Patients who repeatedly DNA – do they need us the most?

How do you view DNAs? What do you do with the time you gain when a patient fails to appear or doesn’t answer their phone? Is it a chance to claw back some of those minutes you’re overrunning by…Make a dent in the overflowing pathology inbox…Maybe even grab a much-needed cuppa? All actions I can completely identify with, but as a recent editorial in the BJGP points out, perhaps DNAs should be seen as missed opportunities. Missed opportunities to help who could be the most vulnerable patients booked in to see you all day.

Missingness has been defined as the “repeated tendency not to take up offers of care that has a negative impact on the person and their life chances.” As the editorial points out, high levels of missed appointments (defined as missing 2 or more appointments a year average over a 3-year period) are a proxy for poor health and social vulnerability. These patients are more likely to have suffered an adverse childhood experience, have reduced school attendance, have more long-term conditions and suffer from socio-economic deprivation. Practices in relatively wealthy areas are not off the hook - patients living in pockets of deprivation in affluent settings were at the highest risk of missing multiple appointments. All interesting statistics, but what makes them important is that patients who miss a lot of appointments have significantly higher all-cause mortality rates than those who don’t. If this is coupled with a mental health diagnosis, they are eight times more likely to die prematurely. I realise that this might feel like yet another thing to add to the very tall pile that overstretched GPs need to consider, but are there some simple things we can do that could help to reverse at least some of this inequality?

First thing to consider is your DNA policy. What do you do when someone fails to turn up or answer their phone? Is everyone doing the same thing? Have you got the right contact details for the patient? Is there someone else you could call like a carer or a support worker? Is there someone in the practice who could actively track down a serial DNA-er? Is this a role for your social prescriber, a motivated receptionist, or a keen medical student?

Is your surgery environment empathic to those vulnerable patients who actually make it through the doors? Patients suffering with their mental health might not respond well to posters detailing how they are going to die quite soon if they don’t have a vaccine/lose weight/stop smoking/attend screening. Angry or frustrated patients are unlikely to be calmed by prominent “zero-tolerance” posters. Positive messages, welcoming staff and a calming environment are more likely to increase engagement.

What about your appointment system? Navigating the system can be particularly difficult for people from inclusion health groups. Austin O Carroll is founder of the North Dublin City GP Training programme, specifically training GPs to work in areas of deprivation and with marginalised groups. In his excellent TED talk “Medicine on the Margins”, he describes the difficulty people experiencing homelessness have with appointments. They lead chaotic lives, don’t have diaries, change their phones regularly and don’t have an address to receive appointment letters. Having a flexible system can help here – don’t penalise vulnerable people for being late for their appointment. Work with local support workers to offer direct access to protected appointments and think about offering longer appointments for patients with complex needs. 

All of this takes work of course and I’m not saying any of this is easy. So much of what we do in general practice is difficult and yet we do it. Finding the missing is one thing that could be worth the effort.

Have you had any success tackling missingness in your practice? Why not share your ideas on NB On Call – the closed, private and supportive forum for professional discussion between GPs. For more information and to register, click here.