Introduction

In a letter to integrated care board (ICB) and trust chief executives, NHS England highlighted the need to reduce instances where people miss their outpatient appointments (‘did not attends’ or ‘DNAs’) to improve patient experience, free up capacity to treat long-waiting patients and support the delivery of the NHS’s plan for tackling the elective care backlog.

In children’s services, DNAs are commonly referred to as ‘was not brought’. For ease, throughout this guidance we will refer to these as DNAs, but in most instances the same principles apply to both.

Of the 103 million outpatient appointments booked in 2021/22, 7.6% ended in a ‘Did Not Attend’; this equates to an average of 650,000 monthly appointment slots.

All groups should be given equal opportunities to access healthcare and as with any type of healthcare, outpatient care should not be ‘one size fits all’. By understanding the many causes behind DNAs and working to reduce them, systems and providers can ensure appointment slots are not wasted.

Many of the same actions can also support patients to take control of their care and reduce health inequalities. It is therefore crucial that systems and providers take appropriate steps to ensure they are not exacerbating health inequalities when managing their approach to DNAs.

There are many reasons why people may not attend an appointment. Many of these are outside of their control. Most providers will have worked on reducing their DNA rates previously. Now is an opportune time to revisit and refresh this work:

• Data shows that there remains considerable opportunity to do more to tackle DNAs.
• Examples from providers show that substantial reductions in DNAs can be delivered within weeks and months, making this a fast and important measure all providers can implement to support elective recovery.
• Prior to the pandemic, many services implemented strategies such as overbooking clinics to make up for the predicted percentage of DNAs. However, changes to infection prevention and control policies have limited how many patients can stay in a waiting area at any one time, making this more difficult.
• Digital solutions such as patient portals are a key enabler for reducing DNAs by providing a route for accessing and sharing patient information electronically, freeing up clinical and administrative time, enabling patient education and encouraging patients to be active participants in their care.

As a minimum, all providers should use appointment reminders (e.g. via SMS) and offer patients an easy option to cancel and rearrange appointments if they need to.

This guidance builds on experience from providers and systems and previous work by quality, service improvement and redesign. It outlines initial steps providers should take to reduce their DNA rates, through:

• defining DNAs
• highlighting the main causes of DNAs
• listing the first actions providers should take to reduce their DNAs
• highlighting the benefits of reducing DNAs
• highlighting implications on health inequalities when reducing DNAs
• explaining how to measure DNAs
• highlighting risks and mitigations related to reducing DNAs
• case studies and support resources.

Future practical tools and support will be available as part of this focus on DNAs, drawn from current practical work and experience in providers.

This document focusses on acute settings, although many of the same principles apply in other settings including diagnostics, primary, community and mental health.

Causes of DNAs

Existing literature emphasises that non-attendance is a complex problem. However, most research and actions taken by providers focus on changing the behaviour of the patient to address why they have missed an appointment. This approach does not address any broader reasons that may be at play.

Patients have told us that when they miss an appointment, it often stems from difficulties with processes and communication. They also told us they were more likely to miss an appointment if they had a poor experience of attending a healthcare appointment previously.

Providers should look at a combination of factors around patient characteristics and the healthcare setting to understand why patients might miss their appointments:

Reasons for DNAs within patients’ control include:

• Patient has forgotten about the appointment.
• Patient has not attended because they felt they no longer needed the appointment.

Reasons for DNAs outside of patients’ control include:

• Patient unaware of appointment.
• Unclear, inaccessible or incorrect appointment information given to patient.
• Patient unable to attend but has difficulties cancelling or rearranging their appointment.
• Appointment booked a year or more ago and patient not given a more recent reminder.
• Difficulty taking time off work (particularly when face-to-face appointments are offered as the only option).
• Transport issues.
• Difficulty arranging carers at the time of the appointment (either for the patient or for people they care for).
• Cost issues.
• Limited clinic hours making it challenging to find a suitable time to attend.
• Patient has not been brought to the appointment by a carer or guardian responsible for their care (‘was not brought’).

Reasons for DNAs can vary substantially between organisations and regions. To successfully reduce DNA rates to support elective recovery, organisations will need to understand the local reasons behind their DNA rates, the relationship with health inequalities, and the effect of the COVID-19 pandemic.

