In defence of the DNAs

Jim Pink; Elizabeth Ryan Harper

doi:10.3399/bjgp19X701549

Another day, another negative story about the NHS, broadcast on breakfast radio, at just the correct time to put my back up before even stepping into the surgery. Yesterday was about unacceptable waiting times in A&E, the day before about how we are earning too much money, and today it’s all about the patients who failed to show up for their appointments — the much maligned DNAs.

It seems that someone who isn’t busy seeing patients has found the time to count the number of appointments ‘wasted’ because of patients not turning up. The quoted figures came from West Fife where there were 252 DNAs in one week.¹ The report in question focused on the costs of these missed and cancelled appointments, and implored the public to attend the appointments they had made in order to prevent increased costs to the NHS. Other studies suggest that DNAs account for 10 million lost appointments a year.² Such figures are bound to raise eyebrows among managerial types. The drive for increased efficiency within the NHS is laudable, but we mustn’t forget that the NHS is one of the most cost-effective healthcare systems in the world.³ We can only squeeze the sponge so much.

FROM THE PATIENT’S PERSPECTIVE

Clearly, on paper, DNAs are a very bad thing for the NHS. Demand for appointments is overwhelming and patients not turning up leads to others having to wait longer. The frustration is understandable. As a GP partner, I know about distributive justice in the provision of healthcare services. But I also think the fuss about DNAs is missing two important points.

First, do we fully understand why patients don’t attend? Are these patients forgetful? Are they disorganised? Do they have a physical or mental impairment that prevents them from understanding appointment details? Has the problem gone away?

Has there been a breakdown in transport provision? Are they simply inconsiderate? Are they just scared? Perhaps there is a combination of the above.

For a recent minor issue requiring an outpatient appointment, I received two appointments with different specialists on different days for the same problem, both of which required confirmation via telephone during office hours. Having confirmed the correct appointment and cancelled the incorrect one, I still received an automated telephone message asking me to confirm the appointment that I had already cancelled. I am an NHS doctor, with intact faculties, but this is not the case for all of our patients. I’m not surprised some people either turn up to the wrong clinic, or not at all.

THE SILVER LINING

What can we do to help patients who struggle to keep appointments? The increasing trend for standardised letters from hospital stating that because a patient has missed their appointment they will need a re-referral from their GP is punitive to both the patient and primary care. It assumes that the only patients who don’t turn up are inconsiderate and completely ignores the multitude of other reasons why they may not have attended that day, while adding unnecessary additional workload for the GP.

Second, I don’t know of any doctor who hasn’t on at least one guilty occasion been delighted when a patient hasn’t turned up. This is because, throughout the NHS, demand outstrips supply, so clinicians constantly feel they have insufficient time to see patients, manage the clinical admin, deal with the bureaucracy, and develop services. Just as many hospitals are running on bed occupancy rates of greater than 100%, so too are many clinics being overbooked, or routinely running over time (as 10-minute appointments just really aren’t long enough). When faced with an overbooked, over-running clinic, a DNA can be a pressure valve: an opportunity to check an email or blood result, write a letter, chat to a colleague, look something up, visit the bathroom, sip a cup of tea, or, more likely, catch up on lost time. These 10-minute unscheduled mini-breaks may well be protective against burnout.

Recently, I was sitting at the dinner table with my two young children, and we all had a pleasant surprise when the children’s mother walked in: ‘Hello, darling. You’re not normally home in time for dinner.’‘No — I got away on time for once, as I had two DNAs!’

The NHS is a highly efficient healthcare system, and it is imperative that we keep it this way, but we mustn’t forget the dangers of improving efficiency. A little slack in the system is good for those who work in the NHS, and allows them to recharge their emotional and cognitive batteries once in a while. We are then able to ride out the bad days better. Aiming towards 100% efficiency in an already efficient system is only a good idea on paper. If we are able to reduce DNA rates to nil, we had better start thinking of alternative ways to decrease clinician workload, as currently the patients who don’t attend without cancelling may just be doing their doctor a favour, despite what the powers that be may claim.