenly across all?
- Are most of the missed appointments being caused by a limited number of regular patients?
Practice staff probably already have a pretty good idea as to where the problem lies, but this data, collected over a period of time, will enable management to develop appropriate strategies to address the problem.
Know your patients
Every practice will have a number of patients who are regular attenders but liable to forget their appointments, and others who are unlikely to make it into the surgery until the afternoon. Good reception staff can help reduce the DNA rate by steering patients towards appointments later in the day and calling the forgetful to remind them to come in. This may only be possible in smaller practices with low staff turnover and a relatively stable patient population, but it can make a real difference.
One obvious strategy is to send patients text reminders of upcoming appointments. If a practice is considering doing this, it is advisable to:
- Obtain patient consent to being communicated with in this way.
- Keep reminder wording as general as possible in case the patient shares their mobile phone with another person.
Modern technology makes it very easy to send text reminders. Unfortunately, however, not all patients have mobile phones or wish to receive text reminders, and some people change their mobile phone number frequently.
How easy is it to cancel?
Another point to consider is how easy it is for a patient to cancel an appointment. If the practice telephone system is overloaded it may be difficult for patients to get through to speak to a receptionist on the phone, which will put off many people calling to cancel. It may be worth considering a dedicated cancellations line, even if this is simply a voice mailbox for patients to leave a message.
Another tool is to educate patients about the importance of cancelling appointments if they are no longer required so that they can be given to somebody else. Most practices probably already have notices to this effect in the waiting room, in the practice leaflet and on the practice website. It may help patients to understand just how much time is being lost through missed appointments if this is quantified, for example:
“More than 90 appointments were missed last month. This represents 15 hours of wasted clinical time.”
If nothing else, this advertises to patients that the practice is monitoring the situation, and some of them may realise why it is sometimes so difficult to get an appointment.
Members of a patient participation group (PPG) can also play a useful role in educating patients on the importance of cancelling appointments by discussing the matter with them informally when they attend the surgery.
Once a practice has started to record and monitor the DNA rate, management may wish to consider writing to patients who keep missing appointments; and, if the behaviour persists, removing them from the practice list. It is important to have a robust protocol on how this is going to be done. Some questions for consideration are:
- Who will be responsible for running the searches to identify patients who have missed appointments? And how often will they do it?
- How many missed appointments will trigger a DNA letter?
- What time frame do the missed appointments have to occur in?
- Who will make the final decision as to whether it is appropriate for a DNA letter to be sent to a patient? It is advisable for GPs to be involved as they will be aware of which patients are especially frail and/or vulnerable.
- Which members of the practice team need to know if DNA letters are being sent? For example, health visitors should be informed in case there are any children involved, and reception staff may receive phone calls from patients who have received a DNA letter.
- What message should the DNA letter contain?
- How many DNA letters will be sent before a patient is removed from the practice list?
Understandably patients can get very upset when they receive a DNA letter. The practice will need to have a designated contact for such patients to speak to, and there may be mitigating circumstances such as a family bereavement.
One frequently heard excuse is that the patient did not make any of the appointments, but it may be possible to use the date/time-stamping of appointments booked on the clinical system to prove that the patient made the appointment when attending the surgery for a previous appointment.
One risk with this strategy is that patients may cancel appointments at the last minute rather than missing them. Management will need to decide on a cut-off time, after which a cancellation becomes a DNA, and communicate this clearly to the reception staff.
This strategy can be criticised as a very negative way of addressing the problem of missed appointments. Most GPs are probably secretly rather pleased to discover a few empty slots (from cancellations) in their surgery as they always have some paperwork or phone calls to catch up on. Patients could argue that their time is also often wasted when they have to wait because the GP is running late. And it is quite possible that a patient who is removed from one practice list simply goes on to miss appointments at another practice - so all that happens is that the missed appointments move round the locality.
Carrot and stick
A combination of ‘carrot’ and ‘stick’ is probably the best way of addressing the problem.
- Keep reminding patients to cancel appointments rather than missing them.
- Try to ensure that patients get appointments at times that are suitable for them.
- Use modern technology to send text reminders to those patients who can be contacted by mobile phone.
- Develop a robust protocol for dealing with regular DNAers.
While it might sometimes feel like there are few options available to practice managers when dealing with patients who miss appointments, hopefully the tips in this article will help staff to maximise the opportunity for patients to cancel appointments when necessary, and to reduce the number of appointments that are missed due to patient circumstances or errors.
Ruth M Law is a practice manager in Edinburgh and was previously a practice manager in London. She moved into practice management after a career in IT support for the private sector.