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At the heart of general practice since 1960

How ‘DNA Man’ is helping us gain back missed appointments

Dr Amar Rughani and colleagues at the Chapelgreen practice describe their innovations to educate patients not to miss appointments - including a cartoon strip 

dr a rughani

The problem

Our practice is in on the northern edge of Sheffield, bordering Barnsley and Rotherham, and is a well-established training practice with over 15,000 patients. We have a mix of eight partners and four salaried GPs, and on a weekly basis offer 58 bookable sessions, 10 sessions of duty doctor cover and two sessions of nursing home cover. We have a wide range of medical students, physician associates, registrars and a very competent nursing team who years ago brought triage to our service.

As with all practices, DNAs have been an unfortunate fact of life. Although they give welcome respite in over busy work schedules, cumulatively they amount to a significant loss of clinical time and more importantly to worsening access issues, which have both denied those in need and affected the practice’s reputation and popularity.

What we did

As a practice we have strived to drive the figures down, not just though our own efforts but with the wider community. Our historical starting point was to ‘RAG’ rate the DNAs, follow up those most at risk from DNA and address DNA opportunistically when next seen. This was clinically ‘safe’ but had no influence on patient behaviour. We recognised that to make a difference we had to do things differently.

In mid-2016, we set up a small multidisciplinary group, including patient representatives, and came up with a number of interventions. Poster boards were updated weekly, initially displaying the numbers of appointments lost and what this represented in lost clinical time and cost to the practice. Later, we portrayed the information in a more positive way, showing how many patients attended in bold and then showing the DNA in a small bubble, using peer effects to suggest that the majority of the community kept their appointments, thereby encouraging outliers to reform and be part of the group. This approach has been successfully used by government in letters saying for instance that ‘98% of your neighbours pay their council tax on time’.

We joined a citywide group led by the CCG, sharing data, testing small interventions and sharing outcomes with the group. For example receptionists asked patients to ‘promise to let us know if you cannot make the appointment’, the practice identified and wrote a letter to the top 10 repeat offenders and the Patient Participation Group (PPG) wrote a patient-to-patient letter to appeal to non-attenders to act more responsibly, not just for the doctors but for the other patients in the community.

We also began to work closely with Ecclesfield School, the largest secondary school in Sheffield, where many of the children are looked after by our practice. Our project group had suggested that a cartoon strip would be innovative and attractive to a new audience. A storyline was drawn using the artistic skills of fellow GP Dr Jamie Hynes, showing how one person’s actions can cause misery and worry for another person who wants to see a GP urgently. A cartoon strip needs a superhero and from this DNA Man, drawn by one of the partner’s sons, Henry, was born.

The practice worked with five local practices and used neighbourhood funds to commission the artwork and keep it generic and therefore useable by the whole NHS. To create a bigger impact, packs were created for each practice containing posters, badges, 6ft-tall window stickers, cardboard cut-outs for the waiting rooms and a short animation for practice display screens.

dna man

DNA Man

As well as advertising the project in the practice, we ran an article in a local newspaper that is delivered free to the neighbourhood.

We also shared DNA Man on Facebook and Twitter recently, which received a lot of interest, even being re-tweeted by RCGP chair Professor Helen Stokes-Lampard, to her 7,700 followers.

All staff have now added the DNA Man character to their email signatures so every recipient sees the logo and motto ‘Can’t make it? Cancel it!’ and we have made DNA Man a member of staff on our practice website.

Challenges

Perhaps the major challenge was to become open to the idea that a complex problem that seemed insoluble had to be tackled in different ways and this needed much wider ownership, involvement and psychological approaches. We have involved the whole community from schoolchildren to the older members of the PPG.

We have used diverse ways of getting the message across, for example using data on the DNA boards, written communication, posters and cartoon strips. The lesson is that messages need to be shared in a number of ways, not the same way more loudly.

Other challenges were with funding and time restrictions. However, everyone remained motivated and driven to get DNA Man out into the public domain.

Overall the project has cost us £1,110.14 so far; this is excluding the hours of the Ecclesfield School, PPG members and our own staff from the practice.

