Dr Ellie Mein
Ellie Mein explains how not to miss something yourself when tackling the issue of missed appointments.
A GP member wrote into the MDU's medico-legal department with a concern about a long term patient of the practice. The patient had multiple chronic conditions and was a frequent attender for mental health issues, but over the past year he had begun not attending appointments.
The GP was worried about the patient and wondered what else they could do to try and ensure their attendance. The GP was also concerned as to whether they would be medico-legally vulnerable if the patient suffered harm that might have been prevented if they'd had a medical review.
Missed appointments are an ongoing problem within the NHS, with Jeremy Hunt revealing in 2015 that they cost the health service almost £1 billion per year. Specifically, missed GP appointments were estimated to contribute to this figure by £162 million. It is no surprise therefore that much consideration has been given on how to reduce the number of 'Did not attends' (DNAs).
In responding, the MDU adviser acknowledged that this was a common concern for GP members, and that while GPs cannot compel patients to attend appointments, there are steps they can take to show they have made reasonable efforts to engage and help the patient.
With that in mind, the GP was advised to consider why the patient may be missing appointments, particularly when their attendance had previously been good.
- Might the patient not be receiving correspondence about appointments? Were their contact details current?
- Had they any memory issues or health reasons that might prevent them remembering they were due at the practice?
- Was there any reason the patient would be reluctant to attend the practice, or leave their house?
- Were there practical reasons which might prevent the patient from attending, such as caring for a sick relative or poor mobility?
- Did they understand what the appointment was for and why it was important to attend?
- Similarly, did they realise the implications for their health of not undergoing medical review?
The GP explained that the practice had sent out reminders for these appointments and had started to send letters to the patient, telling him when he missed an appointment. Despite these, the patient had not responded to the letters or attended the practice.
In the first instance, the adviser suggested that a conversation with the patient may be helpful in answering the above questions. The GP felt that inviting him in for a discussion would be unsuccessful given his recent attendance record, so decided to phone him instead. The GP learned that the patient had received the appointments but didn't think he needed to keep being seen, as his condition had been present for so long and he felt he was doing well on medication.
The GP explained to the patient why it was important that he attend for monitoring of his chronic conditions and medications, emphasising the risks of not being monitored along with the impact frequent DNAs have on waiting times and the availability of appointments for other patients. The patient agreed to attend future appointments.
The phone conversation was followed up with a letter reiterating the risks for the patient of not being monitored and the impact on other service users. After this, the patient's attendance rate improved and he cancelled appointments he couldn't attend.
In answer to the GP's question about liability for missed appointments, the MDU adviser explained that answering that question was always difficult, as where responsibility might lie would inevitably depend on the precise circumstances of each individual case. Should the issue result in a GMC referral, then the steps that the doctor had taken to speak with the patient and check on their condition would clearly help.
The adviser explained that in a claim, the legal test first set out in Bolam would apply; the GP would not be negligent if their actions didn't fall below the standard expected of a reasonable GP.
The adviser explained that careful records of the correspondence sent to the patient and any discussions with the patient setting out detail of the advice given, and in particular a record of the explanation given to the patient as to why it was important to attend, would help if there was a problem in the future.
Explainer: what is the Bolam test?
The Bolam test comes from the case of Bolam v Friern Hospital Management Committee  1 WLR 582, where the patient made a claim for negligence after suffering fractures while receiving electro-convulsive therapy. In line with usual practice at the time he wasn't restrained or given muscle relaxants, and because he hadn't asked, he also wasn't warned about the minor risks associated with the treatment.
The claim failed, with the court holding that by following the generally accepted medical procedures and protocols of the time, the medical team were not negligent because they had acted in accordance with a responsible body of medical opinion.
A number of subsequent cases (notably Montgomery vs Lanarkshire Health Board) have affected how Bolam is applied, particularly as regards consent to treatment.
While it won't be practical to chase every patient who misses appointments, the above considerations can be helpful in ensuring that practices can demonstrate they have taken appropriate steps to mitigate the risks associated with frequent DNAs.
It is important to keep a record of any steps taken in case you need to justify how the practice approached the problem of a frequent non-attender.
Sending patients who miss multiple appointments a letter via recorded delivery that outlines the risk to them, and the problems this behaviour causes for others, can also be invaluable. This can be used to demonstrate that the patient was fully aware of the risks of non-attendance for chronic conditions or medications, if a problem arises at a later date.
As a last resort, some practices consider a warning letter being sent to patients who do not attend their consultations where there is no apparent reason. However, we would advise practices to contact us for specific advice if this option is being considered.
Dr Ellie Mein
MB ChB MRCOphth GDL LLM
Ellie joined the MDU as a medico-legal adviser in 2013. Prior to this she worked as an ophthalmologist before completing her Graduate Diploma in Law in Birmingham.
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