Do missed appointments cost money?

There has been a rash of stories about missed appointments costing vast amounts of money:

• The BBC quoted Epsom and St Helier who estimated that missed appointments cost the Trust £5.6m
• The Sunday Express quoted a figure of £800m lost for the whole of the NHS

The question is: do they cost so much money?

Let us look at how these figures are arrived at.  They are arrived at by multiplying the number of missed appointments (DNAs in the jargon - Did Not Attend) by a notional cost of the missed appointment. And the notional cost in these two articles are c. £120 per appointment.

There are two weaknesses to this methodology.  First, the analysis assumes that a missed appointment means that the whole infrastructure of out-patient care (nurses, receptionists, test facilities, and doctors) are just kept waiting looking at their watch, and wasted.  Second, the analysis assumes that the cost of this is the same as PCTs are charged for each appointment (which is roughly £120 when averaged between new attendance and follow-up tariffs).

The first is a ridiculous assumption.  I know of very few clinics that work on the assumed basis.  In reality, most clinics are overbooked, assuming some DNAs.  Moreover, outpatient clinics are very poorly analysed and planned according to some ancient template.  As a result, patients are allotted times that may bear little relation to reality.  How many times have you gone to see a outpatient waiting area that is rammed full?  How often have you as a patient waited for far too long to see a clinician.  The basic point here is that in reality DNAs are a small wrinkle in our imperfect outpatient demand and capacity management; and only a small fraction of the allotted time is actually wasted if any.

The second assumption is just wrong.  It shows a misunderstanding of cost and price.  If you break a pram in John Lewis, the cost to John Lewis (assuming they do not charge it to you) is not the full price of the pram - but the cost to them (what they will pay to have it replaced).  Similarly the price of outpatient consultations is not the same as their cost.  And the marginal cash cost of a consultation will be much lower than the £120 charged to PCTs.

So these losses are just paper losses.

In reality, DNAs impose large costs when clinics are analysed and managed very well.  But hospitals who manage that will also be managing their DNAs to the minimum unavoidable level.  These bald and high-level estimates are just idiotic, and we could do without them.