Initial actions providers should take to reduce DNA rates

Most providers have already worked on reducing their DNA rates. As a first step we therefore recommend that providers review any previous work they have done on this, alongside looking at how they compare to other similar providers through the data presented in the Model Health System outpatient compartment.

Based on examples and feedback from providers and other stakeholders, we recommend you consider the follow actions as ways to reduce your DNA rates:

Sending appointment reminders to patients

Reminders include letters, SMS and phone calls. Sending reminders has been shown to reduce DNAs by up to 80%.

Providers have told us that they see better results when communication is ‘two way’ (i.e. patients can reply to cancel their appointment), and patients also told us that they like this.

Organisations should ensure appointment letters and reminders are written in simple language and are accessible to the individual patient, for example in Easy Read formatting. Information should include what the appointment is for, with what service, and should include service contact details.

Improving contact access and cancellation/rebooking processes

It is important to allow patients to cancel or rearrange their appointments easily. Providers also need to have reasonable and flexible call times – i.e. patients are able to call outside of the standard 9am-5pm and the call is answered quickly or has a voicemail service. They should also offer other methods to cancel, such as via a patient portal or two-way messaging service. Local care co-ordinators may be able to support with this.

Improving booking processes

Do not book appointments too far in advance; instead using partial booking processes. Also, standardise booking processes across specialties/departments to make booking appointments more straightforward for patients with multiple conditions. Consider offering the option of evening and weekend appointments if capacity allows.

Implementing digital enablers

Continue to offer remote consultations when appropriate, and the use of patient portals with appointment reminder and booking functionality, which can give patients more control over booking and cancellations. Work on digital enablers to review and overcome barriers.

Senior awareness

Review DNA rates and clinic use and build into regular service reporting.

Provider access policies

There should be a clear process to follow when a patient does not attend and cannot be contacted, to decide on next steps. It is important that this remains a clinical decision.

Further information on reasonableness can be found in section 7 of NHS England’s guidance on recording and reporting RTT waiting times for elective care.

Safeguarding policies and procedures

In the case of children, young people and vulnerable adults, not being brought (‘was not brought’) to an appointment could signify potential safeguarding concerns. For these situations, providers need to ensure they have appropriate safeguarding procedures in place. See the Sherwood Forest Hospitals NHS FT example.

Providers can also refer to the checklist in Annex 1 for a quick review on their services and the most effective actions for reducing DNA rates.

Benefits of reducing DNAs

Reducing DNA rates will have the primary benefit of better patient experience. However, reducing these rates will also help with a variety of other issues, including:

• releasing capacity which can be used to clear backlogs and reduce waiting times
• predicting demand for clinics improving this and leading to fewer overruns
• patients receiving the care they need how and when they need it
• improving administrative processes and communication with patients
• allowing care to become more personalised and empowering patients
• reducing unnecessary follow up appointments by understanding when patients feel they no longer need an appointment
• reducing health inequalities through understanding issues faced by particular demographic groups
• improving the efficiency of resource allocation by systems and therefore improve how providers can use their capacity to deliver care. Further information on cost implications can be found on our website here: National tariff payment system documents, annexes and supporting documents.

Case studies

See below for a list of case studies showcasing the impact of successfully reducing DNA rates in different services. These are local examples that you may want to explore further, they are not recommendations of specific software or providers, and the analysis represents local estimates of impact.

• e-Consult: How much money could the NHS save by reducing outpatient DNAs
  • Estimated that by reducing outpatient appointment DNAs to 2%, the NHS could save £266 million.
• NHS trust cuts DNAs by 80% with efficienC from Wellbeing software
  • Main changes included text message appointment reminders sent seven and three days prior to appointment.
  • Response rate of 82%.
  • Staff manage responses to text messages from single dashboard.
  • System resulted in 282 cancelled appts, which could have been DNAs.
• North Lincolnshire reduce DNAs with help of GP Connect
  • Reduction in DNAs from 12.6% to 1.2%.
  • Talked to patients to understand why they DNA – largely due to restricted opening hours and travel from rural areas.
  • Community based local hubs were introduced to provide choice of clinics closer to home with extended opening hours.
  • GP Connect enabled easier and less costly answer to the issue.
• Reducing DNA rates at the Royal Orthopaedic Hospital (DrDoctor)
  • 35% reduction in DNAs – from 10.9% to 7.1% within nine weeks.
  • £100k projected annual savings.
  • Nine-week rollout time of appointment management – patients receive text message reminders and have access to an online portal where they can view/reschedule their appointments online.
• Patient-led booking system at Guys and St Thomas’ (DrDoctor)
  • Estimated £2.6m financial savings by improving the appointment and scheduling platform.
  • 1% reduction in DNAs over 6 months – from 117% to 10.4%.
  • 91% of patients asked recommended the new appointment communication stream.
• Equalities: Planned care analysis (Royal Cornwall Hospital NHS FT)
  • Patients within the lowest two deprivation deciles remain most likely to DNA outpatient appointments.
  • Although the variation is smaller, DNA rates are shown to be higher for BAME patients than for white.
  • The trust is regularly monitoring its DNA rate for different deprivation deciles.
• Patients engaged with portals are less likely to miss appointments (Patient Knows Best)
  • 39% difference in DNA rates between registered and unregistered patients.
  • The 39% difference equates to over 45,000 reduced DNAs, measured across an 18-month period.
  • For most of these organisations, there has been minimal/no transformation or change management needed to achieve these results

