PRACTICE MATTERS MISSED APPOINTMENTS
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DILEMMA M
Risk adviser Kay Louise Grant looks at risks associated with missed GP appointments and possible mitigation
ISSED general practice appointments are an enduring source of frustration to practice managers and indeed all primary care staff in the UK. Over 15 million appointments (around
one in 20) are missed each year in England alone, with an estimated annual cost to the NHS of around £216 million. Dr Richard Vautrey, BMA GP committee chair, recently commented:
“Every appointment at a GP practice is precious, especially at a time when GP services are struggling to cope with rising patient demand, staff shortages and inadequate budgets.” But missed appointments are not simply a matter of cost or
inconvenience – a recent study published in BMC Medicine linked DNAs (did not attend) with a higher risk of death in patients, particularly those with mental health problems. Data from 136 GP practices in 11 different health boards within Scotland revealed that “around five per cent of patients who missed more than two appointments a year over a three year period had died within a year of follow-up”. The cause of death was commonly “non-natural” and often suicide. This research suggests that even something as simple as a five-minute medication review could have significant implications if missed.
CAUSATIVE FACTORS Practices bear an obvious responsibility in ensuring patients do not miss appointments. MDDUS has seen an increase in claims being made against GPs where a missed appointment has played a factor in patient harm and sometimes in early/unexpected death. It is important you can demonstrate that you have given your
patient all relevant information relating to their treatment, including the risks associated with not engaging. GMC guidance on Consent states: “You should not make assumptions about: (a) the information a patient might want or need; (b) the clinical or other factors a patient might consider significant, or (c) a patient’s level of knowledge or
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understanding of what is proposed.” Patients with alcohol and drug misuse problems, or those with
cognitive impairment such as dementia, may lack motivation or capacity to cancel or rearrange their appointment. There may be other mental health issues, such as anxiety or phobias, that prevent patients from engaging. It is important doctors realise that their duty of care extends to ensuring that patients fully understand the reason for appointments and the consequences of not attending. Certainly, competent adults have a responsibility to ensure
they attend scheduled appointments – though there may be genuine reasons for non-attendance, such as being unaware of the cancellation process or simply forgetting. However, with vulnerable patients or those undergoing ongoing care for a chronic condition, practices are expected to be more proactive in understanding and mitigating any factors behind non-attendance.
PREVENTING DNAs Existing primary healthcare appointment systems may not be effective for everyone, and practices are being urged to develop interventions to reduce non-attendance. Obvious suggestions include ensuring you have up-to-date contact details for each patient and that they are aware of the importance of cancelling appointments they cannot attend. Practices and clinics should also review their policies and protocols for missed appointments and ensure that all staff are trained and clear on these. This should include a system which checks contact information and flags patients failing to turn up for review appointments, allowing clinicians to follow-up those that habitually do not attend or those at higher risk. Once the practice has taken measures to make contact with the patient and rearrange an appointment, it is important to keep accurate records of these steps and follow a set protocol of further
SPRING 2019 ISSUE 20
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