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Missing the ap-point-ment


As accountants we are taught, during years of professional training, to be right miserable bastards. Pessimists. Doom and gloom merchants always looking to spoil someone’s fun. We give it a fancier title though and call it being prudent. And a consequence of this prudence is that we learn to treat numbers, especially ones with pound signs in front of them, with a dose of scepticism. If we think something looks odd then we examine the evidence and challenge it if necessary. That’s our job.

And it’s no different for those of us who crunch numbers for a living in the NHS; poring over our spreadsheets and budget statements we are there to assist clinical colleagues to manage the increasingly limited resources at their disposal as well as they possibly can. All of the time being careful not to deliberately over-state or under-state a number to make it look better or worse than it actually is. So when these figures that we’ve sweated over for days, weeks and sometimes months are released into the public domain and are, in some cases, misused and abused you’ll excuse us if we get a bit annoyed.

So it was disappointing to say the least to see the recent Guardian headline “patients missing their appointments cost the NHS £1 billion last year” merely repeating, word for word, the comments of NHS England’s chief nursing officer Professor Jane Cummings. You’d like to think that when journalists are presented with a large number like this that they would perhaps do a little bit of digging to verify its accuracy. Even a five minute search on the internet would begin to cast some doubt on its robustness.

To put this figure into some health-related context for starters; it cost just over one billion pounds to run the trust that provides hospital care for the adult population of Sheffield in the 2016-17 financial year which includes two large city centre hospitals and a total workforce of around 16,000 staff. Which begs the question, if more of us turned up for our outpatient appointments or gave sufficient notice of any cancellations would we really save enough money to provide hospital care for one of the largest cities in the country for an entire year? Really? Alternatively, according to NHS England the money “wasted” by missed outpatient appointments could fund one million more cataract operations or 250,000 hip replacements in some make believe health service where doctors in, say, cardiology sat twiddling their thumbs as a result of patients not turning up to their clinics could scurry on down to the operating theatres and knock out a few cataract or hip operations.

At times it really does feel like we’ve entered a so-called “post-fact” age where anyone with more money than sense can make up a big number, plaster it on the side of a bus and drive it round the country and no one’s going to go “hang on a minute mate, how did you work that one out?” Or have we simply become too inured to the mind boggling array of numbers that are scatter-gunned at us on a daily basis that they cease to have any real meaning beyond looking large and, occasionally, quite scary? £45 million pounds for a bridge across the river Thames that they never started building? £100 million pounds for a half decent footballer? A one billion pound bung to the Democratic Unionist Party to prop up the government? £5 billion for the rights to televise twenty two men kicking a bag of wind around a patch of grass? £133 billion of taxpayers’ money to bail out the banks following the 2008 financial crash? A billion pounds worth of missed hospital appointments? Oh, go on then, I suppose that seems reasonable.

So where does this £1 billion figure come from then? Well, NHS England have derived this number by multiplying the 7.9 million missed hospital appointments in 2016-17 by the average cost of an outpatient attendance (£120) in the same year. But if we take a peek at both of those figures it’s apparent that this calculation is barely more than a quick multiplication on the back of a fag packet. Two figures plucked from the mountain of data that is collected annually about NHS services and multiplied together, with scant regard for how the figures are calculated or what they represent, to produce a figure that is ridiculously misleading and blatantly incorrect.

Firstly let’s look at the number of missed appointments. Figures compiled by NHS Digital (formerly the Health and Social Care Information Centre) show that there were 118.6 million outpatient appointments in 2016-17 with 7.9 million (or 6.7%) of those missed by the patient. That’s a combination of patients that simply didn’t turn up for their appointment and those that turned up late and were unable to be seen. Those in the latter category may have been stuck in traffic or struggled to find a parking space or couldn’t get to hospital because of bad weather and through no fault of their own missed their appointment. It could happen to any of us.

