The purpose of this document is to provide guidance regarding the management of patients who failed to attend their appointments. It is essential to make the best use of the clinicians’ availability to ensure that all patients have access to appointments within an acceptable time frame.

1.2 Status

This document and any procedures contained within it are non-contractual and may be modified or withdrawn at any time. For the avoidance of doubt, it does not form part of your contract of employment.

1.3 Training and support

This practice will provide guidance and support to help those to whom it applies to understand their rights and responsibilities under this policy. Additional support will be provided to managers and supervisors to enable them to deal more effectively with matters arising from this policy.

2 Scope

2.1 Who it applies to

This document applies to all employees of the practice and other individuals performing functions in relation to the practice, such as locums.

2.2 Why and how it applies to them

This document sets out the procedures for monitoring and recording and the required actions to be taken to effectively manage missed appointments at Ottershaw Surgery. Within general practice, failure to attend appointments is commonplace. It is therefore essential that an efficient management system is in place.

The practice aims to design and implement policies and procedures that meet the diverse needs of our service and workforce, ensuring that none are placed at a disadvantage over others, in accordance with the Equality Act 2010. Consideration has been given to the impact this policy might have in regard to the individual protected characteristics of those to whom it applies.

3 Definition of terms

3.1 Did Not Attend

Failure to attend an appointment is commonly referred to as “Did Not Attend” or DNA. For the purpose of this policy, the acronym DNA will be used.

4 Policy

4.1 Statistical evidence

As well as being costly in financial terms, patients who fail to attend their agreed medical appointments often create excessive waiting times for other patients.

In 2016, Dr Robert Varham, the then Head of General Practice Development at NHS England, published his “Releasing Time for Care: 10 High Impact Actions for General Practice”[1] of which “Reducing DNA” featured as being one of the areas that was needed to improve productivity.

More recently, a BBC news article dated 2 Jan 19 stated that patients who miss GP appointments are currently costing NHS England £216m a year, with data showing that more than 15 million consultations are being wasted because patients fail to show up[2].

At Ottershaw Surgery during any month, an average of 40 patients are recorded as being a “DNA”, meaning that the patient neither attended their appointment nor advised the practice within 24 hours prior to the scheduled appointment, to enable a cancellation or change to their appointment to be made.

The effects:

· An increase in waiting times for patients, resulting in the risk of worsening patients’ health

· A waste of practice time – not simply the clinicians’ time, but also the administration team’s as the appointment invariably needs to be rebooked

· Cost to the wider NHS in the requirement of additional clinicians

4.2 Recording DNAs

All DNAs are to be recorded on EMIS in each patient’s healthcare record as follows:

· Did Not Attend – Reason given – #9N41

· Did Not Attend – No reason given – #9N42

The practice manager will review DNA statistics on a monthly basis. DNAs are to be displayed, highlighting the facts in the waiting room.

Statistically, signs that communicate the number of patients who did not attend in previous months, with signs that conveyed the much larger number of patients who did turn up, resulted in a 31.7% reduction in DNAs compared to the previous 12 months’ average[3].

4.3 Preventative measures

In order to reduce the number of DNAs, the practice will offer:

· Easy cancellation

· Appointment reminders

Patients are sent a text message to remind them about a forthcoming appointment. The reminder includes an explanation of how to cancel the appointment if it is no longer wanted

· Read back

The administrative team will ask the patient to repeat the details of the appointment to them, to check that they have remembered and recorded it correctly.

· Report attendances

The practice manager will publish DNA information monthly and make it readily available in the waiting room.

· Patient engagement

Ottershaw Surgery will discuss the issue with the patient participation group (PPG) to highlight the numbers and plans for improving the DNA rates.

4.4 Managing DNAs

Clinicians are responsible for recording DNAs using the correct read codes as detailed in this policy. Should a patient call and cancel an appointment, giving less than 24 hours’ notice, the person taking the call is to record this as a DNA using read code #9N41[4].

It should be noted that, whilst unacceptable in most cases, there may be extenuating circumstances as to why the patient has failed to attend their appointment. Therefore, prior to any letter being sent to a patient, it would be reasonable to discuss this with their clinician. Should there not be any mitigating reasons, then a text message explaining the DNA will be sent to the patient (if a mobile number is available), if no mobile number is available then a letter will be sent using the template at Annex A. If the patient fails to attend a second appointment within a 12 month period, and should there be no reasonable mitigating circumstances, a letter will be sent to the patient using the template at Annex B. Should the patient then fail to attend a third appointment within the same 12 month period, this will be taken to the Practice Meeting and discussed as to whether the patient is to be removed from the practice list.

