Equitably tackling non-attendance of scheduled appointments
Jade Okeke, Evaluation and Insight Intern for Q, shares emerging insights from teams working to reduce waits in health care through reducing the non-attendance of scheduled appointments.
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In this piece, Jade shares the emerging learnings from improvement projects and key lessons they can offer in supporting people to attend their scheduled appointments.
A persistent issue for health care providers and patients is the non-attendance of scheduled appointments. Of the 103 million outpatient appointments booked in 2021/22, 7.6% ended in ‘did not attends’ [ref]Reducing did not attends (DNAs) in outpatient services – NHS England[/ref]. Not only do they put patients at risk of worsening conditions, but they drain resources for health care providers and create delays for other patients. Non-attendances of scheduled appointments are an important contributor to the broader issue of long wait times in health and care.
Through our funding programme, Q Exchange, and Q Lab’s latest project, we have supported teams using improvement and innovation approaches to tackle waits. For some of these teams, missed and cancelled appointments was a main focus. We wanted to share some common threads through their learning that provide actionable insights for others working on similar challenges. We heard from Q Exchange teams:
- University Hospitals Bristol and Weston NHS Trust (UHBW) and North Bristol Trust: Addressing health inequalities by co-developing change to reduce missed appointments.
- Lewisham and Greenwich NHS Trust: Tackling inequalities in health of patients on surgical waiting lists.
And Q Lab teams:
- University College London Hospitals NHS Foundation Trust (UCLH) working in adolescent and young adult rheumatology.
- Aneurin Bevan University Health Board team working on Head and Neck cancer pathway.
Identify groups most at-risk of missing appointments
The teams used historic data and population health management (PHM) approaches, to identify differences in non-attendance rates between demographic groups. The team at UHBW and North Bristol Trust found missed appointments were 36% more likely among Black and Asian patients and 48% more likely for people living in the most deprived areas.
Inequalities are complex and shaped by a number of intersecting factors. Within these broader patterns, the teams developed more in-depth approaches to understanding the variables that would leave specific patients at higher risk of non-attendance:
- UCLH developed a model with 64 predictor variables, including demographic data and the Index of Multiple Deprivation (IMD), to produce weekly lists of patients most at risk of non-attending scheduled appointments.
- Aneurin Bevan developed a model that was correct 90% of the time in predicting attendance or non-attendance. Using data from all Head and Neck Cancer patients since 2022, they started with 70 variables and reduced this to the eight most meaningful ones.
- Lewisham and Greenwich NHS Trust proactively identified patients needing support to optimise their health ahead of their pre-operative assessment using acute, primary, mental health and community services data. Using the IMD as a guide, they identified key patient factors that pose risks during surgery such as blood glucose levels and anaemia, combined with emergency admissions within the last 12 months amongst patients.
Matt Hopkins from Lewisham and Greenwich NHS Trust offered his tips for a successful population health management approach:
- Make sure the data is accurate.
- Focus on understanding your local population and where the inequalities lie.
- Identify a target group for your intervention: a ‘small enough group that you can actually do something with, and target interventions at, but don’t be too specific, so you’re missing people who might also be facing challenges’.
While providing an important starting point, quantitative data and identifying patients most at risk of missing their appointment can only get you so far in designing an effective intervention.
Dr Aicha Bouraoui, whose team at UCLH developed a predictive modelling approach to identifying the most at-risk groups, reflected:
If we were to stop the project here, it’s just a model giving us a list. It’s not actually addressing the root of the problems. We wanted to truly understand the reasons among young people behind this. I have loved working with both the clinical team and the young people themselves to tease out some of the issues and work together to find solutions to non-attendance.
Talk to patients to understand their barriers
Making assumptions about the barriers that prevent patients from attending their appointments risks ill-informed interventions that don’t work for your specific patient population. Combining quantitative data with qualitative approaches can strengthen your understanding of patients’ lived experiences and the challenges they’re facing.
Teams used a range of different approaches to draw out this understanding of patient experience:
- Telephone conversations with patients to obtain feedback after they had missed their appointments.
- Gathering feedback and reflections from staff.
- Online and in-person events, including interactive and creative approaches (often led by patients or patient representatives).
- The team at UCLH used tools such as the Iceberg Model [ref]The Iceberg Model[/ref] to help uncover the less visible patterns, structures, and beliefs contributing to non-attendances.
- A strong co-production approach, from co-discovery to co-evaluation. This helped the UCLH team to develop their interview guide together with young people, which has since been shared with the wider organisation.
The teams also explored different ways to engage a diverse patient cohort. They wanted to ensure they reached the groups most likely to miss their appointment, and whose input was therefore most important. This included working with GP practices and trusted organisations like Healthwatch, to both facilitate local community events, and join existing events with high footfall.
I think the thing that really helped getting momentum was we looked for high footfall events. So instead of trying to create a group of people and get them together, we looked at events around the Bristol, North Somerset, South Gloucestershire area and asked people, do you know if anything is happening already? Is there anything around health that I could come to? And just by asking that simple question, there were so many different things that we could attend.

