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CAMHS won't see you now

Should GPs charge for DNAs? Yes

If patients DNA, they should pay. Charging for no-shows is the most straightforward way to make patients understand the economics of missed appointments, argues
Dr Richard van Mallaerts 

I have a love/hate relationship with patients who do not attend their appointments. 

I love the fact I can catch up when running behind, grab a quick cup of coffee, or make a start on my ever-growing in-tray. But I hate the fact that patients then complain that they can’t get an appointment quickly enough, and we are always only just coping with the demand. 

About one in 20 GP appointments is missed by the patient, costing the NHS approximately £162 million per year. That’s a lot of money wasted at a time when NHS purse strings are getting tighter and tighter. 

Like most practices we’ve tried various things to stop patients from failing to turn up. One practice I worked in had a ‘three strikes and you’re out’ policy – miss three booked appointments in six months and it was time for you to find a new GP. While this might seem a little harsh, it did have the desired effect to some extent – probably by moving the worst offenders on to other practices who then had to deal with them.

When I make an appointment to see my dentist or solicitor, I am often informed that I will be charged a cancellation fee if I fail to turn up without adequate prior notification. Surely it is time to consider a similar scheme in the NHS to stem the tide of wasted appointments?

By not arriving for their appointment, the patient has prevented another patient from being seen, as well as leaving me twiddling my thumbs wondering if they’ll turn up.
The cost of a GP appointment is £10–£20, I estimate, and a monetary fine to the patient of this value would remind them that there is actually a cost to a service that is provided free at the point of use, as well as acting as a disincentive to them doing the same in future. 

Taking responsibility

If the NHS is seen as having no monetary value, it appears worthless and is treated as such. 

A trial a few years ago presented patients on discharge from hospital with a faux bill detailing their treatment and the costs of it. In a society where few can remember there being no free medical care, all the patients studied were amazed at the cost of their care.

With the ongoing negative press regarding doctors’ salaries and pensions, few patients have much sympathy for wasted GP time, and not many seem bothered about the inconvenience and potential harm their fellow patients are put to either. By reminding them in a way that hits them in the wallet, they are likely to be more considerate next time – just as my car parking behaviour certainly changed after a fine. 

If the fine were pitched so as to cover the cost of the appointment, no GP could be accused of seeking to profit from sick patients, and an appeal scheme could be used when there was a genuine reason for failing to attend (though I’m fairly sure of my dentist’s response if I were to appeal to their cuddly side after having wasted their time).

To make a small charge in the event of a patient failing to attend their booked GP appointment will not bring about the privatisation of the NHS. It will not herald the onslaught of co-payments and a myriad of other charges for services. It will not be the end of the NHS as free at the point of use. 

It will, however, encourage patients to think about the value the NHS has and realise that wasting their appointment comes at a cost. And it may even help prevent further privatisation, as patients wake up to the real worth and value of the NHS.

Dr Richard van Mellaerts is a GP in Kingston in Surrey

Click here to read Dr Jonny Tomlinson arguing that GPs shouldn’t charge for DNAs

Readers' comments (8)

  • And how about the doctors paying patients for having to wait to be seen past the appointment time?

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  • Another comment from cowardly 'Anonymous' I see. Tut! tut! Stop hiding and sniping and have the courage to reveal yourself.

    Dentists do it, so why shouldn't doctors. You cannot charge private fees for NHS treatment, but dentists get around this by saying that as you never attended for your free NHS treatment, the charge is not for NHS care. In other words it is a non-NHS charge.

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  • In response to the comment about GPs paying patients, that would be fine as long as the patient is happy to leave the consultation when "their time" is up. My GPs give the patients the time they need, not the time allocated. Innevitably this means they run behind. But the patients are (mostly) happy to wait, because they know that when they see the GP, they have the time they need. We could issue each GP a timer and when the buzzer goes, so does the patient.

    I've always wondered whether we should be able to take a £10 deposit at the time of booking, refundable on arrival. Billing people after the fact won't work, as they just won't pay and it will cost more to persue them. But a deposit system..? Food for thought.

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  • I read 'Freakonomics' recently - interesting story in it about how a nursery in Canada started charging parents who arrived late to collect their children. Had the opposite effect to the one intended and late pick-up rates soared. Why? Because it replaced a moral incentive with a financial one.

    By charging for DNA's we go further down the commodification/commercialisation route that so many of us are lamenting. My preference would be to stick with 'the NHS is a cherished national resource that needs to be used wisely and not squandered/DNA's waste this precious resource and denies an appointment to someone who may be unwell and genuinely needs to see a doctor' line.

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  • The reason why solicitors charge for DNAs is because they incur the same cost but lose out on the income from a fee paying client. As GPs are paid the same irrespective of whether the patient turns up or not, they are not making a loss from DNAs. The only real cost is the increased waiting times for other patients. I have no problem with GPs charging patients for DNAs to incentivise attendance, but we have to accept that any financial penalty would increase GP income rather than offset a loss (as is the case with Solicitors). If we eradicated DNAs tomorrow where would the £162m a year come from? Reduced payments to GPs?

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  • There is no "fee-for-service" component in the funding, it is population based. A DNA does not cost the system anything although it may add marginally to waiting-times. A DNA may in fact save the system money - treatments not given, referrals not sent, investigations not performed.

    The problem is that the system is free to users and when something is free it has no measurable value. The patients don't really value it because it is free (and hence they resent the "over-paid" doctors) and the doctors (potentially) do not value the patients because they get paid irrespective of attendance (and may tend to value the QOF payments more - or at least the patients may see it that way). What really seems to stick in peoples craw is that somebody did not show up to see you and the implication is thus they do not value you or your service. That hurts the self-esteem.

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  • Nothing more frustrating than sitting waiting for an overrun appointment whilst a full desk of work lies waiting to be done. (not very good for BP readings?). I would be more than happy to pay a £10 charge for a convenient appointment that happened on time, so that I could spend the minimum amount of time out of the office and get back to work promptly. Even with BUPA you have to go through the GP for a referral. Difference is that once you get to the consultants office they will keep you informed if there's a delay. Its not just the patients that see the 'free service' as having no value. Feels like its a free service so we have to put up with bad service. I don't think most working people feel like that (its hardly free at paypacket point). How about instead of trying to charge the people who don't attend, you give priority to: 1) those who don't attend very often, 2) those who work and are on time constraints 3) those who don't miss appointments.

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  • Tut tut......naughty people. Maybe if it was possible to get through to reception there'd be more cancellation.or maybe the service would improve if practices had a financial penalty for not answering within a certain time limit..say £10 -£20 per individual time wasting costly call.

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