The real cost of a did-not-attend, and what actually reduces them

Most did-not-attends come down to one thing: the appointment was booked a long time ago and nothing happened in between. The longer the gap between the booking and the day itself, the more chances there are for a patient to forget, to get better, or to quietly decide not to come. Almost everything that genuinely reduces DNAs works by shortening that gap or filling it.

The short version

• A DNA costs the empty hour plus the admin time to clean it up.
• Long booking lead times cause more misses than forgetful patients do.
• Reminder timing matters more than reminder wording.
• A cancellation list turns a lost hour into a booked one.
• Charging a fee reduces DNAs less than most owners expect.

What a did-not-attend actually costs

The obvious cost is the fee you did not take. For scale, NHS England reported that more than 15 million general practice appointments a year are missed, at an average of £30 each, putting the bill above £216 million. Private practice is a different shape, with fewer appointments at a much higher value each, and the person carrying the loss is usually the one who was standing there ready to treat.

The second cost is the admin, and almost nobody counts it. Someone has to mark the appointment, decide whether to charge, write to the patient, try to rebook, and update the notes. In the clinic I managed, that cleanup was rarely under ten minutes per miss, and it always landed on the person who already had a full desk.

The third cost is the one that never shows up on a report. A patient who misses an appointment is often mid-course. The session they miss is frequently the one that never gets rebooked, and the course of treatment quietly stops there. Over a year that is worth far more than the DNA fees.

Why they happen

In eleven years I saw four causes account for nearly all of it, and only one of them is about the patient being disorganised.

Lead time. An appointment booked six weeks out has six weeks to go wrong. Diaries that run a long way ahead look healthy and lose more slots.

No point of commitment. Booking is not the same as committing. If nothing happens between the booking and the day, the patient has never had to reconfirm the decision.

Reminder timing. A reminder that lands too early gets forgotten again. One that lands too late gives the patient no room to rearrange, so they say nothing and do not turn up.

No easy way out. If cancelling means phoning during clinic hours and explaining yourself to a person, a fair number of people will avoid the call and take the silent option instead.

What actually reduces them

Start with reminder timing, because it is the cheapest change and usually the largest. Cliniko will send an email or SMS reminder up to nine days before the appointment, with an option to skip weekends, so a Monday morning slot does not get its reminder on a Saturday. Two reminders usually beat one: an early one that catches "I forgot I booked this" and a day-before one that catches "I forgot it was tomorrow". SMS is billed per credit and anything over 160 characters costs a second credit, so keep the wording tight.

Then make cancelling easy. Clinic owners resist this, and they are right that it increases the number of cancellations. It also converts silent DNAs into cancellations you can see days in advance, and a cancellation you can see is a slot you can sell. A patient who cancels on Tuesday for a Friday appointment has given you something valuable. A patient who says nothing has given you an empty hour.

Book the next appointment while the patient is still in the room. It sounds obvious and it is the single habit that varies most between practitioners in the same clinic. The rebooking that happens at the desk holds far better than the one chased by email a fortnight later.

Keep a short lead time available. If your first free slot is five weeks away for everybody, you will lose a predictable share of them. Holding a handful of near-term slots back gives you somewhere to put the people who need seeing soon, and those appointments almost always get attended.

The other half of the problem is refilling the gap

You will never prevent every miss, so the second job is turning the hole back into an appointment. This is where a cancellation list earns its money, and where most clinics have the feature switched on and never use it.

In Cliniko it is the wait list. Patients go on with their availability, preferred practitioner, business and appointment type, and when a slot opens you create the appointment and choose select from wait list, which shows only the patients available that day for that practitioner. It takes about a minute.

The reason it goes unused is not the software. It is that nobody is watching the diary at twenty to nine when the cancellation lands. A gap spotted at nine can usually be filled. The same gap spotted at two in the afternoon is gone. That is a watching job rather than a clever job, which is exactly why it falls off the list in a clinic where everyone is treating.

Charging for a did-not-attend, honestly

A DNA fee does two useful things. It makes the policy real, and it gives whoever is on reception something concrete to say instead of an apology. What it changes less than owners expect is behaviour, because the patients who miss most are often the ones least able to absorb the charge, and in most clinics I have seen the fee gets waived far more often than the policy suggests.

If you do charge, decide two things in advance. Put the policy in the booking confirmation so nobody is surprised by it, and agree who has authority to waive it, so that decision never lands on a clinician between patients.

There is also a tax question worth asking properly. Cancellation and no-show charges are not automatically outside the scope of VAT simply because they look like compensation, and HMRC set out its position in Revenue and Customs Brief 2 (2022). I am not an accountant and this is worth five minutes with yours rather than an assumption.

Get the baseline, then change one thing at a time

Most clinics guess at their DNA rate and guess high. Pull the real numbers first, by practitioner, because the variation between practitioners in the same building is usually bigger than anything you are about to change.

Worth having: misses as a percentage of booked appointments, cancellations and how much notice they came with, how many of those cancelled slots got refilled, and the average gap between booking and appointment date.

Cliniko has a Missed appointments report under Reports covering did-not-arrive and cancelled appointments, filterable by date range, practitioner and business. One detail catches people out: cancelled appointments are filtered by the cancellation date, while DNAs are filtered by the appointment date. Compare the two columns without knowing that and the numbers will not reconcile.

Run the same report a month after you change the reminders. If nothing moved, change the timing rather than the wording. Change one thing at a time or you will never know which one worked.

None of the above is hard. It is relentless, and it needs doing at the exact times of day when you are with a patient. That is the honest reason clinics tolerate a DNA rate they know is too high, and it has nothing to do with not caring. If you are on Cliniko, most of what is described here is a settings job and then a watching job rather than a new system to learn.