Results

We have very much tried to change culture through education, and feedback from schoolchildren is that they now discuss DNAs with their families and encourage them to understand that missing appointments is unacceptable.

We have received excellent feedback on our social media site, indicating we are steadily reaching out to more people, with DNA Man becoming a major talking point.

DNA rates per month used to run at about 300 out of 7,000 appointments 18 months ago. They are now down to around 200 per month, and with DNA Man generating huge interest since it was introduced in recent months, we are hopeful of bigger gains to come.

The future

We will continue to develop, review and expand the DNA Man project with plans to further raise awareness of DNA by designing merchandise including cups/mugs/mouse mats/toys etc.

Our vision is DNA Man will spread across the city of Sheffield and even further, to help the NHS be more effective with its resources and allow others who need an appointment to be able to get one.

Dr Amar Rughani is a GP Partner, Kathy Peasegood is deputy manager and Jemma Smith is management support officer at Chapelgreen practice

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Readers' comments (16)

  • Anonymous Locum GP

    DNA's are my catch up slots to make up the time spent on dealing with 'I've waited so long to see you doctor I have a list of problems ...'

    the problem is we need more GPs.

    getting rid of DNA's = more stress for us

    patient's don't care about how much stress we are under but they do care if we are running late or don't have time to go through all their problems.

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  • Healthy Cynic

    So when do you drink coffee now?

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  • Agree with @4:45
    Missed appointments provide time for results / letters / phone calls.
    The main downside is they are distributed unevenly and unpredictably across the practice and across the week.
    But decreasing DNAs without blocking out equivalent admin time? Rather not, really.

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  • High DNA rates are only an issue on forward booked appointments. This is because

    1/ by the time the appointment comes round the problem has either resolved or the patient is no longer bothered about the problem

    2/ the appointment is concerning a chronic disease that needs to be monitored or a vaccination.. that the patient is not that concerned about.

    Same day appointments eliminate all other DNAs, but my experience is that the demand for same day appointments is just no longer tenable with our current low resources, even using telephone consultations as the first level of care.

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  • Cobblers

    A lot of work. Unfunded. 300 DNAs in 7000 appointments i.e. 1 DNA in every 23 appointments. Less than 1 DNA per surgery session!

    Jeez not a huge problem then. And as other wags have noted it could be catch up time or coffee time.

    Be careful of the "bee in the bonnet" approach. Your time may well be spent on other more profitable things.

    If DNAs are a problem then use the yellow card, red card approach. Persistant DNA-ers who miss appointments, then are on the phone for another, often wanting 'Urgents' should be yellow carded by word and letter. Then, if the behaviour continues, red card them and chuck them off the list for breakdown of doctor-patient relationship.

    Emollient moi?

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  • Cobblers

    Tony (10:51) same day appointments help but as a locum I see people the same day but they still DNA!!

    Sometimes we can be too accommodating.

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  • Cobblers @10.57

    If telephone consultations are the first level of consultation the patient has had a consultation so there can not be any DNAs as the problem(s) have been dealt with over the phone. A few (my experience no more than 5% of telephone consultations) are asked to attend in person on the same day. Yes, a very very small number of these patients DNA, but this is so rare if the face to face appointment made is same day. We used to have unlimited telephone consultations, but as I said this is no longer tenable given the reduced resources in General Practice and the fact that just like adding another lane on a motorway, given time, traffic becomes even heavier. Increasing access to General Practice leads to an ever increasing demand for care. Ultimately there needs to be brakes, probably financial, to limit patient demand. Imagine if there were free restaurants, free fuel, free holidays, free clothes..., paid out of taxes....

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  • Can we be like airlines and kick patients out if we don't get enough expected DNAs and are overloaded?

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  • As a retired urologist used to say 'DNAs - God bless every one of them!'

    Don't get me started on latecomers though - that's the worst.

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  • Would be interesting to look at whether care actually goes down when you reduce DNA slots. I think for me it would. I generally over run and DNAs keep me vaguely to time, also if I knew a full clinic would be attending each time I think I'd be able to give less to each patient, be stricter at enforcing the number of problems a patient can bring etc...

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