Intended for healthcare professionals

Opinion Primary Colour

Helen Salisbury: Zombie health policies and missed appointments

BMJ 2022; 378 doi: (Published 16 August 2022) Cite this as: BMJ 2022;378:o2001
  1. Helen Salisbury, GP
  1. Oxford
  1. helen.salisbury{at}
    Follow Helen on Twitter: @HelenRSalisbury

As reliably as the sun rising in the east and September bringing a new school year, in any discussion about the health service someone will raise the idea of charging for missed appointments. It’s such an obviously stupid proposal that I don’t think I need to rehearse the arguments against it here—but I will. Not for fun, but because we should recognise this for what it is: a dangerous and ideological attack on the founding principles of the NHS.1

Why do people miss appointments? Because they didn’t get the letter (our local hospital has absurdly outdated notions about the speed and efficacy of the postal service). Because they’re too ill to go. Because they’re having a mental health crisis. None of these will be helped by issuing fines. Perhaps a few people do decide, “You know what? I’d rather go down the pub than get my piles seen to,” but I honestly think that they’re a tiny minority.

And what will be the consequences of a fine? People for whom £10 is no big deal will continue as before, but the (quickly growing) number of people for whom it’s a significant proportion of this week’s grocery money may decide to never book an appointment unless they can guarantee that they’ll be well enough to attend. This is a way to bake in inequalities: punching down, rather than levelling up. We want the NHS to major in preventive care, but this would be one more disincentive for people to arrange a blood pressure check or diabetes review, or to consult about that cough that just won’t go away. More treatable conditions will be missed, discovered only when patients arrive in the emergency department with advanced disease.

Practically speaking, this idea is a non-starter. Sources close to the wannabe prime minister Rishi Sunak (the latest politician to make this daft proposal) admitted that it would be up to GPs to decide who would be fined, making exceptions for people who were vulnerable or had good reason to miss an appointment.2 Because, of course, we GPs know exactly whose baby cried all night so that they couldn’t sleep; who has an unreasonable employer who changed their mind about giving them time off; and who is merely being selfish and thoughtless. And as the patient clearly isn’t there, how exactly do we charge them? Is Sunak suggesting that we should ask for patients’ bank details when they register?

Most worryingly, this policy is an attack on the fundamental principles of the NHS. Care is given according to need, publicly funded, and free at the point of use. Once the cash registers are installed in GP clinics we’ll be on a slippery slope that ends where NHS dentistry now finds itself—defunct.3