Bulletin October 2008.
qxp 12/09/2008 12:37 Page 316
DOI: 10.1308/147363508X333987
AT T E N D A N C E R AT E S
DURING WORKING-HOURS
V E R S U S O U T- O F - H O U R S
OTO L A RY N G O L O G Y C L I N I C S
AJ Donne1 SpR
R Swindell2 Medical Statistician
1
University Department of Otolaryngology – Head and Neck Surgery, Manchester Royal Infirmary
2
Medical Statistics, Christie Hospital NHS Trust, Manchester
In the foreword to Choice matters:
Increasing choice improves patients’
experiences, the minister of state for
delivery and quality states that
patients want and expect convenient
services tailored to accommodate
their increasingly busy lives.1 The
British Social Attitudes Survey 22nd
Report indicated that patients with
semi-routine and routine
occupations were more interested
in choice compared to patients with
managerial and professional
occupations.2 However, almost 60%
of the latter group were still
interested. Clearly a major
proportion of the general public are
keen to be empowered with greater
choice.
Ann R Coll Surg Engl
(Suppl) 2008; 90:316–319
316
D Siau1 SHO
JJ Homer1 Consultant in Otolaryngology
It has always been assumed that patients
would prefer to be able to attend clinic
out of hours. Feeney et al. published a
survey of 264 patients, of which two-
thirds of the patients questioned
expressed a desire for out-of-hours or
weekend clinics.3 If the proportions of
patients not attending a clinic could be
used as a crude indicator of patient
interest, then a survey of 9am–5pm
versus evening clinic visits would be a
valid starting point to assess whether the
patients’ response to the Feeney et al.
survey3 actually resulted in an improved
attendance.
The non-attendance rate varies among
the different specialties, eg 6.5–42% in
primary care4,5 and 26–33% in
otolaryngology.6,7 Reduction in the rate of
non-attendance has been successfully
achieved by mobile phone text reminders
to patients.7 However, despite a text
reminder the ‘did not attend’ (DNA) rate
was still high at 22%. The fundamental
difference between new and follow-up
patients is that the former are allocated
an appointment that requires the patient
to contact the hospital to alter the date.
The follow-up patient typically makes an
appointment at the end of the
consultation, which should at least be
convenient at the time of making the
appointment. The ‘choose and book’
system should even this out.
Method
We prospectively collected data on
patient attendance numbers to routine
otolaryngology clinics. Three clinics ran
on the same day: morning, afternoon and
evening for the same sole
otolaryngologist. Information was
retrieved during a six-month period from
November 2005 to May 2006. The data
were collected at the completion of each
day’s clinics from a register of attendance
status for each patient. All new patients
were sent an appointment date by post.
The allocation of morning, afternoon or
evening times was random for new
patients.
The letter stated in plain English that if
the appointment were inconvenient it was
possible to postpone it. However, the
letter to new patients did not contain an
invitation to change specifically to an
evening clinic if more convenient. Follow-
up patients were given the next available
clinic date, which may or may not have
been an evening clinic slot depending on
the availability of daytime slots. Follow-up
patients could request evening clinic
appointments: as they were more
informed they were given some choice.
For both new and follow-up patients who
expressed a need to change their
appointment, their preference was always
accommodated depending on clinic
availability.
The attendance categories were
‘attended’, ‘cancelled and rebooked’
(CRB) and DNA. The CRB category
included any person who contacted or
telephoned the outpatient department to
postpone his or her visit with insufficient
notice to allow another patient to benefit
from that appointment slot. New patients
(once seen) were kept under the same
surgeon until discharge. Also, many
follow-up patients were originally seen in
the clinic as new patients.
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The patients’ referral letters were not

TABLE 1
addressed specifically to the surgeon in
the clinic. The patient group included only SUMMARY OF CLINIC ATTENDANCE IN THE THREE TIME PERIODS
routine otolaryngology problems with no Appointment Attended TDNA (% of total)
presumed head and neck malignancy and
Morning 330 235 95 (28.8%)
only rarely was the patient a child. The
Afternoon 316 222 94 (29.8%)
attendance data were entered into an
Excel spreadsheet and grouped into Evening 256 172 84 (32.8%)
morning, afternoon and evening clinics. Total 902 629 273
The data were further subdivided into
new and follow-up patients. The statistical
analysis was carried out using a FIGURE 1
partitioned chi-square test.8
PROPORTIONS OF SEEN, CRB AND DNA FOR FOLLOW-UP AND NEW PATIENTS

Results 100
Data were rejected for two weeks during
90
the six-month period, notably the weeks
commencing 28 November 2005 and 26 80

December 2005. The former date had the 70

evening clinic cancelled on that day and
therefore the morning and afternoon did 60

not have the necessary control. For the 50

latter date, data were rejected as the
40
department restricted patient review for
emergency work only. 30

