I was meant to be seeing a patient this morning, but she’s not turned up. In doctor speak she ‘DNA’d’ – did not attend.
It’s not easy going to the doctor, especially when the doctor is a psychiatrist. People think that going to a psychiatrist makes them ’mad’, and other members of their family may tell them not to go. There’s also a strong association with psychiatrists and being ‘locked up’. Worse still, when they do pluck up courage to go along to the appointment, they get asked all sorts of nosey questions, which can be taken in a way not intended. This is particularly acute with child and family services where questions about parenting can be interpreted as accusatory.
I’m pretty philosophical about all this; this sort of attitude is necessary to do a job where most of your patients don’t want to see you and some don’t even think that they have a problem. But in less charitable moments I do find myself wishing that more of my patients would call to let me know that they’re unable to make it so that I could plan do to something else. So many of my patients have DNA’d recently that I’m completely up to date with my paperwork, which is why I’m writing this post.
When I was a student and had nothing to do I’d sit around and do the crossword (the quick one). Crucially for the NHS I was doing this for free, with the understanding that someone would give me a job at a later date. That time has come, and tax payers are now paying for these missed appointments. The most recent data that I can find on the total cost to the NHS is from an article in the Telegraph from 2005. Which suggests that DNAs cost almost £200 million in 2004, and the total cost of missed appointments was £575 million. Regrettably it doesn’t quote its sources and if anyone knows how I can get hold of this data please let me know. MP Grant Shapps gave a speech on the subject in May 2006
The article says that in 2004 there were 5,707,288 missed appointments in the NHS. Of these approximately one-third are ‘no shows’/DNAs, one third are cancelled by patients before the appointment and the remainer are cancelled by the hospital. It seems that in two thirds of cases of DNAs patients simply forget about their appointments. A smaller percentage, roughly 25%, feel better and do not turn up, without informing the hospital.
It’s not an original point to make, but the ‘free at the point of delivery’ philosphy of the NHS is both its greatest strength but also its greatest weakness. Things that are not paid for have no value.
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I have an impressively low DNA rate. In the last 6 months I only had one person DNA. The six months before that, zero. Not bad at all. I’d like to say it’s because I’m such a wonderful empathic clinician, but I think it is a combination of well selected referrals from my supervisors’ perspective and a good habit of making therapy contracts.
I don’t think it is a good idea to be too philosophical about it. Yes, DNAs are inevitable – perhaps much moreso for psychiatry, but I think that there’s a lot that can be done to make things easier for people. In a service I used to work in, well over 50% people were DNAing on first appointments. People didn’t tend to DNA after that – once they started coming, they seemed to like us. So we pulled all the stops out in making first appointments easier. We rang people beforehand to arrange an appointment at a mutually convenient time (no excuses) and we got a clinical team member to do it, not a secretary so they could establish contact and let the person realise that we’re pretty nice really and we were able to explain what would happen if the person was very anxious. Anything to make the initial appointment less intimidating. DNA rate dropped to about 5%.
That’s interesting. I thought about calling people, but then I thought it might intimidate people who would rather I left them alone. Also I had one or two experiences when I was a house officer where I called people who then started to ask me questions about their problems that were very difficult to deal without a face to face meeting; this put me off calling patients unless I had met them first. Perhaps it’s time to reconsider.
If you charge for appointments, won’t it just deter people from agreeing to see a psychiatrist in the first place? People that are unhappy about going to see a psychiatrist will find it an easy excuse not to go. I’ve only ever DNA’d once, and even then, I got as far as reception at the CMHT before doing a runner, but I have attended many, many appointments when I didn’t want to see a psychiatrist. If I’d had to pay, I’d have refused to co-operate at all.
I have no doubt that there are issues around calling people. If you do it in a nice way, most don’t mind. If someone DNAs, I might call and say, “I’m just calling to check everything is ok” not “Where the hell where you, you waster of NHS resources.”
I’ll also get them to agree to an appointment time that suits both of us. And of course you must have a policy about what to do if someone tells you about their difficulties over the phone. I would probably tell them that it sounds like they’re having a difficult time but in order for me to be of help to them, we’ll need to discuss it in person, not over the phone. Then I’d make a note in the file to remind me to ask at the appointment. I haven’t found that to be an issue.
However, opinion amongst psychologists on this is very divided. Some would say it is a boundary issue and that we shouldn’t be drumming up business. Others (and I am amongst them) think that we need to go the extra mile to make services more accessible for people who find it really difficult to come.
I think when you’re working with people who are intimidated by services, anything that helps to establish person to person contact and allows them to hear a friendly voice rather than an impersonal letter with an intimidating sounding name with Dr. is likely to make showing up to that first appointment a lot less frightening.
If I am working with someone who DNAs a lot, I don’t call, I make a therapy contract which says (in a nice way) that if one of us needs to cancel, we’ll let the other one know as soon as convenient and that if they miss, then I won’t call them or send an appointment, but they can call me and re-establish contact within 2 weeks. It is a nice way to give them responsibility and means I know what to do if they miss.
Then again, seeing a clinical psychologist is always optional. No-one has to see me – I imagine as a psychiatrist, there are more tricky issues to get around.