Choose and Book increases DNAs

Tags: BMJ booking Choice Choose and Book DH DNAs feedback Government GP

03 Feb 2009

Attendance in outpatient clinics is worse for patients referred via Choose and Book than for those given an appointment after a traditional GP referral, according to a new study.

Hospital doctors at University Hospital Lewisham compared 700 patients who had been referred via the electronic booking system with the same number of patients referred on paper.

They found a did-not-attend (DNA) rate of 18% for Choose and Book referrals compared to 12% for traditional GP referrals, according to a letter sent to the BMJ.

Dr Prince Cheriyan Modayil and fellow registrars from the ENT department at University Hospital Lewisham decided to investigate the figures after anecdotal feedback from their consultant, David Bowdler.

Dr Modayil told EHI Primary Care: “We would expect most of the patients who come through Choose and Book to turn up, but Mr Bowdler was seeing a different pattern so we decided to look at the cancellations and came up with figures that are statistically significant.”

Mr Bowdler told EHI Primary Care: "The view from the shop floor is that this is a bad top down system imposed by the government but although I had an instinct about the DNAs I was still surprised by the results. "

Mr Bowlder said it was impossible to say why the DNAs were higher but said he thought patients were sometimes booked in toa clinic with the lowest waiting time through Choose and Book and then discovered it was further away than their local hopsital and opted not to travel. He said there was also too little information on Choose and Book to allow proper targetting of referrals to the right specialists.

Dr Modayil said the pilot study would be followed up by more work to examine why patients did not attend.

He added: “We are going to look in more detail at the cancellations, including if patients have cancelled before, how many times they have cancelled and what sort of problems these patients have.”

Dr Modayil said it was too soon to pinpoint the reasons behind the differences in DNA rates but pointed to research last year that showed most patients referred through Choose and Book were not experiencing a significant choice in appointment time, date or hospital.

In the letter to the BMJ the doctors added: “Choose and Book has failed to achieve its main goal of improving patients’ satisfaction and attendance. Moreover, it creates an unnecessary economic burden on the health system and jeopardises the prioritisation process by removing clinicians from the process.”

However the Department of Health said it was surprised by the study's findings as it said all other evidence suggested Choose and Book significantly reduces DNA rates.

A DH spokesperson added: "It is logical that if a patient is actively involved in
decisions about their care, attendance is likely to improve. We note that
further research is being undertaken to test these findings and seek an
explanation for them."

Fiona Barr

Reader's Comments

Anyone asked. . .

03 Feb 09 12:02

Has anyone asked if the patients were offered a choice of convenient date and time (which has been proven to reduce DNAs)?

Or is this yet another local health economy that skips that critical part of the process and simply sends a brown envelope dictating the appointment?

Could this be another case of blaming a screwdriver for being rubbish at knocking nails in. . . .

Asked?

julian.spinks@nhs.net

04 Feb 09 08:02

The comparison here is between Choose and Book where the patient would be offered a choice of appointments (by the practice or central appointments) and the traditional system where they would be sent a letter with an appointment (no choice). In both cases it is the same clinics at the same times

Even allowing for some patients finding the range of appointments offered inconvenient, you would expect more offered choice to be satisfied than those given no choice.

Targetes and Short Cuts?

04 Feb 09 09:02

Is this not a case of target problems? GPs being bullied into achieving high rates of Choose and Book referrals?

In order to achieve the targets C&B referrals are being churned out as fast as possible and some are skipping the 'let's have a conversation with the patient who ums and ahs for 10 minutes over where they wish to go'? It is time consuming, GPs have enough to do and farming it out to admin staff leads to its own problems.

Plus - taking the first available appointment at all costs is leading to further travel and unfamiliarity with large out of area hospitals.

Also - The information that Choose and Book churns out to give to patients isn't very user friendly, doesn't explain things properly and so patients just ignore it for fear of going to their surgery and asking somebody to explain it to them!

C&B appointments difficult to cancel

04 Feb 09 09:02

If you don't have your password handy it is quite difficult to cancel a choose and book appointment. I, for one, gave up and became a DNA. Too many hoops to jump through.