20
In total 902 patients who had clinic
appointments made for the period 10

between November 2005 and May 2006 0

%

where analysed. The breakdown of Morning Afternoon Evening

Follow-up patient portions
appointments was 36.6%, 35.0% and
28.4% for morning, afternoon and evening Seen CRB DNA

respectively. The follow-up-to-new ratio

was 3:2 for morning and afternoon but
100
3.3:1 for the evening clinics. The
percentage of patients who either DNA 90
or CRB (‘total DNA’ (TDNA)) was 29%,
80
30% and 33% in morning, afternoon and
evening clinics respectively. The TDNA 70

rate did not differ between morning, 60

afternoon and evening when assessed by
50
chi-square test: p=0.56 with 2 degrees of
freedom and a χ2=1.17 (Table 1). 40

30
A summary of the data is demonstrated
in Figure 1. The breakdown of numbers of 20

patients in each category used for 10

statistical analysis is displayed in Table 2.
0
New patients attend better than follow-
%

Morning Afternoon Evening

up patients for all periods throughout the New patient portions
day (p=0.00005, χ2=3.8). Seen CRB DNA

The proportion of new to follow-up

patients in the evening clinic was lower
than the morning or afternoon clinic as
the evening clinic was intended to be a
lighter clinic. Of the cases not attending,
the CRB rate for follow-up patients was
significantly higher (49.3%) for the evening
clinic compared to morning and
afternoon clinics (29.7%), χ2=7.52,
p=0.006. The new patients in general
were unlikely to CRB. New patient CRB
rates were 3.1%, 2.3% and 1.7% for
morning, afternoon and evening clinics
respectively compared to 9.4%, 12.0%
and 17.7% respectively for follow-up
patients.

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figures. Furthermore, pragmatically, these

TABLE 2
patients failed to give enough notice to
PATIENT NUMBERS (AND EXPECTED NUMBERS) FOR EACH CLINIC TYPE FOR give the slot to another patient –
FOLLOW-UP AND NEW PATIENTS therefore the detrimental effect on
Follow-up New service delivery is the same.
Seen CRB DNA Seen CRB DNA Total

Morning 139 19 45 96 4 27 330

(137.6) (27.8)
Afternoon 110 22
(131.7) (26.6)
Evening 127 35
(106.7) (21.6)
Total 376 76
TABLE 3
ALL FOLLOW-UP VERSUS ALL NEW PATIENT ATTENDANCE TYPE
All follow-ups
Seen 376 (407.9)
CRB 76 (54.5)
DNA 133 (122.6)
Total 585
Separating the data into either new or
follow-up rather than morning, afternoon
and evening was performed to avoid the
bias of fewer new patients in evening
clinics, ie even though there are more
follow-up patients in evening clinics this is
not relevant to this analysis. It is clear
that there were significant differences
between the two groups as the analysis
revealed that new patients are more likely
to attend and follow-up patients to CRB
(p=0.00005, χ2=33.8, see Table 3).
Discussion
This is the first published survey of its
kind and we have only been able to
perform it given the particular situation of
three clinics running on the same day each
week, performed by the same surgeon.
The data for this prospective survey are
for an almost continuous six-month
period except for the two dates indicated
earlier. We felt a six-month period was a
reasonable study duration that was based
on predicted numbers of patients to
receive clinic appointments in that time
(about 1,000). The numbers acquired do
allow a good comparison between clinics.
There may be inherent bias within this
study as new patients were allocated the
It is interesting that the CRB rate for new
(48.7) (92.6) (2.9) (20.49) patients is significantly smaller. This may
reflect the fact that they may either be
52 112 3 17 316
(46.6) (88.6) (2.8) (19.62) anxious to be seen as soon as possible
for diagnosis (one assumes most follow-
36 45 1 12 256
(37.7) (71.8) (2.3) (19.89)
up patients have had a diagnosis). Indeed,
this probably explains the overall better
133 253 8 56 902
attendance for new patients. When each
new patient was sent an appointment by
post, the patient had a clear invitation to
cancel and rebook for a more convenient
time. The follow-up patients chose their
All new Total
own appointment slot at the end of the
consultation.
253 (221.1) 629
8 (29.5) 84 We believe it would be worthwhile to
56 (66.4) 189 study the DNA rates for ‘choose and
317 902
book’ versus non-‘choose and book,’ both
now and when the system is fully
established. It would also be interesting to
ascertain how many patients choose
next available appointment. However, evening clinic appointments, if offered.
follow-up patients had more opportunity
to negotiate their appointments. There will inevitably be more routine
Therefore, follow-up patient attendance evening clinic for all hospital specialties.
should have been better than new patient Indeed, as an incentive under the new
attendance. consultant contract, it is suggested that
evening clinics are paid as an extra
The data clearly show that the total DNA programmed activity at an additional 10%
rate is the same for all three time periods of basic salary (http://www.bma.org.uk/
of the day. The new patient TDNA rate ap.nsf/Content/CCSCcontractFAQs/), a
was significantly lower than for follow-up clear indication that out-of-hours clinics
patients. Therefore, as there were are likely to develop further. Many NHS
relatively more follow-up patients in the trusts are obliged to operate extra clinics,
evening clinic, DNA rates balanced often in the evening, in order to reduce
between daytime and evening. waiting times and ultimately adhere to the
Furthermore, new patients did not attend 18-week target.9 The 18-week patient
the evening more reliably than daytime pathway is to be implemented in January
clinics. 2007 and aims that no patient will wait
longer than 18 weeks from GP referral to
It can be initially assumed that the very hospital treatment.
high CRB rate for evening follow-up
patients might be interpreted as a The cost of out-of-hours clinics has been
conscientious effort to keep an assessed in primary care. It has been
appointment. Patients may be placing estimated that the cost of these clinics
more value on being given an evening was 22% more than expected by the
clinic appointment. However, this may government10 and this may be expected of
simply indicate late rebooking, since early hospital-based clinic also.
rebooking was not represented in these
data as it was not accessible. It can Non-attendance has been previously
therefore be considered acceptable to studied and some conclusions drawn.
include these patients in the TDNA Patients with self-limiting problems are

