GP access: Why fining patients for DNAs would be both abhorrent and pointless

It's easy to blame patients for appointments lost to DNAs, says South Yorkshire GP Dr David Coleman. But writing for GPonline, he argues that resorting to fines for missed appointments would be an insult to the ethos of the NHS, and describes practical steps his own practice used to eradicate the problem.

A recent poll of 500 Britons, conducted by Astellas Pharma Europe, revealed that nearly a third of respondents would be prepared to pay a fine of more than £10 for a missed GP appointment. Only 29% of patients were not prepared to pay anything at all.

While these figures suggest growing support for charges, the argument that we should fine patients perceived to be ‘wasting resources’ by missing appointments is not a new one. Indeed, even our esteemed health secretary Jeremy Hunt voiced tentative support for the principle as recently as last year. Fortunately, for those who find the concept of financially punitive measures for vulnerable patients abhorrent, the argument remains a lousy one.

The truth is simple: high DNA rates cannot solely be attributed to lazy, wasteful patients. The increasing prevalence of language like ‘inappropriate demand’, ‘misuse/abuse of the service’, or ‘time-wasters’ seems to be a symptom of fatigue caused by our spiralling workload. It’s easy to play the blame game and to bemoan the decline of modern society; it can be cathartic, too. It strikes me as far more constructive, however, to reflect on why patients fail to attend.

Read more: 14m appointments a year lost to DNAs

Like many practices struggling to cope with demand, we finally addressed the thorny topic of DNAs a few years ago. Experience of contacting patients who had failed to attend told us that patients had frequently recovered since they’d booked the appointment; sometimes they had deteriorated and were no longer well enough to attend; many others had simply forgotten.

The latter was easily addressed. An SMS reminder service was swiftly introduced at minimal cost, proving to be an immediate game-changer as our DNA rate plummeted. Maintaining up-to-date mobile telephone numbers for our patients is a constant challenge, but SMS messaging capability also provides benefits in terms of recall for chronic disease reviews and health promotion campaigns.

The problem of patients missing appointments due to a change in their condition proved trickier to solve. It ultimately boiled down to access; the longer the wait, the higher the probability of recovery/decline and of subsequent DNA. An evolutionary process eventually led to the creation of our own demand-led telephone-triage model, which prioritises both swift access and continuity of care. The vast majority of our patients are now seen within 48 hours at a time of their choosing, unless of course they specify otherwise.

Acceptable appointment times, a choice of clinician (if desired), shorter waiting times and SMS reminders have all but eradicated DNAs in our practice. Indeed, as a full-time GP it’s highly unusual for me to have more than one per week. Our patients are satisfied and our workload is more manageable than it was two years ago despite an increased list size.

The costs have been negligible; overall these interventions have helped us to save money. Crucially, no vulnerable patients have been harmed.  Until someone convinces me that a £10 fine can achieve these outcomes, I’ll continue to reject the policy as an insult to the very fabric of NHS primary care.

  • Dr David Coleman is a GP at the Conisbrough Group Practice, Conisbrough, South Yorkshire

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