Outpatient appointment no-shows cost hospitals £600m a year

Missed outpatient appointments cost NHS hospitals in the region of £600m a year, data from Dr Foster Health and the NHS Information Centre have revealed.

Men in their early 20s are the worst offenders for appointment no-shows, while patients of both sexes aged 70 to 74 years are the most conscientious about keeping an appointment.

The total average income of a first outpatient appointment to an NHS hospital is £156, while income generated by second appointments averages out at £76. In 2007/8, 6.5 million appointments were missed in the UK, with hospitals losing around £100 per patient in revenue.

To cut down on the numbers of missed appointments, the NHS launched the Choose and Book initiative in 2006 as part of the Free Choice government policy introduced in April 2008.

The new system allows GPs to offer patients a choice of times and places for their outpatient and other treatments. Technical glitches with the related software however have delayed the roll out of Choose and Book.

Cost to the NHS

The graph below (figure 1) shows the cost to each Strategic Health Authority (SHA) in Britain for total no-shows of outpatients to their hospital appointments in the 2007/8 financial year:

Figure 1 - Did not attend (DNA) cost 2008/9 financial year

Regulatory viewpoint

Outpatient Did Not Attend (DNA) rates vary between hospitals, regions and medical specialty. Current opinion is that DNA rates can be reduced by reviewing appointment and other procedures from the point of view of outpatients.

The Care Quality Commission (CQC) assesses individual NHS Trusts on the basis of their DNA rates ⁽¹⁾ and has stated that large numbers of missed appointments may indicate poor provision of community services. High DNA rates may also be an indicator of inappropriate referrals and reflect the quality of the interface between primary care (GP surgeries, clinics, Primary Care Trusts) and secondary care (hospitals and NHS Trusts).

Why do patients miss their appointments?

Studies investigating why people do not attend their outpatient appointments have revealed a number of possible reasons.

A 2004 US study identified three types of issues related to missing appointments without notifying the clinic staff ⁽²⁾:

1. Emotions - fear and anxiety about both procedures and bad news
2. Perceived disrespect by the healthcare system
3. Not understanding the scheduling system

A 2005 UK study found that patients who missed appointments tended to cite practice factors and their own forgetfulness as the main reasons for doing so. Most attend within three months of a missed appointment ⁽³⁾.

Which patient groups are not attending?

The graph below (figure 2) shows the proportion of patients by deprivation level who did not attend their first and follow up outpatient appointment. The largest group of no-shows were patients identified by the highest level of deprivation. As patient deprivation decreases, the likelihood that they will attend their first and follow up outpatient appointments increases:

Figure 2 - DNA rate by social deprivation for appointments in 2007/8

The following graph (figure 3) reveals the highest no-shows to be in younger age groups. As patient age increases, there is less likelihood of them missing an appointment. The increase in missed appointments in the older age groups may be due to other existing health issues or transport difficulties from care homes to hospitals.

Figure 3 - DNA rate by age group for appointment in 2007/8

Overbooking and fines do not work

Some clinics in the UK are over-booking patients in anticipation of no-shows ⁽²⁾. Such an approach however does not solve the problem of increasing DNA rates and can create knock on effects. For example, hospitals who over-book may put patients at a disadvantage if there is a 100 per cent turn-out ⁽⁴⁾.

Other solutions to the problem have been mooted in the past, such as fines which could be avoided by cancelling within 24 hours, thereby giving clinics the time to find a replacement patient.

However, penalty systems have associated problems with administration - means testing of fines, how to enforce fine payment, fine exemption and appeals systems - which is why such a proposal has met with little enthusiasm ⁽⁴⁾.

Choose and Book to the rescue

Choose and Book is the NHS' electronic booking system for first outpatient appointments in secondary care and was formally launched in January 2006 after an initial 2004 pilot study.

Barring certain exceptions, all patients requiring elective treatment should be offered the choice of at least four providers, once their GP has decided a referral is required ⁽⁵⁾.

Choose and Book is a key project within NHS Connecting for Health and is central to the government's Patient Choice agenda. By phoning an appointments line, booking over the Internet or booking at the GP surgery, patients can choose the time, date and place for their appointment.

Choose and Book also furnishes a choice of appointment date and time, which is the central element of the business case for electronic booking.