Reducing the impact of DNAs and last-minute cancellations

It is important to have processes in place to reduce the impact of any DNAs or last-minute cancellations, to make the most of valuable clinical time:

• Implementing a ‘short notice list’” so that any last-minute cancellations can be used by people who are able to attend without prior warning, eg hospital staff.
• Using clinical time lost to DNA for other high priority activities, such as:
  • waiting list validation
  • reviewing patient notes for people booked into future clinics to see if those appointments are still needed
  • responding to requests for specialist advice.

Health inequalities

All groups have equal opportunities to access healthcare. As with any type of healthcare, outpatient care should not be ‘one size fits all’ but should be adjusted to meet the requirements of everyone who uses it.

People in some groups are generally more likely to miss their appointments; for instance, Royal Cornwall Hospitals NHS Trust found that the 10-20% of their patients from the most deprived backgrounds were most likely to miss an outpatient appointment.

Systems and providers should therefore take appropriate steps to ensure they are not exacerbating health inequalities in relation to their approach to managing DNAs. Steps may include:

• Completing a local Equality and Health Inequalities Impact Assessment (EHIA) for outpatient services
• Continued engagement with patients
  • This should take place across a representative cross-section of patients and communities to understand how services are working for them; the reasons behind DNAs; actions the organisation could take to address this.
  • For example: do patients feel they can access appointments and clinics easily; would they like more support to attend appointments; do they know what support is available?
  • It is important that this engagement includes patients who may not ordinarily be consulted with, and those with lower health literacy. By engaging with patients and understanding the reasons behind DNAs, North Lincolnshire Clinical Commissioning Group managed to reduce their DNA rates by 90%.
• Build in options to capture patients’ preferred means of communication, appointment times and appointment types
  • For example, remote consultations rather than face-to-face
  • Information should be provided in a way that suits patients (eg available in different languages and in easy read formats) and link to local shared care records where possible.
• Assess your organisation’s local levels of digital literacy and how this may be affecting your DNA rates
  • For example, if patients can only cancel or amend appointments by sending links via text message, this does not take into consideration those without a mobile phone.
• Linking in or referring to local safeguarding team when appropriate
  • For example, if a patient, or child, DNAs an appointment, has their history been considered? Does it suggest them to be vulnerable and in need of further support?

Through our engagement with patients and providers, the following groups were raised as needing particular consideration or adaptations:

• People with financial difficulties
  • for example, those in need of financial support for transport or childcare.
• People who require carers to be brought to their appointment
  • for example, services may need to work around the availability of the patient’s carer.
• Children and young people
  • for example, those who are not brought to their appointments may come from difficult home lives or backgrounds.
• People with mental health conditions
  • for example, may require additional support and reasonable adjustments to attend appointments
• People who are neurodiverse
  • for example, may be more anxious about attending appointments and require additional support to attend appointments
• Patients who are vulnerable because of their experiences
  • for example, people recovering from addiction or coming from violent homes/in domestic violence support shelters, or homeless patients
• People with a disability
  • for example people with a learning disability or a physical disability who may require reasonable adjustments to support their attendance at appointments.

Monitoring and reporting your DNAs

DNA rates needs to be understood and broken down by the underlying reason causing the patient to miss their appointment. Organisations should seek to measure and monitor themselves against the areas where they experience greatest inequity and variation in ability to access appointments.