What patients said
The teams reflected that the insight they gathered sometimes challenged their assumptions about what the main barriers were, and who they affected.
Across the projects there were a wide range of key barriers, including:
- Communication about the appointment, including language barriers.
- Trust in the service/NHS.
- Level of flexibility with appointment times, competing priorities and responsibilities.
- Transport to and from the appointment, which can be costly and tiring, especially for people with chronic pain.
UBHW and North Bristol originally assumed transport would be the largest obstacle their patients were facing in attending their appointments. Travel arrangements and cost can indeed disrupt appointment attendance for people living in the most deprived areas, the scale of this is reflected in the £460 million per year the NHS spends on non-emergency transport [ref]Strategies to reduce inequalities in access to planned hospital procedures – The Strategy Unit[/ref]. However, UBHW and North Bristol Trust found that ineffective communication was the largest contributor to DNAs in their system.
I know people say that the car parking is difficult and that the buses are unreliable, but these are not the biggest reasons why people miss appointments. It’s because they didn’t know about the appointment or they didn’t understand what the appointment was for or they thought the appointment had been re-arranged, that sort of thing. We are shooting ourselves in the foot by not communicating clearly.
Communication was also highlighted as a major barrier to attendance through the patient engagement work of Lewisham and Greenwich NHS Trust:
Communication was a massive issue for people; our communication to them. Patients told us that from having their first appointment with a surgeon, and being put on the waiting list, they then felt silence for months and the anxiety of waiting and/or not knowing […]. So that’s a big thing that we need to think about in terms of how we better communicate
Co-produce holistic, equitable solutions
The teams used co-design to ensure solutions were led by patients and centred around their needs. The interventions to support patients attending their appointments included:
- More flexibility in appointments [ref]Learning from Q Lab: Slowing down to move forward? – Sarah Rae[/ref].
- Proactively contacting people at risk of non-attendance ahead of their appointment.
- Providing support around key barriers, such as developing travel guidance for people in need of help with transport.
- Co-producing and sharing additional resources with health information [ref]Adolescent resources – North Thames Paediatric Network[/ref].
- Improved, regular and personalised communication.
- Using a ‘relay’ approach: booking in the patient’s next appointment before they leave.
- Introducing new roles dedicated to supporting patients to attend their appointments, such as Equalities Access Coordinator (UHBW and North Bristol Trust) and Peer Support Coordinator (UCLH).
Importantly, teams who tackled non-attendances successfully were strong advocates for taking an holistic approach. They highlighted that the barriers that prevent people from attending their appointments are likely to negatively impact their health and lives in other ways. With this in mind, the teams developed additional health coaching, accessible health resources and peer support.
While the projects are still in the early stages, it’s fantastic to see some positive impact already emerging from their work. For instance, the UCLH team have seen a reduction of 30% in the non-attendance rate. Building their work around these steps; finding the most vulnerable groups, engaging with them meaningfully and co-creating solutions, creates the potential to reduce non-attendances in a way that centres equity.
We look forward to seeing what these teams will continue to achieve.
Learn more about the projects
Read more about the Q Exchange projects:


Read more about the Q Lab project:

Further reading
Using Art to Amplify Young People’s Voices in Healthcare – UCLH Arts and Heritage
Improving clinic attendance and reducing health inequalities in children and young people – UCLH rheumatology team
Reducing did not attends in outpatient services – health inequalities – NHS England
Improving non-emergency patient transport services – NHS England
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Equitably tackling non-attendance of scheduled appointments
Opinion piece 2 December 2024 8 minute readJade Okeke, Evaluation and Insight Intern for Q, shares emerging insights from teams working to reduce waits in health care through reducing the non-attendance of scheduled appointments.