Patients need reminding!

jjablo@txttools.co.uk

04 Feb 09 10:02

I like the NHS Choose and Book system and have experienced this through my own GP Surgery. However even if a patient has chosen their own appointment they could still forget! According to research over the past few years the main reason patients DNA is because they simply forgot! Text reminders for booked appointments works and feedback from patient surveys say "they love it". Try it! www.txttools.co.uk

Misleading

andyjedwards@btopenworld.com

04 Feb 09 16:02

The article is misleading. We all know that a DNA is an appointment that is not fulfilled. What this report refers to is patients not even booking the appointment in the first place.

So please do not make the C&B = DNA equation; my own experience has shown that if the patient actually books their own appointment the DNA rate is lowered since they "own" the appointment.

We have some 12,000 patients on our list and Lewisham could say that some 11,900 patients have DNA'd today (because they didn't book an appointment)

errrrrrrrr

04 Feb 09 19:02

"We have some 12,000 patients on our list and Lewisham could say that some 11,900 patients have DNA'd today (because they didn't book an appointment)" said the previous poster.

You might want to revisit that analogy. The DNAs refer to patients who have been allocated a slot in a clinic but who do not turn up.

You (presumably?) do not allocate all 12,000 of your patients on your list a new appointment each and every day?

Your 11,900 are "stay aways" or "did not need to comes" and your logic is flawed. Regards Paul C

Additional Information needed

06 Feb 09 17:02

I would be very interested to know the reletive rateof DNA when a The DNA was from a slot directly booked at the time of referral b Booked through the TAL c Originally booked into a slot through CaB but then cancelled and replaced with a forced booking (i.e one decided by the Trust) d Originally booked into a slot through CaB but then cancelled and replaced with a booking chosen by the patient.

That would give us a lot of information about why the patients are DNAing and about how hospital processes and CaB interact to create this problem.

Attention to Detail.....

10 Feb 09 15:02

I draw your attention to this quote from the article...“We are going to look in more detail at the cancellations, including if patients have cancelled before, how many times they have cancelled and what sort of problems these patients have.”..........I was always under the impression that a DNA was where a patient failed to attend without giving notifcation (wasted appointment slot, wasted clinic staff time)....whereas a cancellation was notification of intention not to attend (appointment slot is then available to be used by another patient)

Is this another case of a dissenting voice shouting the loudest with the most spurious claims.......and being listened to?

@ Paul C

andyjedwards@btopenworld.com

11 Feb 09 15:02

Extract from the way Pulse reported it...

"The crux of the matter is this – it’s not about Did Not Attend rates, which Choose and Book may technically cut. It’s about the total number of patients who never make it to an appointment. And in order to get that true figure, you have to take into account the one in ten Choose and Book patients who, once referred, never goes through with booking their appointment."

Full article: http://www.pulsetoday.co.uk/story.asp?sectioncode=20&storycode=4121783

devil in the detail

12 Feb 09 13:02

If this report is accurate it is significant Can anybody point me to when and where this report is published. All I can find is the pusle article but no reference to the actual report.

Was it peer reviewed. Were the cohorts of patients equivalent. In particular did the comparison include all referalls that started by letter in the GP surgery and didn't reach the hospital, ended up in the consultants draw, reached the booking centre but the phone number was wrong and the patient couldn't be contacted, the patient was contacted but decided not to book, was given an appointment which was then cancelled and the patient not rebooked properly.

If so this will be a significant finding. If not it may be a phenomenon caused by the very tracability which is a benefit of using a well defined and measured process supported by an electronic system.

Confusing language

13 Feb 09 10:02

The reference to DNAs seems confused. If they mean 'failure to book' or 'cancellations' they should say that. They're very different things.

As a few have commented, all the reviews I've seen indicate a significant reduction of DNAs when a patient is referred using CaB 'properly' (i.e. offered a choice of date and time).

Here's one example: http://www.chooseandbook.nhs.uk/staff/commsmaterials/case-studies/penn-br.pdf

details

simonwheat1964@tiscali.co.uk

13 Feb 09 11:02

I concur with comment 11.....and to further expand I suspect that any reports on unresolved appointments (ie patients not rebooking after cancellations) run on the provider side of C & B in most Acute Trusts, will be in a large number of cases around 50 % accurate.........due to appointment rebookings being manually entered in PAS systems which is not messaged back to C & B............training, processes, policies and awareness anyone!