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At the heart of general practice since 1960

Are we selling ourselves short?

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As I write, the streets are still awash with joggers and it’s a fight to find a parking spot at the gym.

I also decided to join the January good intentions club, and perhaps gain some much needed spirituality, by signing up for a yoga class on the first Sunday of the New Year.

Do we value anything that is free? 

Now I haul myself up at 7am every Sunday even though every bone in my body is telling me to stay in bed. You may ask what could possibly beat the urge to lie in, read the papers and enjoy a massive fry-up with my family. Simple: the £1 penalty for non-attendance. As I’m a gym member, the classes are free, but if I fail to show up to a booked class, I pay the fine. Rationally, I know I wouldn’t even notice the loss of £1, yet I’ve not missed a class.

If you think £1 is not a big enough deterrent, just look at the new policy to charge for plastic bags, which tells us people will change their behaviour for as little as 5p. Since the introduction of this meagre levy, the use of plastic bags has gone down by nearly 80%. It is clear from this that it’s not where you set the bar that matters – it’s the mere presence of a bar that causes such profound behaviour change.

My enthusiasm for a yoga class made me reflect on the extended hours surgery we offered after New Year’s Day to relieve the access pressures from the holiday week. Of a total of 13 booked appointments, eight patients failed to show up – a DNA rate of more than 60%. This is how little the public values extended access to their GP practice on a bank holiday weekend.

It comes down to the question, do we value anything that is free? Event organisers will tell you they can almost double attendance if they charge a small fee, rather than offering free entry. A free event will certainly have more people signing up for it, but a paid event will secure the greater turnout.

We also place greater value on that which is scarce. EasyJet and Booking.com use this to incite us to buy flights or book hotels – by flagging up how few places are left.

This marketing psychology can help us understand demand in general practice. Despite being a scarce resource, access to GPs has never been greater. What’s more, we’re also completely free with no penalty for non-attendance.

By introducing a penalty amounting to the price of a skinny latte, I predict we could make a big reduction in DNAs and save some cash in the process. Data from medium-sized practices that have cut DNA rates from 20% to less than 5% through telephone triage show they save around £100k a year by employing fewer clinicians. And knowing I’d be seeing patients who’d committed to being there would help me drag myself out of bed each morning. In the words of philosopher Julian Baggini, it all comes down to one thing – commitment: ‘When we pay for something we are showing commitment in a very practical way. We put something of ourselves – in this case money – into whatever it is we want. And by paying for it, we are proving to ourselves that we value it.’ 

Dr Shaba Nabi is a GP trainer in Bristol

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Readers' comments (20)

  • Vinci Ho

    My similar argument for charging a fee for Saturday and Sunday ROUTINE GP appointments. Of course , you still need enough GPs to be around!

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  • Kevin Hinkley

    Great blog. For a wonderful gateway in to behavioural economics can I perhaps recommend Rory Sutherland (The Wiki Man). He shows with colourful examples how small creative tweaks in a process can lead to big changes in behaviour. He’s also very funny!

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  • Let me be perfectly candid and say that I love a DNA. 10 minutes respite from the onslaught. It is not the patients that don't turn up who are the problem, it is the ones that do when they come with absolute trivia and who then want to argue with you because they know better than you anyway because they have internet access.
    We run a time dependent system similar to airlines and they manage the issue by using mathematical modelling to overcome it. It seems to work.
    Wrong issue and a solution that would just lead to a massive admin headache and poor patient feedback.

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  • I, too, love the non attenders. it gives me a few minutes to catch up. I still do 11/14 hour days, so God help me if they all showed up as sometimes they do.

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  • People 'just check' because its free. When they have to pay £20-50 for the privilege, they figure it out for themselves. Nothing worth anything is cheap.

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  • I agree with the token fee option.
    £1 booking fee for ANY nhs appointment. Simple.
    But maybe the easyjet option is the best for GP...£1 for an appointment 3 weeks, £2 in next 7 days and £5 to book for today. Its a start.

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  • "But I cancelled my appointment!"

    "How could I cancel my appointment when I can't get through on the phone?"

    "You can't make me pay."

    "I didn't arrive too late, I was waiting to check in."

    Just some of the arguments that will take place at the desk. That's before they get started on NHS Choices!

    Anyway I don't think everyone thinks like Shaba. I know loads of people who pay for gym membership and only use it once or twice.
    Getting out of bed for a £1 - might work for GPs but I'm not so sure the general public is that cheap.

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  • Anything given away apparently 'free' is quickly seen as valueless and there for the taking. Not enough free GP appointments to go round Monday to Friday? Open up the doors Saturday and Sunday too ...we can't get enough of it
    Can't cope? Why bother...any vaguely medical issue on my mind, free medical advice 7/7...coooshtie

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  • I agree with Dr Zoe Norris, the NHS is going down hill and patients expectation still very high , I work 5 days a week and for the last 15 years as a GP and I can see the difference, but I will not like to leave the NHS , our job is rewarding and yes hard working , as a lot of other jobs . We are very fortunate that we have options . I agree the things need to change and very quickly before is too late

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  • I think Dr Zoe Norris is spot on in her commentary.If you take cancer detection rates for example, they are not low because Doctors are ignorant, or patients do not know when to present. So the answer is not to keep bombarding GPs or public with signs and symptoms, threats and scares. Instead the government should be spending time and resources educating the public on the scarcity of resources and appropriate use of them by common sense and self management. This would then free up some appointments so GPs could actually do the job of detecting and referring instead of being deluged under guidelines and patient inappropriate demands.
    The government instead is blatantly electioneering by raising unrealistic public expectations and pretending to be the people's champion while battling the primary care ogres. While this remains the case, there is no hope for general practice and a few extra pounds and a few extra primary care 'assistants' is not going to prevent the impending catastrophe. Meantime, those of us who value the NHS and take pride in the job we do, will continue to bravely do the best we can for as long as we can.

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