Prior to writing to the patient, using the template at Annex C, the senior GP will assess whether removing the patient from the practice list would be detrimental to the patient’s health or well-being and cause significant harm. Should the decision be made to remove the patient from Ottershaw Surgery the BMA has provided the following guidance that must be followed:

www.bma.org.uk/advice/employment/gp-practices/service-provision/removal-of-patients-from-gp-lists

Letters sent to patients are only valid for a 12 month period. These letters are to be saved in each patient’s electronic health records.

By reducing the number of DNAs, the practice will:

· Enhance the efficiency of clinical sessions

· Reduce costs

· Increase productivity

· Offer a more effective service to patients

· Enable more effective booking of slots

4.5 Children who fail to attend

Awareness is to be given to children who fail to attend an appointment.

Whilst all missed appointments have traditionally been classified as a “Did Not Attend”, this group actually needs to be classified as “Was Not Brought” as it is not a child’s responsibility to attend the appointment, it is their parents’ or carers’ responsibility to take them. As such, awareness must be given to this and the consideration that this could be termed as medical neglect[5].

For further information The Nottingham Safeguarding Children Board have developed a video to assist with understanding the differences between medical neglect and from a simple DNA.

4.6 Actions needed for a ‘Was Not Brought’

Although it is a subtle difference, by coding non-attendance of children as ‘Child not brought to appointment’ and coding on EMIS as 9Nz1, the practice is emphasising potential failure on the part of those responsible for the child’s welfare.

Any non-attendance by a child to their medical appointment will trigger a letter that needs to be sent to the parent or carer to ascertain the reasons behind the non- attendance. Any response from the parent or guardian will also be noted in the patient’s clinical records.

All missed appointments should be flagged with the safeguarding lead.

Further information can be found in the Safeguarding Policy.

4.7 Practice information

In order to remind patients of the significance of DNAs, templates for posters to display in the waiting room can be found at Annex D.

4.8 Summary

Patients who fail to attend their medical appointments continue to have a significant financial impact across the NHS.

Having a robust management system in place will help to reduce the number of DNAs at Ottershaw Surgery and ensure that all patients have improved access to an appointment within an acceptable time frame.

Annex A – First letter to patient

Dear [insert patient name],

Our records show that you had an appointment booked with [insert clinician’s name] on [insert day and date] but failed to attend this appointment. If you believe this to be incorrect, please contact us on [insert phone number] to discuss.

Appointments at Ottershaw Surgeryare at a premium and this missed appointment could have been used by another patient if you had provided the practice with at least 24 hours’ notice that the appointment was no longer required.

During this last month, [insert number] appointments were recorded as “Did Not Attend” (DNA) which represents [add percentage] of appointments at Ottershaw Surgery. Please be advised that this practice has a DNA policy which, for patients who repeatedly fail to attend, may result in them being removed from the practice list.

If you need to cancel or change an appointment, you can:

· Call the dedicated appointment line on 01932 875001

· Text CANCEL useing mjog

Please help us to maximise appointment availability in the future. Your cooperation is very much appreciated.

Yours sincerely,

Leah Lawther

Annex B – Second letter to patient

Dear [insert patient name],

We previously wrote to you on [insert day and date] regarding an appointment you had missed on [insert day and date]. This is the second occasion you have failed to attend a scheduled appointment within a 12 month period.

In our previous letter, we advised you that you can cancel or change an appointment by:

· Call the dedicated appointment line on 01932 875001

· Text CANCEL useing mjog

If you fail to attend a third appointment within the same 12 month period, we will consider removing you from the practice list.

Please help us to maximise appointment availability in the future by contacting us as soon as you know you will be unable to attend your scheduled appointment. Your cooperation is very much appreciated.

Yours sincerely,

Leah Lawther

Annex C – Removal of a patient

Dear [insert patient name],

We previously wrote to you on [insert day and date] regarding the appointments you missed on [insert day and date] and [insert day and date]. You have now missed three appointments within a 12 month period without justification.

Having discussed this with the practice manager, we have decided that we are removing you from our practice list. We notified NHS England on [insert date] of our decision and you will be removed on the eighth day following notification.

You are advised to register with another practice in the local area as soon as possible. A list of practices can be found at www.nhs.uk by entering your postcode in the “Find local services” section.

The decision to remove you from the list was not taken lightly, but it is imperative that we provide an efficient service for all of our listed patients and we are unable to do so if a patient repeatedly fails to attend scheduled appointments.

The practice team wishes you well for the future.

Yours sincerely,

Dr Christopher Turner

Annex D – Waiting room posters

In 2023

Appointments were not attended.

This is a waste of valuable GP and nurse time and could have been used for another patient.

Please ensure you call to cancel any appointments that you cannot make

01932 875001

[1] NHS England: Releasing Time for Care - 10 High Impact Actions for General Practice

[2] www.bbc.co.uk/news/health-46732626

[3] www.ncbi.nlm.nih.gov/pmc/articles/PMC3308641

[4] SNOMED CT code to follow

[5] British Journal of General Practitioners