The causes of missed healthcare appointments in primary care are complex and varied, and must be addressed through policy rather than placing blame with individuals, Glasgow researchers say in a first-of-its-kind study.

In the new study, researchers investigated both the causes and consequences of multiple missed appointments in primary care – and the role missed appointments play in widening health inequalities.

By reviewing the current research on this subject of ‘missingness’ across 197 previous study papers, the team aimed to understand better the reasons behind multiple missed appointments, beyond the public narrative of forgetfulness or irresponsible patient behaviour.

Collaborating across the Universities of Glasgow, Oxford and Bath, researchers believe their findings point to the need for the Scottish and UK government to promote a different approach than previously adopted to tackle the challenge of missing patients.

Overall, the study reports that the prominent reasons underlying missed primary care appointments were rooted in the interaction between people and healthcare systems.

This counters the ‘stereotyped’ portrayals of poor patient behaviour, researchers say.

The findings revealing that missing multiple appointments was linked to an overlapping set of factors, from patient expectations for their health to bad prior experiences and mistrust of the healthcare system.

Dr Calum Lindsay, lead author of the study and research associate in University of Glasgow’s School of Health & Wellbeing, says:

“Ours is the first major paper looking specifically at the causes of multiple missed appointments in primary care, which is a major issue for both people and the NHS.

“We have found that patients may not attend because of a range of complex factors in their own lives, as well as factors in the design of health services that can make them harder for patients to access and use.

“Patients might come to believe that services and their offerings are not designed or meant ‘for them’ – not suitable, beneficial or appropriate for their needs or their identities.

“Non-attendance can reflect a lifetime of experiences with services, as well as other meaningful relationships that shape a person’s sense of self, in relation to health services and to other caring relationships, and needs to be tackled in a sensitive way that puts individuals and their needs at the heart of public policy in this area.”

Barriers not forgetfulness

People’s bad prior experiences of seeking care, including poor communication and power imbalances that make them feel excluded from their own care, compound the issue of missed appointments.

Patients may have high levels of mistrust in healthcare providers as a result, and because of wider experiences of trauma, stigma, discrimination and hostility that can make it hard to seek help.

The study also found that patients may feel their problems cannot be solved or they have low expectations for their health, and can experience anxiety, worry, shame or embarrassment about their health.

Travel costs, inadequate public transport and poor mental health and poor mobility were identified as further impacting whether people can get to their doctors.

The Glasgow team echoes the call made by Public Health Scotland earlier this year, for public policy to recognise the ‘vital role’ transport plays in health and wellbeing – highlighting transport poverty as widening health inequalities.

Competing demands

Many patients also struggle to navigate and are deterred by ‘gatekeeping’ in the healthcare system, as well as long delays, administrative errors, and a lack of flexibility in appointment scheduling.

Flexibility is particularly important for patients with many competing demands and priorities, particularly patients with lots of appointments, caring responsibilities or who face difficulties meeting other basic needs.

Last year, Carers Scotland called for urgent investment in both physical and mental health support for unpaid carers, as it reported the ‘devastating’ impacts felt by carers amidst a strained health and care system.

The charity revealed that more than half of carers say that their physical health suffered because of their caring role and 25% said that delays in NHS appointments meant they had not accessed mental health support.

Meanwhile, the Global Ageing Conference heard from one Scottish carer that they are at a health and poverty “tipping point”, often so focused on their caring responsibilities they are unable to meet their own needs:

“I have illnesses that I can’t get treatment and healthcare for because I’m too busy taking care of my son. He’s my priority. By the time I get to 50, 60, I could be in a wheelchair or hospitalised.

“How will that affect the NHS, the government? They’ll have to cover it – I’ve not got work or money. So that’s why we need to make a change now and that’s what I hope we’re all going to have ideas and discussions about going forward.”

Working with colleagues at the Universities of Oxford and Bath on this patient missingness project, the researchers found that these issues are not experienced in isolation.

They say that it is very likely that patients who are missing will experience many of these issues at once, or over a long period of time, restricting their ability to attend appointments consistently.

Previous work has shown that patients who miss multiple appointments often have significant health needs, experience severe socioeconomic marginalisation, and very high levels of premature mortality.

In addition, researchers for this study argue that healthcare policy interventions that do not try to target these causes of multiple missed appointments are bound to fail.

This, the team outlines, leads to further impacts on some of the most vulnerable patients in society, in turn increasingly health inequalities and negatively impacting the NHS.

Perspective from the Deep End

Professor Andrea Williamson, a deep-end GP and Professor of General Practice and Inclusion Health, told healthandcare.scot that UK and Scottish governments alike can support the NHS by applying a ‘missingness lens’ to health policies:

“A start would be to apply a missingness lens to all health policies, which views the health care system as needing to adapt to meet all patients’ needs effectively rather than dismissing patients at risk of missingness as not worthy or not deserving of care.”

As part of the study, researchers identified three main policy principles that should be focused on in order to better tackle the issue of missed appointments: outreach, personalised care, and creating a healthcare system where patients feel safe and not stigmatised.

They say that policy must support healthcare staff to identify and reach out to ‘missing’ patients and tailor interventions to their needs and target the multiple causes identified above.

More widely, researchers call for a focus on making patients feel accepted and safe in the NHS by addressing stigma, judgement, dehumanisation, mistrust and trauma.

Professor Williamson, who also leads on this missingness in health research, says there must be a better focus on patients’ journey through healthcare as the key to good care and outcomes:

“I view silos and exclusions as factors that drive missing patients to feel ‘this is not for me’ and we have the solution already – a no wrong door approach where instead of saying ‘you don't fit our criteria we are not accepting you in our service’ we instead say: ‘this might not quite be the best place to meet your needs, but let us organise for you to get to the right place for you’.

“And then importantly – do that.”

She says this would also reduce the workload for many healthcare professionals, adding that the Glasgow team are already developing actions to address missingness in primary care:

“We are designing a set of interventions to address missingness in primary care at the moment alongside people who are experts by experience of missingness and professionals.

“One of the core principles of that is that addressing missingness needs additional resources – and the link worker role may well be an important part of that.”

Read more: GPs in ‘moral distress' over drug shortage crisis; Breastfeeding in Glasgow: A collective responsibility; Scotland's doctors ‘trying not to lose hope'; Uncovering the hidden role of carers in Scotland; College: Preserve GPs to preserve the NHS; Long COVID: Alone and forgotten; NHS is not a ‘political football', warns BMA; Doctors call for action on air pollution 

Sign up to our bulletin for key health & social care updates straight to your inbox.