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Live and learn blog

Why the no-show?

‘These two have DNA’d’.

The clinic nurse slaps down two heavy sets of notes on my desk, the ones belonging to the patients who have missed their OPAs (outpatient appointments). Now I’ve got to decide whether they should get fresh appointments or not. But why didn’t they come?

If they are new, there is always a question as to whether they got their appointment letters on time. And the more urgent the appointment, the less notice they will have had of it. Conversely, if people wait too long for their OPAs, aren’t they more likely to forget about them?

What about follow-up patients? What if they don’t come to clinic?

The literature confirms that forgetting an appointment is the number one reason for non-attendance. Illness, work problems and recovery from the condition are also possibilities.

But what about more subtle factors, and those that are potentially immeasurable? What if the patient felt that the follow-up wasn’t really necessary? Was I too cautious to bring them back again? Should I have just bid them adieu at their last appointment? Did the presence of the medical students put them off? What if the patient just didn’t like me?

Of course, if patients don’t come to clinic, there is a good chance that you never find out why. Very occasionally, when I’ve had time and there was clinical need, I’ve tried to phone my non-attenders at the end of clinic.

The first patient I telephoned was an older woman. Her son answered the phone. He was rather pleased to hear from me. She didn’t come for her appointment as she was in hospital with a broken hip.

Then there was the patient who couldn’t make it through the snow, but was worse and would definitely like to be rebooked. And there was the young man who forgot his appointment because he was too busy at work – and too busy to speak to me when I called.

From my general observations, young men are the most likely to fail to attend clinic, and a trawl through the trust data confirms this. I analyse and present the factors associated with non-attendance to my colleagues. Given the demographic profile of non-attenders, I suggest that targeting these patients with modern technologies, such as SMS text messaging, might be appropriate to reduce non-attendance rates.

While I have presented DNAs in a completely negative light, my presentation has had a mixed reception. My colleagues’ reaction confirms what I already suspect. Most of us are secretly glad of the unscheduled gap in our already overbooked clinic. A non-attendance provides a welcome chance to dictate a couple of letters or simply to catch up.

‘Reduce DNAs?’ cries a colleague in surprise, ‘but we need a few DNAs to be able to get through our clinics on time’.

Of course she is right. My clinics are probably booked on the assumption that there will be a couple of DNAs each week. When everyone turns up, I run half an hour behind schedule.

Susannah George is an ST4 in dermatology in Brighton