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.
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.
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.
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.
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