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Reducing missed appointments

Steve Martin explains how small changes with zero costs can change patients' behaviour and reduce DNAs.

Steve Martin: 'Increasing a patient’s participation in the appointment-making process should lead to a reduction in DNAs' (Photograph: Author Image)
Steve Martin: 'Increasing a patient’s participation in the appointment-making process should lead to a reduction in DNAs' (Photograph: Author Image)

Reducing 'did not attends' (DNAs) is something every practice strives for - often with mixed success. Recently we have been trying several initiatives at two GP practices that have reduced DNAs by up to 31%.

In partnership with professional services company BDO, consultants Influence At Work tested three innovative and yet costless interventions informed by behavioural science in two GP practices within NHS Bedfordshire.

The Wheatfield Surgery in Luton is a seven-GP practice that provides an average of 7,000 appointments each month. Toddington Medical Centre has four partners with an average 3,200 appointments. Between February 2010 and January 2011 the total number of DNAs across both practices was 4,700. Wheatfield had 3,763 and Toddington had 937.

Choosing two practices allowed us to test separate interventions and their cumulative effect. In each case, we held training sessions with staff members involved in the appointment-making process. These were supported by the partners and the practice manager, and included training on both the rationale for the interventions and their practicalities.

The majority of primary care patient appointments are booked via the telephone by a practice receptionist. In such interactions a patient's role is largely passive. Evidence from behavioural sciences shows that the more an individual is actively involved, especially in the early stages of making a commitment, the more likely they are to live up to that commitment.

Consequently increasing a patient's participation in the appointment-making process should lead to a reduction in DNAs or, at the very least, increase the likelihood that a patient unable to attend will call to cancel.

Making a commitment
Patients calling to make a GP appointment were asked to simply repeat back the details of their appointment before ending the call. The practice staff implemented this tactic with high levels of compliance. The impact on DNA rates was immediate and impressive; we recorded a reduction of 6.7%.

A written commitment
In common with the majority of GP surgeries, Wheatfield and Toddington medical centres held regular clinics led by practice nurses. Rather than a nurse writing down details of the next appointment, a blank card was offered to patients to write down details themselves. This change was implemented for a period of two months, resulting in a reduction in the number of DNAs of 18%.

Communicate the right norms
GP practices attempting to reduce DNAs routinely highlight the large number of patients who fail to attend an appointment without cancelling in advance. This is most commonly done via a large handwritten poster, or occasionally an electronic notice board or plasma screen.

However, far from reducing DNA rates, there are reasons why we believe that such an approach will lead to more, not fewer, DNAs.

First, previous research has shown that drawing attention to the frequency of unwanted behaviours often 'normalises' such behaviour and results in a subsequent increase in its incidence. Second, these signs target the wrong patients because they will only be viewed by those who actually attend their appointments.

So we replaced the sign with a message that conveyed the number of patients who typically do turn up to their appointment in a timely manner (around 95%).

This sign, when used in combination with the active and written commitments described above, resulted in a 31.4% reduction in actual DNAs compared with the 12-month average.

Three steps to reducing DNAs

Our study provides three simple and largely costless changes that a GP practice can implement immediately to improve their appointment attendances.

1. Actively involve patients in the appointment-making process by asking them to repeat back the time and date of the appointment while on the telephone.

2. When using appointment cards for future appointments engage patient commitment by asking them to write down the details on the card.

3. Replace common signs that decry non-attendance with a sign that reports the much greater majority of patients who do turn up on time.

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