Charging patients who Do Not Attend (DNA)

Patients should not be charged for failing to attend appointments.

 Originally published in Pulsetoday 

The introduction of a fine, either in terms of a refundable fee for making an appointment or a charge after non-attendance is an example of a zombie policy. Zombie policies, like user-charges for healthcare are repeatedly resurrected and killed.

The point about zombies is that no matter how many times we kill them they keep coming back. No matter how heavily armed I am with evidence or how deadly my arguments I will not kill them for long. Never mind for that matter, how loosely assembled the zombies are; their limbs may fall off with a slight tug or a casual wallop with a shovel, or they auto-decapitate with an accidental bump on a low doorway, they rise up again with a single brainless purpose, “we … will … punish the non-attenders… ”

Evidence for the effectiveness or even cost-effectiveness of zombies in reducing the numbers of DNAs is lacking. Evidence of cost-effectiveness for most health interventions is lacking, so perhaps it’s unfair to pick on zombies. Evidence for the health gain achieved by introducing zombies is also lacking. Ditto many health interventions.

Zombies and zombie policies nevertheless have a cult following. Some evidence comes from a government e-petition set up last year which ‘suggested that patients who DNA “should be given a small fine such as £30 or £50 – this will encourage patients to attend appointments or cancel them if they don’t need them.”The overwhelmingly enthusiastic respondents who have commented raise another important zombie theme, moral outrage. Moral outrage is usually more apparent when there is no evidence to be debated.

According to the comments after the e-petition, patients who DNA are “time-wasters”, “abuse the system”, “inconvenience other patients”, “don’t care”, “cost millions” and so on. A few people tried to raise concerns about the poor, vulnerable, elderly, forgetful and so on, but were outnumbered by those cheering for the zombie-policy.

Perhaps the most thoughtful analysis of why patients do not attend psychiatric outpatient appointments concluded that, “Low and high illness severity predict non-attendance. In other words the most common reason for not attending a first appointment is feeling better but the most serious is feeling too unwell”[i] Patients with mental health problems are the most frequently encountered in general practice, accounting for 30-40% of all appointments. In deprived areas, rural and urban, the proportions are higher. In other words, Zombie policies are a good way of impoverishing people with mental illnesses that are having a bad day.

Armed with this knowledge, a more humane response to a patient who fails to attend would be to phone them up and ask them if they are ok. Patients who are contemplating suicide might discover the will to live, and patients who forgot might be invited in to discuss their failing memory, or otherwise feel adequately chastised that they don’t do it again. If you take continuity of care seriously, then the patient will have their own doctor and a call can be a powerful force for good. But is it an evidence-based intervention for reducing patient DNAs? Who knows? We also have a range of other interventions including texting, emailing, not booking appointments too far in advance, allowing patients to choose times that are convenient for them, and so on.  An appointment system called “Patient Access” claims an 80% reduction in DNA rates as well as fewer A&E attendances, reduced doctor stress and lower patient waiting times.[ii]

But zombies are brain-dead and cannot be fought with arguments about making things better for patients. For them, the fundamental point is that, ‘patients who do not attend are bad, and need to be fined’. Theirs is a moral vacuum, a market society where money governs social relations.

The final zombie-lesson and the reason we cannot kill them, is that they are a reminder of what we have ourselves become; the zombies represent us. Too many doctors are in survival mode, unable to think beyond protecting themselves from a demand they cannot meet and expectations from patients and politicians they cannot satisfy. Zombies are an expression of our brain-dead selves when we are feeling overwhelmed and bunt-out and want to scream, “I just can’t take it any more!”