‘Let me see,' said the practice manger. ‘Last month we had 353 and the month before that 309.' She was speaking in a voice that seemed to convey both frustration and resigned acceptance in equal measure. ‘They usually average around 300 a month I suppose. It can be a real problem.'
We were discussing DNAs and the manager of this large, inner-city GP practice was right. They are a big problem.
Millions of GP and hospital appointments are wasted each year – at a considerable cost. Health thinktank the King's Fund estimates that some £700m in direct cost alone is wasted every year due to patients who fail to turn up for their appointments and don't bother to cancel with enough time to offer the appointment to another patient.
While in many cases that will be the extent of the financial waste, this will not always be true. Just because a patient has not attended, we cannot assume that a potential medical condition has been resolved. In fact, it is frequently the case that patients re-attend, often at less convenient times and in less appropriate settings – A&E, for example.
The issue of DNAs is not just about cost – patients who do turn up for their appointments, especially follow-up appointments for long-term conditions, are likely to be healthier and have better control of their condition than those who don't.
The problem of DNAs isn't confined to GP practices, and GPs will increasingly need to confront it as they take on commissioning of services, too.
And it's not just the NHS that has problems with no-shows – it is a longstanding issue in the hospitality industry. A restaurant, for instance, depends for its livelihood on people turning up for their booking, so it needs effective policies to ensure that customers do keep their reservations or at least call to cancel.
So can GPs learn lessons from restaurants and similar industries? We, as behavioural scientists, would argue that they can indeed – and some of these lessons have been tested and proven.
We have looked at some of the simplest – and cheapest – approaches used, and adapted them for GP surgeries. In our pilot – the results of which are currently being peer-reviewed by the Journal of the Royal Society of Medicine – these approaches resulted in a reduction in DNAs of nearly a third in two GP practices in England. Here are the steps that your practice can take that can help to reduce your DNA rate:
1. Get everyone in your practice on board
We focused our DNA-reduction trial on two busy Bedfordshire practices that provide care to over 10,000 patients and had annual DNA rates of up to 5%.
As a first step, we held training sessions with all members of the practice staff that play a role in the appointment process.
We went through the interventions we planned to test and the rationale behind them, and left a period of two weeks before we began the project to allow practice staff time to raise questions or concerns about the project.
Not every practice will have access to specialist training, but even so, it is important that you ensure all staff understand the aims and rationale of the changes you are making, as we found that the success of any change depends largely on staff enthusiasm and buy-in.
2. Walk through the appointment-making process as a patient
Spend some time observing the process patients go through to make an appointment. One recurring theme in the practices we studied is the relatively passive role a patient plays in making an appointment.
The patient phones up to book, and once the appointment is confirmed, they hang up and the receptionist takes the next call. This can represent a missed opportunity for practices to engage patients more effectively and in doing so reduce their DNA rates.
Today's world is the most stimulation-saturated ever, and people often do not fully take in all the information presented to them in a communication. As a result of this information overload, the context or environment in which a communication occurs can become as important as the information itself.
By looking at your practice's appointment process through the eyes of a patient, you may identify the opportunity to make small adjustments that can result in big changes for your practice.
3. Get patients to make verbal commitments on the phone
Renowned social psychologist Robert Cialdini cites the example of Chicago restaurateur Gorden Sinclair, who changed two words that his receptionists used when making customer bookings by telephone.
Typically reception staff would say: ‘Please call us if you need to change or cancel your booking' before hanging up the phone. But Sinclair asked his reception staff to instead ask customers: ‘Would you be willing to call us if you need to change or cancel your booking?', and then pause and wait for the customer to answer: ‘Yes.'
Such a small change might seem unlikely to yield big results, but this verbal commitment by customers can lead to a notable drop in no-shows for one very important reason. People generally prefer to live up to their commitments, especially those that require their active – rather than passive – involvement.
In our DNA-reduction study, we tested a slightly different version of this strategy. After the patient was given the time and day of their appointment, the receptionist asked patients to verbally repeat back the details of their appointment before the call ended.
There was a reduction in DNAs of 6.7% compared with before this intervention. Interestingly, patients never questioned the change and reception staff reported it was easy to incorporate and quickly became a natural part of the appointment-making routine.
4. Get patients to make written commitments in the surgery
In an attempt to deal with the issue of DNAs, many GP practices will provide patients with a reminder of their appointment details. This is usually done by way of an appointment card written out by the receptionist to prompt patients – but is this the best strategy?
Evidence from behavioural science shows people are more likely to live up to their commitments if they are actively involved. 1-3
Accordingly, it might make more sense to ask patients to write the time and date on an appointment card themselves rather than having the receptionist do so.
Again, such a small change may seem unlikely to make much of a difference, but when we tested it we were able to measure an 18% reduction in DNAs over four months compared with before the change. Of particular note was that this strategy required no extra effort on the part of practice staff and implementing it cost nothing.
5. Make non-attendance seem the exception, not the rule
Another common strategy that GP practices and hospitals employ to reduce DNAs is to highlight the number of patients who failed to show the previous month – usually by way of a prominent poster placed on waiting room walls.
While understandable, there are reasons why such a strategy is not only unlikely to work but could, in fact, lead to an increase in DNAs.
Previous research has shown that drawing attention to the regrettable frequency of unwanted behaviours often normalises that behaviour. Perhaps that's one reason why our frustrated practice manager was never able to reduce no-shows – she was making it okay to DNA.
A more obvious, yet widely undetected, reason why such a strategy is likely to fail is the fact that only patients who turn up for their appointments will see the poster. The wrong message is being delivered to the wrong audience.
Given that people's behaviour is often influenced by the behaviour of many others around them, these posters were communicating entirely the wrong norm.
So we replaced the poster usually found on waiting room walls with a new one that simply communicated that most patients do turn up for their appointments on time.
Specifically, our message read: ‘95% of patients at [name of surgery] turn up on time for their appointment or call [insert appointment line telephone number] if they have to cancel.'
This strategy, used in combination with the appointment card intervention above, resulted in a 31.4% reduction in DNAs compared with before the trial.
Steve Martin is director of Influence At Work (UK) (www.influenceatwork.co.uk). Craig Barratt is director of BDO's Healthcare Advisory Practice (www.bdo.uk.com/sectors/ public-sector/healthcare)
1. Goldstein NJ et al. Yes: 50 Secrets from the Science of Persuasion. Profile Books 2007
2. Cialdini RB. Influence: Science and Practice. Allyn & Bacon 2001
3. Cioffi D and Garner R. On doing the decision: effects of active versus passive commitment and self-perception. Personality and Social Psychology Bulletin 1996:22;133-44