Internal monitoring and analysis

DNAs should be monitored internally to support efforts to improve services and patient experience.

Providers should calculate a DNA baseline position over a period of time (eg weekly or monthly across a year to account for natural variation) and examine variation between the factors below:

1. Service/operational factors:
   1. Specialties
   2. Clinic/appointment times
   3. In hospital site (if multi-site provider)
   4. Days of the week
   5. How much notice the patient was given of the appointment.
2. Socio-demographic factors:
   1. Age
   2. Gender
   3. Ethnicity
   4. Distance to travel to hospital
   5. Deprivation as according to indices of multiple deprivation

Once a baseline position has been established, providers should aim to identify a reasonable reduction goal for DNA rates across different specialties. Understanding where you are against peers is a useful way to identify the possible opportunity for DNA reduction, for instance through the Model Health System.

National reporting

DNAs are reported monthly through the Secondary Uses Service (SUS).

National DNA rates numbers are calculated using a combination of:

• Attendance status 3 – DID NOT ATTEND – NO ADVANCE WARNING GIVEN
• Attendance status code 7 – PATIENT ARRIVED LATE AND COULD NOT BE SEEN

Where the administrative category code is 01 is used for NHS patients and First attendance code 5 for admin events is excluded.

The denominator for DNA rates is the total number of outpatient appointments, excluding cancelled appointments, where administrative category code is 01, again excluding first attendance code 5 for admin events.

Specifically, outpatient appointments defined as [Attendance Status] = ‘3 – patient did not attend’, ‘7 – arrived late and unable to be seen’,  ‘5 – attended’, ‘6- arrived late but was seen’, where [Administrative Category Code] = ‘1’ (NHS funded care), [First Attendance code] is not equal to ‘5’ (RTT clock stop event).

How to evidence improvement

There are multiple ways providers can evidence the impact that reducing DNAs has on patients, staff, and services.

Please note that while organisations should work towards lowering high DNA rates, low DNA rates are not always indicative of an accessible service design – for instance, if a service chooses to discharge patients most likely to DNA rather than respond to their needs.

Therefore, to understand and measure how an intervention positively impacts DNAs, the rate should be considered against multiple markers. For example, the impact of changes to appointment letters or communication material could be measured in multiple ways, including:

• Patient satisfaction scores
• Overall DNA rate, including improvements in targeted groups
• Number of patient cancellations or changes (as a potential marker for improved access to service)
• Cost savings
• Staff job satisfaction
• Clinic utilisation and clinics running to time
• Available clinic slots in future weeks

By improving clinic use, freed up capacity can be used to support elective recovery efforts including seeing overdue appointments, long waiters, and new patients.

Predictive analytics

One study highlighted that previous DNA status is a leading factor in determining the likelihood of future DNAs.

While many of the academic studies use machine learning algorithms to produce prediction models, providers should examine their own administrative processes to identify patients who may DNA in future. The factors outlined above to support the measurement of DNA reduction may be a good starting point.

Risks and mitigations

Below are a few risks and mitigations that have specific relevance to reducing DNAs – these came from both our own research and engagement with various stakeholders. Providers should consider their own risks and mitigations when undertaking work in this area.

Useful resources

A collection of useful resources can be found on the DNAs and Booking Processes FutureNHS workspace. Below is included a list of direct links for useful resources:

Elective recovery

• Principles and approach to deliver a personalised outpatient model
• 2022/23 priorities and operational planning guidance
• Good communication with patients waiting for care

DNA policies and SOPs

• Black Country Partnership NHS FT – DNA and Cancellation Policy
• Northern Care Alliance NHS Group – DNAs and Clinic Completion SOP
• Hertfordshire Partnership NHS FT – Did Not Attend Policy (DNA) (Responding to Service Users who do not attend appointments)

National tools

• Online library of Quality, Service Improvement and Redesign Tools (QSIR) – Reducing Did Not Attends (DNAs)
• Online Library of Quality, Service Improvement and Redesign Tools (QSIR) – Plan, Do, Study, Act cycles and the model for improvement
• Statistical Process Control Tool
• Reducing DNAs – rapid review checklist

Analysis of reasons for DNAs

• Who is least likely to attend? An analysis of outpatient appointment ‘Did Not Attend’ (DNA) data in Scotland

Publication reference: PR2012