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THE ROYAL COLLEGE OF SURGEONS OF ENGLAND BU L L E T I N

thought not to attend11 and this is likely
to be important with ear, nose and throat
problems. Furthermore, others have
suggested that younger patients are less
likely to attend;12 however, this is not
universal.7 It has also been suggested that
men are less likely to attend13 though
others have not found this to be the
case.6 These aspects are all clearly
interesting to generate efficient clinics but
this was not the purpose of the present
study. This information was therefore
specifically not collected as the existing
evidence is inconsistent.
The socio-economic classification may
have an impact upon the DNA status.
However, according to the Office for
National Statistics in 2001 (available
online) the Greater Manchester region
(strategic health authority) has a close
similarity in socio-economic class
distribution to the whole north-western
region and this broadly reflects the
national English picture (http://www.
statistics.gov.uk/). These national data
Manchester population would be a
relatively good indicator of the situation
in England as a whole.
Conclusion
Out-of-hours clinics are becoming more
common in the UK. However, our data do
not support the assumption that they are
more popular and convenient as there is
no difference in attendance between
morning and afternoon compared to
evening clinics. We have shown that new
patients attend better than follow-up
patients in all periods of the day and
efforts at reducing overall DNA rates
should perhaps target follow-up patients
in particular.
References
1. Department of Health. Choice matters: Increasing choice
improves patients’ experiences. London: DH; May 2006.
2. Appleby J, Alvarez A. Public Responses to NHS
Reform. In: British Social Attitudes Survey 22nd Report.
London: Sage Publications; 2005.
3. Feeney CL, Roberts NJ, Partridge MR. Do medical
outpatients want ‘out of hours’ clinics? BMC Health
Serv Res 2005; 5: 47.
are they and what can be done about them? Fam Pract
2000; 17: 252–53.
5. Macharia WM, Leon G, Rowe BH et al. An overview of
interventions to improve compliance with appointment
keeping for medical services. JAMA 1992; 267:
1,813–17.
6. Lloyd M, Bradford C, Webb S. Non-attendance at
outpatient clinics: is it related to the referral process?
Fam Pract 1993; 10: 111–17.
7. Geraghty M, Glynn F, Amin M et al. Patient mobile
telephone ‘text’ reminder: a novel way to reduce non-
attendance at the ENT out-patient clinic. J Laryngol
Otol 2008; 122: 296–98. Epub 2007 May 1.
8. Armitage P, Berry G, Matthews JNS. Statistical Methods
in Medical Research, 4th edn. Oxford: Blackwell; 2002.
9. Department of Health. Tackling hospital waiting: the 18
week patient pathway. An implementation framework.
London: DH; May 2006.
10.O’Dowd A. Cost of out of hours care was 22% higher
than predicted in England. BMJ 2006 May 13; 332:
1,113.
11.Leese AM, Wilson JA, Murray JAM. A survey of the
non-attendance rate at the ENT clinic of a district
general hospital. Clin Otolaryngol Allied Sci 1986; 11:
37–40.
12.Sawyer SM, Zalan A, Bond LM. Telephone reminders
improve adolescent clinic attendance: a randomized
controlled trial. J Paediatr Child Health 2002; 38: 79–83.
13.Frankel S, Farrow A, West R. Non-attendance or non-
invitation? A case-control study of failed outpatient
appointments. BMJ 1989 May 20; 298: 1,343–45.

may indicate that studies on the 4. Waller J, Hodgkin P. Defaulters in general practice: who

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319