Missed hospital appointments (DNAs) – a more complex calculation?

Having listened, last week, to the BBC’s “More or Less” programme (, which had a short article dealing with whether missed appointments (DNAs) really do cost the NHS £1bn last year, I was surprised to hear an expert health statistician state that, in his view the cost of a missed appointment was “nearer £0 than £120”. I must admit to having been more than slightly surprised by this, given that he was an expert in this field.

Yes, the simple calculation – that a DNA causes doctors and nurses to sit around and waste time, lights and heating – is probably a highly inaccurate way of calculating the costs, as the NHS overbooks its lists to ensure that staff do not waste time or resources. I do believe, however, there are a significant number of more complex elements that have been left out of the equations and that may underpin possibly more cost, rather than less.

For example, and I speak as someone who has spent time at the “sharp end” of endoscopy day lists, there was no mention of the following:

  • When a patient DNAs, clinic time is wasted by pulling new notes, updating old notes, and possibly changing the type of equipment needed to cater for the “new” patient – all of which delays the next patient being treated.
  • Patients, in general, do not DNA because they want to – they DNA due to circumstances usually outside their control; e.g. trees on the line, commuting on Southern Rail, children falling sick, having been sent three different dates for the appointment (after the clinic has rebooked them without their knowledge or consent) and being unsure of which date to arrive on, etc.
  • Being unable to contact the hospital out of hours – and then facing a 20-minute wait on the telephone trying to contact the department (as this is usually the only method of contact available to them – after which they usually give up in frustration).
  • Clinics being short-staffed (a more and more common occurrence) – again causing delays and reorganisation of lists.

The key thing is that DNAs do cause financial repercussions – not only the “obvious” wastage in the system, both related to time and (occasionally) resources, but more importantly they cause stress for both patients and staff.

For patients, this has a knock-on effect that, whatever their condition was before, it is likely that it will have worsened by the time they are finally seen, potentially causing a more complex and costly procedure to be undertaken, than if it had been treated earlier, and with consequently longer recovery times, more days off work, etc.

For staff, the disruption and confusion caused by DNAs increases the (already considerable) stress that they currently find themselves working under and leads to more long-term sickness and staff absences – which simply compounds the problems - not to mention the additional overtime bills or extra expenditure on bank-staff needed to cover for sickness.

I truly believe that it is dangerous to underplay the importance of trying to minimise DNAs in the system overall – or the costs associated with them. I also suggest that the statement they are “nearer £0 than £120” is well wide of the mark. If the wider implications are taken into consideration, I suspect the overall cost of DNAs in the NHS – especially related to the increase in a patient’s “time to treatment”, their exacerbated stress levels and the rise in lost working hours – could actually exceed £1bn.