Two strikes – when the patient ‘Did Not Attend’

The nib of my pen hovers over the ‘outcome’ form*. In the lower third are various options; Follow up x weeks/months, Await results, Discharge, Refer to another consultant, DNA – rebook, and finally, DNA – discharge. DNA. Means Did Not Attend. The patient Did Not Attend their clinic appointment. A stark term behind which there may lie many reasons, some not of the patient’s own making. But the decision to discharge will terminate the patient’s relationship with this clinic, and with me. Responsibility for monitoring them will return to primary care, or may evaporate entirely. Perhaps their symptoms, or the nagging thought that there was unfinished business in the clinic, will draw them back to the GP. The GP will decide whether they need to be seen again by ‘the specialist’, and if so they will need to write a new referral letter. Then they will re-join the waiting list. The process could take months.

NHS Trusts have strict policies on DNAs. After all, 1 in 10 appointments are not kept, and you can’t keep offering them to those who don’t come. The National Audit Office reported that DNAs cost the NHS up to £225 million in 2012/13. Failure to attend means that a slot was wasted. Another patient could have been seen instead. One strike and you’re out, some Trusts dictate. Many consultants are more comfortable with two. The first time could have been an ‘honest mistake’, a slip, a simple oversight. Too harsh then, to strike them from the system on the first occasion. But a second missed appointment must surely mean that either they feel better and do not want to be seen, or they have moved, or they are just too busy and choose not prioritise their health over everyday life.

In a study of 73 patients who had missed appointments, the reasons given were:

  • Forgot to attend or to cancel (30%)*
  • No reason (26%) [I’m guessing they literally said, ‘No reason.’]*
  • Clerical errors (10%)
  • Felt better (8%)*
  • Fearful of being seen by junior doctor (3%)
  • Inpatient in another hospital (3%)
  • Miscellaneous other (20%)

I have asterixed the reasons that seem genuinely to ‘deserve’ a discharge. They make up 64% of the reasons (or ‘no reasons’), so at least a 3rd would be discharged entirely unjustifiably, based on this sample. Those who were subject to clerical error deserve the opposite – a new appointment at their best convenience. I wonder if that happened.

This is Mr Jackson’s 2nd DNA. I know him. He has been coming to the clinic for three years, with a chronic condition that requires regular review by a specialist. Something must be up. We get on well. He may feel healthy, but his condition could be changing beneath the surface. I worry that if I discharge him he will never come back. The pen moves to ‘DNA – re-book’. But… but… why waste another slot when the chances are he won’t come back. The waiting list is long. Every appointment counts. I could call him up to find out why, but to be honest I don’t have time to chase up every DNA. I’ll write a letter to the GP stating that he didn’t attend and asking the GP to keep an eye on things. And another to the patient himself, to keep it personal. So, I’m not exactly severing all connection, but… I will discharge him. Discharges are important. Senior doctors have a duty to keep the lists turning over. And if he develops a complication, a cancer say, it won’t be my fault.

The Medical Defence Union has just published guidance on this subject. Pertinent to Mr Jackson, they say I should,

  • Respect a patient’s decision to refuse an investigation or treatment, even if you consider the patient’s decision to be wrong or irrational.
  • Explain any concerns clearly to the patient, as well as the possible consequences of their decision, and document your discussion in the patient’s clinical records

And that,

  • Previous knowledge of a patient’s circumstances, including the severity of their condition necessitating referral or follow-up, will need to be taken into account.
  • It may fall to a patient’s GP practice to follow up the patient who misses an appointment.

I circle the words, ‘DNA – discharge’. I dictate the brief letter to his GP: “I was sorry not to see Mr Jackson in clinic today. I hope that he remains well. It is important that he attends for regular surveillance. I would be grateful if this can be emphasised to him when you next see him, and I will write separately to him. For now he has been discharged.”

A bridge, a compromise, between bureaucratic imperative and therapeutic relationship. For all I know his family have taken him in to their home up in Yorkshire; or perhaps he has died. I don’t know. Or perhaps he’s decided that these appointments were a bit of a waste of time, as nothing ever seemed to change. He’ll find his way back, if he needs us. I’m sure of it.

Next patient please.

[Fictional patient]


* These forms (either paper or electronic), and the options available, vary between organisations.

The significance of children not attending clinics can be very different. Clinicians are encouraged to use the term ‘was not brought’. This video explains why.


5th collection of articles, out now [click image to explore on Amazon]

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