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Gold, incentives and meh

Dealing with patients who miss hospital appointments



Steven Rees presented with an odd pigmented lesion 10 weeks ago. He was referred urgently but failed to attend. A further appointment was sent, with a second non-attendance. The dermatologist wrote explaining

the situation and a further letter was sent to the patient asking him to get

in touch. Today he has come to

renew his antidepressant medication. Dr Richard Stokell advises.

Why do appointments get missed?

It is frustrating to have to write a third letter and see several very expensive outpatient slots wasted. It impacts on the practice, hospital waiting times and the responsibility for this patient seems to be being passed firmly back to you.

About 11 per cent of first hospital appointments are missed1. Common reasons cited are a long waiting time, losing the appointment details, not receiving the appointment and transport problems. Inconvenience, especially where there are family and work commitments involved, are also factors.

Mental health appointments have a particularly high DNA rate and those patients are also poor at attending other appointments. Chaotic lifestyle, lack of continuity among professionals, anxiety and lack of understanding of proposed treatments have all been particularly highlighted in this group. Confusion caused by the illness and not being able to find the way to hospital also cause problems. Thirty per cent of suicides occur in patients who missed their last outpatient psychiatric appointment2.

Factors such as the perceived cost-benefits of attendance may be important and this may reflect the style of consultation that generated the referral.

How should we assess this patient?

Our first task is to reassess the problem for which he was referred. Does further history taking and examination suggest this is still necessary? If so, what is the patient's understanding of the problem? 'Why do you think Dr Smith wanted you to go to the hospital?' 'What were you expecting them to do at the hospital?'

These questions may reveal a fear of painful treatment, a lack of perceived seriousness or a fatalistic fear of a diagnosis of incurable malignancy.

Our next task is to look at the barriers to his attendance. Did he receive the appointments and what stopped him going? If he is too sluggish in the morning due to antidepressant medication, could an afternoon appointment be arranged? Can he read and speak sufficient English?

What can we do now?

Assuming the appointment is still necessary there are a number of ways we can improve the chances of him attending. The first is to work on his health beliefs by providing clear information about why he needs to be referred, what the possible outcomes are and what effect not treating him might have. 'How do you feel about all this?' may allow you to assess his understanding.

Our next strategy is to minimise the logistical obstacles to his attendance. How is he going to find out about the appointment, what time and on what day will it be most convenient? How is he going to get there? Interventions such as having the appointment sent to you and then telephoning the patient to remind him, or involving a community psychiatric nurse, may be necessary.

But what about the patient's responsibility for his own health?

Why should you take so much of the responsibility for the patient? Clearly you would not go to such lengths for a bunion in a similar type of patient. In those circumstances, discussion of the reasons for failure to attend may still be profitable.

Would you discuss the costs to the NHS? What steps would you take in rearranging the appointment given that one DNA doubles the risk of a subsequent missed appointment. Can you refuse to re-refer?

What is the NHS doing about this problem?

After some successful pilot schemes the National Booking Scheme is being developed, allowing GPs and patients to choose a convenient date and hospital. Many hospitals have facilitated changes of appointments with well-publicised helplines. The introduction of a call centre in Aintree Hospital in Liverpool reduced DNA rates from 16 per cent to 5 per cent.

Other local schemes involving telephone booking have been successful. GPs are shortly to provide copies of letters to their patients being referred, presumably to improve the flow of information. This has not been shown to improve attendance rates3.

As for GPs, 'on the day' booking of appointments has had a big impact on our DNA rate and many practices confirm longer appointments such as baby checks by telephone. Other approaches range from flexible open surgeries to the removal from the list or even the threat of a fine.

Key points

 · A positive patient-led decision to be referred based on sufficient information may improve attendance rates

 · Take account of the patient's particular difficulties when he has

failed to attend an appointment

 · Inconvenient appointments arranged after long delays have the

worst attendance rates

Richard Stokell is a partner in a practice in Birkenhead, Merseyside


1 UK National Audit Office ­ 2004

2 National confidential inquiry into suicide and homicide by people with mental illness ­ 2003

3 Hamilton et al, BMJ ­ 1999


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