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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)

  • But it's gone to my chest...

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  • 100% with you on this one - people don't value a free service. Need some charges in UK GP sector like we have here in Oz.

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  • Not rocket science. Free stuff is not appreciated, human nature.

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  • The underlying principle of the NHS is to be free at the point of delivery or in the case of DNA of non-delivery, I ask my colleagues to imagine the paper work to charge patients. Even if it is a fixed penalty there would be a right to appeal.

    The obvious scenario comes to mind that they have ended up in the secondary sector because of having to wait two weeks for an appointment.

    and would the patient get compensation if they were kept waiting for the statutory 15min or greater? It may be a tentative idea but a patient's time is also valuable.

    A seductive proposition and an easy target, but rather like opening up the Pandora's box, there will be unforeseen repercussions

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  • Dear author please stop being self righteous.

    Dont expect that all the patients should turn up for their appointments only on the days GPs decide to come in to work (as most GPs work part-time). Patients sometimes agree to take an appointment that is forced upon them and therefore there will be DNAs.

    If GPs moan about an odd DNA, then just think about the daily problems that patients face with G N A (GOT NO APPOINTMENT).

    First GPs should be focussed on reducing GNAs by working full-time by not indulging in leisure activities during the working days of the week.

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  • Dr Nabi,
    I am left wondering about your blogs, I have no personal view of you,
    [1] I have noted that you have felt it inappropriate that a patient does not have ''Calpol'', which you considered to be standard issue in your own home. I would like to suggest to you that they may have been really worried about their child and not come to you for a prescription that is free under the NHS. I simply ask you to revert to your earlier comments.
    [2] May I ask you, how can you equate going to a GP , to you going to you gym, with or without fiscal penalty. The patients that come to see you are at least ''potentially' ill..........

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  • I think simply looking at DNA as a measure of wastage within the NHS is a far too simplistic analysis of the situation. I have observed over time that good doctors often get lower DNA rates, in fact these poor souls have a full list plus a few others who want to be seen on top of what everyone else is seeing. DNA's actually serve to buffer the relentless clinics and allow most GP's to be within time or run less later than they would otherwise. I am lucky if i get DNA's but when i do it's usually because the patient has arrived and forgot to check themselves in!

    Coming to he question of whether people value free.. there has been extensive studies that suggest overall we value it less. In fact free is only valued more when you initially are or expect to pay for something or a service.

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  • great but i think works better to pay when you book and get money back if you turn up. better psychology i?

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  • Spot on Shaba. I always say...Give it away for free and it loses value. We do oursleves a great disservice by being theer at everyones beck and call, agreeing to a house call that was rung it at 17.59 pm as its within contracted hrs and pt cant be arsed to ring OOH 2 minutes later. One can only hope the public will soon get the healkth service they deserve...where they will pay for every little thing

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  • I have just paid privately for my step son to see a Psychiatrist. The practice demands upfront payment and you lose this money if you don't attend. The upside is that I can get him seen this week.

    On the same subject but from a different view point, we hear how GP's are suffering from low morale, taking early retirement or emmigrating abroad. The main problem seems to be the inability to control or work load and therby our work/life balance. Might I suggest that it is not medicine that brings these difficulties but rather the NHS. Maybe, we shoud all of us have confidence in the service we offer and follow the dentists' lead and become private practices. The BMA is a toothless tiger that can not even protect Junior Doctors. By going "Private" we bypass the BMA and the Government.

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