David Oliver: Missed GP appointments are no scandal
BMJ 2019; 364 doi: https://doi.org/10.1136/bmj.l545 (Published 12 February 2019) Cite this as: BMJ 2019;364:l545
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David Oliver is right to challenge the dominant narrative surrounding the newly released data on GP appointments and the number of missed appointments.
The uncritical repetition of the estimated cost of missed appointments is naive and unhelpful. Missed appointments are a problem but simplistic cost estimates don't help anyone and don't point to solutions.
But Oliver falls into another trap. He (rightly) opposes the knee-jerk reaction of many commentators that sought to put the blame on feckless patients. He argues that many may have good reasons to miss appointments. But in looking at the justifiable reasons why patients might miss appointments he (along with many academics who have sought to explain DNA rates using health and socioeconomic factors) misses the single biggest cause of missed appointments in the data: GP behaviour.
In the 6 months of data where DNA (did not attend) rates are available (problems with the source systems muddied the results for the other 6 months) there is one single factor that completely dominates any explanation of the missed appointments: how long the patient had to wait for the appointment. For patients offered appointments on the same day fewer than 2% fail to turn up; but when the appointment is delayed until the next day the DNA rate goes to 5%; and when the appointment is next week or later it is 8-9%. So the number of missed appointments more than doubles if the GP can only see the patients the next day and nearly doubles again if the appointment is next week.
The wait for an appointment is such a big factor that it simply isn't worth even looking at the other factors if you want to tackle the problem. The problem is GP processes that are not designed to handle the majority of urgent requests on the same day. GP processes, not feckless patients, explain the vast majority of the problem. We won't fix this problem by fining or punishing patients: we will only fix it be encouraging GPs to design their processes so that most appointments can be handled on the same day.
It is simply astonishing that such a large and obvious factor in explaining the problem has been largely ignored by commentators and academics. Such is the strength of the idea that feckless patients cause the NHS problems that the system can't see the far bigger factor inside its own control.
Competing interests: No competing interests
GP clinics, at least where I work, are not booked on the basis that we assume some patients will not attend! If there are gaps, due to non attendees, then there is space to offer a little more time to everyone else without the doc and remaining patients feeling too stressed about it; but that's not the plan.
Competing interests: No competing interests
Unfortunately this theme of "scandal of Did Not Attends" has been repeated many times in the past. My favourite reply to the calls for charging patients is from @mellojonny https://abetternhs.net/2013/11/19/charging/
The recent BMJ sixty seconds on article sums it up nicely too: https://www.bmj.com/content/364/bmj.l69
Competing interests: No competing interests
Re: David Oliver: Missed GP appointments are no scandal
We agree that the 'feckless' patient story about missed appointments is facile and the common media response, often Draconian, is disappointing.
Moreover our recent research which analysed around 1/6 of Scottish GP patients data tells us it is downright dangerous.(https://doi.org/10.1186/s12916-018-1234-0 and https://www.bmj.com/content/364/bmj.l485)
Patients who have a pattern of missing appointments experience high socio-economic deprivation, have more long term health conditions, and patients with mental ill health who miss appointments have unacceptable premature mortality.
Practice characteristics are at least as important as patient characteristics in terms of frequency of missed appointments so we need to examine accessibility of services for this high risk group: https://doi.org/10.1016/S2468-2667(17)30217-7
The RCGP has used our evidence to rebut this media strategy and we would like to see others do the same.
Competing interests: No competing interests