What’s perhaps more interesting though is that if we delve into the NHS Digital outpatient statistics for 2016-17 it’s apparent that the real story isn’t the one that’s generating the headlines; the percentage of missed hospital appointments has actually decreased over the last ten years from 8.4% in 2006-07 and, for the first time in the last decade, more appointments were cancelled by hospitals in 2016-17 (8.3 million) than were not attended by patients – a huge increase in hospital cancellations from 3.0 million in 2006-07 that is indicative of an under-funded healthcare system that is struggling to cope with the demand for services. But clearly that’s not the message that the government and NHS England want you to hear – it’s your fault, remember, for missing all those appointments.

As for the cost of any missed appointments, it’s probably worth noting to begin with that hospitals are not actually required to cost missed appointments. Instead, to come up with that £1 billion figure NHS England has looked at the publicly available annual reference costs that are collected from all hospital trusts. But the first problem with that is that the costs submitted in the annual reference costs exercise are those of an appointment that the patient actually attended – that’s why we refer to an average cost of £120 per “attendance” rather than per appointment.

The second problem with this calculation is that the average costs of hospital attendances taken from the reference costs are “full” costs i.e. they include not only the costs of the doctors, nurses and therapists who deliver care to a patient but also the costs of running and maintaining the buildings in which those services are provided and the “overhead” costs of an array of hospital staff who, whilst they do not treat patients, support those staff who do by providing expertise in areas such as finance, information technology and human resources. Typically these overhead costs can account for around 30% of the total cost of an outpatient attendance. But clearly if a patient does not turn up for an appointment this doesn’t impact directly on the workload of someone, say, working in the hospital’s finance department. So, again, it’s nothing like a true reflection of the actual cost of a missed appointment.

The true cost of a “did not attend” really boils down to the cost of any action that is required as a result of the patient not attending the appointment. For instance, a consultant will probably need to review the patient’s notes and decide whether another appointment should be booked or the patient should be referred back to their GP. In addition, there will be the administrative time spent typing letters and confirming the ongoing course of action. All of this is likely to cost closer to £20 per missed appointment rather than the £120 used by NHS England. Indeed, many hospitals, particularly those that over-book clinics to allow for some patients not attending in the same way that airlines over-book flights, see the costs associated with missed appointments as being relatively immaterial.

Not turning up for hospital and GP appointments clearly risks wasting precious NHS resources and we all have a role to play in turning up to our hospital appointments or, if we can’t make it or the appointment is no longer required, cancelling them in good time. As a result, many hospitals now send text messages to patients in advance of their outpatient appointments warning them of the cost to the NHS if they do not turn up and a study by Barts Health NHS Trust in London in 2014 revealed that sending a text message that specifically referred to the cost incurred by the NHS as a result of a no show reduced the level of missed appointments by 23%. But trotting out meaningless figures like the £1 billion risks deflecting attention away from a government that is simply not committed to a publicly funded health service and since 2010 has systematically under-funded it.

Since the NHS was established spending on health care has grown by an average of 4% per year yet the Department of Health budget will have grown by an average of 1.2% in real terms between 2009-10 and 2020-21; the longest squeeze on NHS funding since it was established seventy years ago. Yet I’ve lost count of how many times I’ve seen Tory politicians on the box boasting of how they are pumping “record levels of spending” into the health service without being pulled up on it. The health service requires additional spending each year to simply stand still and cope with inflation, technological developments and the additional demands that are placed on it by an ageing population and not least by the failures of government policy on social care and the increasingly obscene levels of inequality. A GP in Salford estimates that poverty is a major factor in around 60% of the patients that she currently sees.

The real story here is not that we, the patients, are endangering the NHS by failing to turn up to our appointments but that the health service has been deliberately under-funded since 2010 – yes, spending has gone up but by nowhere near enough to cope with demand. It’s time we all, particularly those whose job it is to investigate and report on such matters, turned into right miserable accountant-like bastards and began questioning what’s happening to our NHS rather than simply regurgitating the “facts” that are presented to us.


From → NHS, Politics

  1. Reblogged this on In Whose Interests? and commented:
    Reblogging this very informative piece about the misleading claims made about the cost of missed appointments in the NHS – by an NHS accountant

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  1. Missing the ap-point-ment « Derby People's Assembly

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