Ten million GP appointments and five million practice nurse appointments are missed each year, according to a survey by health education charity Developing Patient Partnerships (DPP). With each GP appointment costing the NHS £18, that means £180 million is being wasted on missed GP appointments alone.
Explain to your patients
Educating patients is increasingly being recognised as the most effective way to encourage them to keep appointments. Patients might not realise the effect they are having on a practice by missing an appointment, so talking or even writing to them about the waste of resources and other problems associated with DNAs can help.
Pamela Prentice, DPP joint chief executive, says the method should be tailored to local circumstances and will depend on whether the offence is a one-off or happens frequently.
'Practices generally have a pretty good handle on who is offending,' she says.
North London GP and DPP spokesman Dr Terry John believes that informally phoning patients to explain why they should let the practice know if they cannot keep an appointment is more likely to be effective than writing letters.
Ms Prentice adds that there are other things practices can do before they should consider removing patients from the list.
'Patients aren't going out of their way to create this waste,' she says.
Raise awareness at the practice
There are many opportunities for communicating the 'please keep or cancel your appointment' message. DNA rates can be included on repeat prescriptions and on posters in the reception and waiting areas.
The practice leaflet, and registration information, should tell patients how to cancel appointments. When patients register, they should be encouraged to contact the practice if they cannot keep an appointment.
Involve practice staff
Have a practice meeting to discuss and agree a policy for DNAs. All staff at the practice should give a consistent message to patients when they book to 'please let us know if you cannot keep your appointment'.
Staff should also be aware of opportunities to reinforce the message.
DNAs should be recorded, so that the effectiveness of new initiatives can be evaluated.
The practice's patient participation group may also help generate solutions.
Make appointments easier to cancel
Phone lines are busy before surgery and patients trying to cancel at this time might not be able to get through.
Ideally, practices would have a dedicated cancellation line. But if resources will not allow for this, tell patients when they make appointments when the surgery phones are less busy, in case they need to cancel. This information can be displayed in the surgery, in the practice leaflet and on appointment cards.
Make changes to access
Changing the way your practice offers appointments can help reduce DNAs.
For example, the practice can encourage frequent DNA offenders to take same-day bookings. In addition, more telephone consultations can be introduced.
Automatic text, telephone or email appointment reminder software packages have been developed, but will be prohibitively expensive for most GPs.
Missed appointments are inefficient but GPs themselves do not lose income from them, says Ms Prentice.
There is therefore an argument that primary care organisations or the government should pay for these packages.
CASE STUDY - Identifying non-attenders
DPP spokesman Dr Terry John (left) says that his north London practice keeps a running tally of DNAs for GP and practice nurse appointments.
The practice has 7,500 patients and three GPs. In early 2005, there were 29-30 DNAs per month. This has since dropped to 25-26 per month. This is due to a number of initiatives.
Firstly, the practice has a large poster in the waiting area displaying the number of appointments missed, the time wasted and the request, 'Please don't miss appointments'.
Secondly, receptionists flag up patients who have missed appointments.
This gives the GPs and nurses an opportunity to mention it to the patient during the next appointment that they attend, making the patient aware that it would have been better to cancel than simply not turn up.
Thirdly, for regular offenders who have missed two to three appointments out of five or six, the practice manager has a quiet word on the phone with them to discuss the reasons.
Dr John says: 'We felt those changes were significant enough without being overbearing.' Before the changes were introduced, the issue was discussed at a practice meeting. 'We had to get everyone involved, otherwise it wouldn't work,' says Dr John.
The aim is to reduce the numbers to 10 DNAs a month, and future initiatives may include talking to the patient participation group about what else the practice can do.
DPP's 'Keep it or cancel' campaign package, including a wipe board poster, guidance on managing DNAs and translated fact sheets can be ordered at www.dpp.org.uk, price £70.50 incl VAT.