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Tackling DNAs in a community trust

Looking at ways to reduce DNAs at Hull and East Riding Community Health NHS Trust

Why was the initiative launched?
What was done?
Did it work?
Tips for success
For more information contact

Why was the initiative launched?

A history of large numbers of patients not attending outpatient clinics prompted the Trust to invite the District Audit Office to carry out an audit of the systems used to operate outpatient clinics in 1996. At the time the Trust had one of the highest DNAs rates in the region about 29%. The audit highlighted a number of problems that would need to be tackled if clinics were to be run efficiently and the numbers of DNAs reduced. Since the report was received the Trust has set in hand a number of initiatives to reduce the rates of DNAs.

What was done?

The District Audit report recommended the establishment of a policy for the management of outpatient clinics together with the introduction of standard operational guidelines and procedures. Better recording systems were seen as essential to ensure that management could monitor progress.

The Trust organised two workshops in 1998 to discuss the report and review the handing of appointment systems and DNAs with medical secretaries who had a unique insight into the problem. The consensus was that the key to success rested on better communications, both within the Trust and with patients. A means of assembling better information about why patients did not attend was also seen as a potentially useful way forward.

The Trust subsequently established and adopted, from 1 st January 1999, a Trust-wide standard outpatient clinic procedure for issuing appointments. The main features of this are:


In addition the Trust developed a questionnaire to be sent to people who did not attend to ask why. It would cover a range of issues that the Trust could address as it sought further improvement in DNA rates. At the time there was some scepticism that patients would complete the questionnaires, but it was felt worthwhile to try to get the information. The questionnaire would be sent to everyone who failed to attend their appointments and offer a choice of reasons for not attending and a free text section for other comments.

Did it work?

The new policy and procedures had some encouraging early results with average DNA rates falling (Table 1). The Trust no longer has the dubious honour of being near the top of the regional league table for DNAs!

Table 1. Hull and Holderness Community Health NHS Trust: DNAs overall
  Hull Holderness  
  Seen DNA % Seen DNA % Overall DNA (%)
Dec-98 254 85 25 489 129 21 22.3
Mar-99 380 89 19 664 136 17 17.7
Jun-99 322 59 15 579 148 20 18.7

The questionnaire was a good deal more successful than had been expected, confounding the sceptics. In fact about 100 patients returned the questionnaire between January and March 1999, albeit a relatively small proportion of those issued. The information did not offer a magical way of solving the DNA dilemma. Table 2 shows the main reasons given for not attending. Some of the other points made by patients included: they could not get time off work; could not understand the doctor, did not like the location of the clinic, could not understand the letter and bad weather. The high proportion of patients who had not received their appointments led to a review of the postal service to check both out-going and returned mail.

Table 2. Hull and Holderness Community Health NHS Trust: DNAs Questionnaire
Reason Given Number
Forgot 42
Did not receive appointment letter 23
Too ill to attend 20
Appointment inconvenient 9

The Trust decided that further progress will require action related to the needs of specific departments rather than through a Trust-wide approach. For example, each Consultant now receives their DNA rates on a monthly basis. They are encouraged to look at ways to adapt the standard procedure to reflect their patients' needs. Options for restructuring clinics are being encouraged, for example to site clinics closer to where patients live. The Trust covers a large rural area as well as urban Hull and for some patients transport is a real problem.

The steps taken by one consultant psychiatrist illustrate the way that the standard procedure has been adapted. Specific appointment times are only sent to patients who are referred by GPs for an urgent appointment. Other patients are asked to contact the clinic to make a convenient appointment. The experience of this approach has been encouraging (Table 3) and progress is being sustained.

Table 3. Hull and Holderness Community Health Trust: DNAs in Psychiatry
  New patients Reviews
  Seen DNA % Seen DNA %
April 23 5 18 45 11 20
May 17 12 41 46 14 23
June 38 2 5 39 1 3
July 42 3 7 62 6 9

Tips for success

For more information contact

Valerie McLellan
Audit Development Co-ordinator
Hull and East Riding Community Health NHS Trust
Victoria House
Park Street
Hull HU2 8TD

Telephone 01482 223191
Fax 01482 617737

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