Since April 2008, the scheme has been further expanded with the Free Choice policy under which most patients should be able to choose from any secondary care provider (NHS or independent sector) across England.

Has Choose and Book been successful?

As of April 2006, Choose and Book had been used for 261,983 bookings, or 12 per cent of the total. It is estimated that bookings are growing by at least 40 per cent per month ⁽⁶⁾.

The take up of the system at that time was estimated to be a year behind schedule, due in part to the extension of the scope of the originally designed e-booking system to support patient choice when referred by their doctor.

While individual case studies have reported reductions in DNA rates due to Choose and Book, a small-scale 2006 Patient Experience Study at University College London (UCL) found that approximately two-thirds of patients at Hillingdon Hospital were not given a choice of date for their outpatient appointment, while another two-thirds said they were not given a choice of appointment time ⁽⁵⁾.

Eighty-six per cent of patients were given a choice of fewer than four hospitals, while almost a third said they were not given a choice of any hospital. Just one of the 104 patients surveyed said they had been offered a choice of four hospitals, appointment date and time.

An NHS Connecting for Health spokesperson argued the UCL study was out-of-date, and that its findings had been superseded by the larger National Patient Choice Survey (2008) ⁽⁷⁾.

Study leader, Dr Henry Potts, conceded that there had been some improvements with the system, but argued the National Patient Choice Survey (2008) also found that just 46 per cent of patients recalled being offered appointment choice ⁽⁸⁾, backing up the UCL study findings.

Dr Potts added, however, that there remained issues that Choose and Book could not solve, especially around what choice was available in the healthcare service without having a considerable oversupply.

Potts concluded that the economic situation was that the choice offered was not feasible and that giving people false choice was never going to solve the problem of non-attendance.

Do alerts and reminders work?

Reminding patients about their hospital appointment via SMS, email or other means has shown some success or is being piloted at certain NHS Trusts, including the Royal Berkshire NHS Foundation Trust and the Royal Cornwall Hospitals NHS Trust.

An SMS alert service has helped reduce missed appointments at Hull & East Yorkshire Trust's Women and Children's Hospital Paediatric Outpatients Unit. The installed software at the hospital allowed text messages to be sent quickly and easily from a PC, either in bulk or to individual telephone numbers.

Of a sample of patients who were asked whether or not they would be happy to receive this type of reminder, over 90 per cent said they would like to, reflecting that in many cases patients just forget their appointment.

Paediatric Services Manager at the hospital, Jackie Timson, said of the reminder initiative: "During the last three months, we've experienced a noticeable drop in the number of patients who haven't attended appointments."

"Because we're continually introducing new initiatives to bring the number of missed appointments down, it's difficult to say how much of this improvement can be attributed to the reminder system and how much to other activities we're undertaking, such as changing the way we book appointments in the first place," explained Timson.

She concluded: "However, because improving the health and wellbeing of children is so important, we need to use the full range of tools at our disposal to address the problem of missed appointments" ⁽⁹⁾.

Can hospitals reliably predict no-shows?

Previous studies have shown that targeting adolescent and young patients can effectively help reduce appointment no-shows.

A 2008 study looked at the possibility of predicting the risk of an adolescent patient missing an appointment, based on previous appointments and on the characteristics of the patient and the appointment.

The findings showed that patients who had already defaulted also had a higher risk of missing their appointment a second time. The researchers concluded that hospitals should focus on defaulters to decrease the associated workload and that various reminders could be a solution for the follow-up appointments scheduled with a long delay ⁽¹⁰⁾.

Correctly identifying no-show risk among patients and targeting reminder services to those groups may offer a solution to the numbers of missed appointments and reduce the financial burden among hospitals which experience high levels of no-shows.

Dr Foster Risk Model helps identify potential appointment defaulters

Dr Foster has developed a Risk Model to predict the likelihood of which types of patients will not attend their outpatient appointments.

The Model can effectively help NHS Trusts accurately predict which patients will be more likely to default on their appointments and target these specific groups for prevention measures.

As young males often tend to be the commonest no-shows for outpatient appointments, counteractive strategies such as text or email alerts can be instituted to remind these patients about their appointments, reduce DNAs and reduce the pressure on hospital budgets.