NHS must stop penalising patients for missed appointments, University of Glasgow study finds

NHS services should stop blaming patients for missed appointments and instead focus on the barriers preventing them from attending, researchers have said.

A “move away from patient blame” is key to improving the issue in Scotland’s NHS, according to the new study from the University of Glasgow published in BMC Medicine.

Missingness is defined as “the repeated tendency not to take up offers of care such that it has a negative impact on the person and their life chances”.

Evidence from the study, together with real-world examples from GP practices, have highlighted the need to focus on the many complex and overlapping reasons why patients miss appointments in order to be able to effectively tackle the issue.

Missing GP and hospital appointments is associated with poorer health outcomes and a higher risk of early death. The people most likely to miss appointments are often those with the greatest health needs.

‘Punishing patients worsens equalities’

Current methods to tackle missingness often focus blame on poor patient behaviour and ultimately penalise the most vulnerable. Warning letters and automatic discharges force patients to seek new referrals, placing responsibility solely on the individual while ignoring underlying barriers like poor health, transport difficulties and unstable living circumstances.

They say healthcare services should focus on understanding why appointments are missed, rather than blaming patients.

Suggested measures include identifying people most at risk of missing appointments, improving communication, offering more flexible appointments, considering transport barriers, and introducing staff dedicated to supporting patients who repeatedly miss care.

Dr Calum Lindsay, first author of the paper from the University of Glasgow, said: “We know that patients at risk of missingness are already more likely to have multiple physical and mental health conditions. In addition, they are also more likely to live in adverse or precarious circumstances and experience a range of negative health outcomes.

“However, existing approaches designed to address missed appointments rarely focus on these patients, and when they do it is often through a punitive lens rather than one that engages meaningfully with the causes of missingness. As a result, existing interventions are often ineffective for these patients and may instead worsen access inequalities.”

Addressing missingness in healthcare is a tangible way to address health inequalities, a central goal of the Scottish Government’s Population Health Framework.

The Scottish Government has funded Glasgow Deep End practices, serving the most deprived communities, through Inclusion Health Action in General Practice funding to address missingness, which has led to GP practices changing what they do.

The concept of missingness is also gaining traction across the UK and was included in the recent Royal College of GPs ‘Fairer Practice Toolkit’.

‘A flexible, more compassionate approach’

In Glasgow, the Victoria Practice at Govanhill Health Centre has taken significant steps to tackle missingness over the past three years.

By working with the Govanhill COPC (Community-oriented Primary Care) group and learning that other services in the area were also having issues with patients missing appointments, the practice made a number of changes.

These included increasing appointments from 10 to 15 minutes, working with the community and local groups to better understand barriers to attending appointments, taking a more proactive and flexible approach to speak with patients following a missed appointment, and participating in sessions on health inequality.

The practice also changed how it offered bookable and on-the-day appointments and introduced a missingness coordinator to reach out to patients to offer support or guidance, particularly those who frequently fail to attend screening services.

Between January 2024 and January 2025, they saw a 30.7% improvement compared month on month, and anecdotally, there are now days when they have no missed appointments.

Practice manager Robert Shaw said: “When I joined the practice as practice manager in June 2023, I could see we had a severe problem with missed appointments, which was causing problems, including patients not receiving the care they needed, wasting interpreters’ time and a lack of continuity of care.

“It wasn’t uncommon for us to have patients register with us having already been registered and removed from one (or more) of the three other practices in our local vicinity.

“By making a series of changes and small steps over the past three years, including identifying our practice value, who we want to be and what kind of service do we want to offer, we’ve significantly reduced the number of missed appointments at the practice.

“I’d also add the positive impact this work has had on our team. They’re not exhausting themselves trying to get patients to fit into a system that doesn’t work for them. A more flexible approach has seemed to ease the pressure on them significantly, allowing them to respond with compassion rather than frustration.”

Professor Andrea Williamson, GP and professor of General Practice and Inclusion Health at the University of Glasgow, said: “Our research shows that we need to move away from a system of patient blame for service problems, towards an approach where services are incentivised and committed to identifying and addressing barriers to care.

“The study highlights the importance of both building and repairing relationships to help patients feel safe, alongside directing responses to those who need them most, ensuring they are tailored to fit their priorities and circumstances.”

The study, ‘Addressing the causes of ‘missingness’ in healthcare: a co-designed suite of interventions’ is published in BMC Medicine. The project is funded by the National Institute for Health Research (NIHR).