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The causes of missed healthcare appointments are complex and varied, and not an issue to blame patients for, according to new research which suggests addressing the issue of ‘missingness should be a policy priority.

The new research, which is published in BMC Medicine and led by researchers at the University of Glasgow, looked at the causes and consequences of multiple missed appointments in primary care, and the role this plays in producing and widening health inequalities in society. This is the first major paper to look specifically at the causes of multiple missed appointments, and researchers believe the findings suggest a different approach is required to tackle the challenge of missing patients.

The study is a realist review of current research on this subject, taking into account 197 previous papers in order to better understand the reasons behind multiple missed appointments, beyond the public narrative of forgetfulness or irresponsible patient behaviour. Overall, the research found that the reasons behind missed primary care appointments were rooted in the interaction between people and healthcare systems, countering stereotyped portrayals of poor patient behaviour.

Study results showed that missing multiple appointments were caused by an overlapping set of complex factors. Patients may not feel that primary care services are the right place for them: they may feel their problems cannot be solved or have low expectations for their health, or experience anxiety, worry, shame or embarrassment about their health. They may have bad prior experiences of seeking care, including poor communication and power imbalances that make them feel excluded from their own care. 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.

Many patients also struggle to navigate healthcare systems and are deterred by ‘gatekeeping’ staff, 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. Travel costs, inadequate public transport and poor mental health and poor mobility impact whether people can get to their doctors. 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 don’t try to target the real causes of multiple missed appointments are bound to fail, further impacting some of the most vulnerable patients in society, increasingly health inequalities and negatively impacting the NHS.

As part of the study, the research team identified three main policy principles that should be focused on in order to better tackle the issue of missed appointments: identify and reach out to ‘missing’ patients and tailor interventions to their needs; target the multiple causes identified above; and focus on making patients feel safe in the NHS by addressing stigma, judgement, dehumanisation, mistrust and trauma.

Dr Calum Lindsay, lead author of the study from the University of Glasgow’s School of Health & Wellbeing, said: “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.”

The study, ‘Understanding the causes of missingness in primary care: A realist review’ is published in BMC Medicine and the study team includes team members from the Universities of Oxford and Bath. The work was funded by the National Institute of Health Research UK.

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Enquiries: ali.howard@glasgow.ac.uk or elizabeth.mcmeekin@glasgow.ac.uk

First published: 1 July 2024