David Oliver: Missed GP appointments are no scandal

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.