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.

CPD: confused public health doctors

Militant Manager wanted to self-mutilate again when he read the latest BMJ's editorial.  Penned by Jamie Lopez Bernal and Martin McKee (both of the London School of Hygiene and Tropical Medicine), it is so flimsy and polemical, that I wondered if they had not veered away from the GMC's Duties of a Doctor which include the requirement to "Recognise and work within the limits of [your] competence."

The central tenet of their article is that any potential economic benefit of higher speed limits is likely to be outweighed by the adverse effects on health.

To try and get a handle on the adverse health effects, they postulate (and work hard to exaggerate) these:

• Greater casualties on the road.  They quote a US study which showed a 16.6% increase in deaths when speed limits were increased.  They postulate that this could be due to both greater traffic and greater collision risk.
• Greater emissions
• (Potentially) greater obesity as more people take to the cars, rather than walk.

I must say that I have not laughed so hard since NPfIT was cut off at the knees.

Surely the point of speed limits and travel is not to minimise road casualties.  If that were true, this study suggests that only men between the ages of 25-44 should drive as they are the safest in terms of casualties per 100,000.  Actually, an even better way to minimise traffic casualties is to shoot babies at birth in the delivery suite - that would reduce road casualties by 100% in due course.

And surely no sensible person is going to really think that increased speed limits would have an impact on obesity!  Where is the evidence?.

Of course, they acknowledge that there may be some benefits.  The only one they mention of course is widely positioned as "economic benefits."  The two particular areas of economic benefit that they note are freight transport (the benefits to which they dismiss contemptuously saying that HGVs would continue to have a 60 mph speed limit); and small vehicles transport - where they do not see any impact on journey times (as most small vehicle transport happens during the busiest times, they claim, when there will not be an impact from higher speed llimits).

Doctors who - after 6 and more years of training - cannot master public health, cannot be expected to understand the basic tenets of economics. MM would like to point out that economic benefits of higher speed limits accrue to consumers as well as producers.  These include leisure travellers, sunday drivers and everybody else.  Economic benefits are the sum of consumer and producer surpluses (not just the latter as these authors seem to believe).

And even the benefits to producers cannot be quantified by theoretical argument.  It is an empirical question.  That these proposals have resulted in such voluminous coverage, and as they would have the impacts on casualties that the authors believe show that we may expect higher speed limits to alter behavoiur and travel times.  And therefore the economic benefits are likely to be substantial - and need to be shown empirically.

That is the central point that is missed by these authors.  That you need empirical evidence both for the benefits as well as the costs.  You cannot conclude an argument purely by juxtaposing an estimate of one of the costs (casualties) with a flimsy theoretical dismissal of the benefits, coupled with shroud waving over obesity.

Only if they have such evidence can they write "In the light of this evidence, it is difficult to see the proposal to raise the speed limit as anything other than a populist gimmick . . ."  Without it, this is just a rhetorical device.

And once these benefits have been shown, the choice should not be left to some paternalist, confused public health doctors; but voters.

Lastly, I cannot rest without pointing out that "extending coach and bus lanes on motorways during busy periods or subsidising rail fares" are not really alternatives.  They require more money.  They are alternatives in the same way that Buckingham Palace is an alternative to a terraced house in Tottenham.  Clearly the former is a place where Militant Manager would be comfortable; but it is only the latter that she can afford.

Overall, I cannot see how the BMJ can take itself seriously when it publishes such drivel.

Most popular Militant Manager posts in 2011

These were the most read stories in 2011, with the number of unique people reading them during that year.  Please note that the number of unique readings are an underestimate of true readers (the majority of viewers go directly to the main Militant Manager blog page - militantmanager.blogspot.com - and cannot be attributed to any one article without detailed analysis.  And as we know NHS Managers are not capable of doing any analysis).


1.  Noble resignation or convenient excuse to focus on greener pastures 279 views
This readership is surprisingly large given the article was only posted on 13 December, and so only had 3 weeks in 2011.


2. Why consultants need more natural predators 270 views
Another post that focused mainly on issues related to doctors.  Interestingly, when I started the blog, my view was that it would be more read by managers.  But it seems that the blog is far more read by doctors . . .


3.  More Del boys will become GPs  124 views
Another issue focused on doctors, and looking at the subtle effect of the health reforms on the composition of GPs.  I must point out that I neither support nor condemn these effects - I am just pointing them out.


4.  The similarities between car design and NHS structures  111 views
The most popular article focused on management issues.  I thought this article deserved greater readership, but it was not to be.  Maybe it will develop a cult following.


5.  The point of Academic Health Science Centres 97 views
On the whole, my more tongue-in-cheek articles (on Clare Gerada, on Bruce Keogh, on Cynthia Bower, David Nicholson, and Richard Smith) did not rouse great interest.  This was the exception.  Probably because Academic Health Science Centres, like Secure Facilities, do not have a point.

Another non-story parading as a story

Militant Manager gets irritated by journalists who print a story with the most convenient headline without looking into the agendas of those involved, the context of the story and an opportunity for someone else to put the converse point of view.

For example, take this article by a journalist I quite like - Martin Beckford - on the rise of dementia patients in hospital.  The headline screams that emergency admissions for dementia has risen 12%.  There are so many things wrong with it.  First, it is an odd use of statistics.  The 12% rise figure is not an annual figure as most of us would assume, but actually the rise over 4 years - so actually the annual rise is 3%.  But the headline is cheap when you take it over 4 years.  Second, what do I compare it to.  How have emergency admissions been rising overall?  What is the rise in other conditions?

The other thing is the article only gives paltry information on the context.  You really have to dig to find out that there was a National Dementia Strategy in 2009.  And in February of this year there was a £2m ad campaign (though that would not have really affected these figures).  And coding has been improving over this time.  So in that context of raising awareness, and greater sensitivity to dementia, 12% over 4 years does not alarm me.

Then, what about the agenda of the people promoting the report.  It is MHP Health Mandate, a PR/ lobbying/ communications (you pick) company and the Alzheimer's Society.  Would you think they would have an agenda>  And if that is the most extreme they can paint the statistics - which when put into context is not really that surprising - then the numbers cannot be that alarming in reality.

The report, however, does not really address these points; and then goes on to quote only people from these bodies.  We know how it works - either these quotes are already on the press release, or the promoters make available well briefed individuals to interview.  It is much more difficult for the journalist to find context, agendas and contrary points of view - so they generally suffer.

While we are on the topic why are press releases written in the third person.  Are they not issued by the organisation themselves; and therefore should they not be in the first person.  Is it to make it easy to reprint without alteration?  I really do not know the answer to this question and would be interested in finding out.

I must say that I am concerned about dementia.  It is an issue that we need to grapple with in its right proportions.  And I am glad there are groups that promote its awareness and impact.

My issue is with those who consume those reports, and re-report it.  They/ we need to put it into context.   If that does not happen, it irritates Militant Manager; and hopefully it will now also irritate you.