Missed outpatient appointments

Dr Murdock and his colleagues (June 2002 JRSM¹) think that an important reason for the 14% non-attendance rate in their clinics was patient apathy. I found a similar rate in an inner-city general practice, audited as part of my final year studies. Of 7282 patients given appointments in the year to March 2001, 1032 (16%) were either late or did not attend. The average appointment was ten minutes; and, if there was no other useful activity when an appointment was missed, the time lost to the practice in a year would have been 172 hours. The running cost of the practice, excluding prescriptions, was about £20 per appointment. If there are 38 000 general practitioners in the UK and each sees 8000 patients a year, and if we take a conservative non-attendance rate of 10%, the annual loss to the National Health Service comes to over £600 million—to be added to the £300 million wasted on missed hospital outpatient appointments.

The solution proposed by Murdock and colleagues is overbooking—as used by many airline companies and hotels to make up for anticipated non-attendance. The difference is that they are dealing with customers who have already paid for their service directly. I feel a more fruitful way to encourage attendance would be to instigate a system of fines for non-attendance. The fine, which might be £10, could be avoided by cancelling within 24 hours, thereby giving the practice time to find a replacement patient. It is impossible to say how much extra revenue would be generated nationally by the system, since we cannot predict how many people would cancel appointments and how many would pay the penalty. Some other questions would arise—for example, should fines be means-tested? Is £10 too much or too little? How should any such payment be made? Who exactly should coordinate penalty fines? Where should the proceeds go? Should the outpatient department or general practice make ‘reminder’ phone calls if possible? Should any group of people be exempt (e.g. the homeless)? Should the penalty be increased if not paid promptly (as happens with parking fines)? What form should an appeals system take?

This system of fines would not compromise the ethos of free healthcare at the point of delivery, nor could it be condemned as a ‘stealth tax’ since the fine is entirely avoidable. Many other institutions impose fines for rule-breaking—for speeding, for late return of library books—and these seem to work. The general public might support the scheme since most people do keep their appointments and are paying through their taxes for those who do not.