Breaking the ABCs of policymaking: is charging for missed appointments the wrong solution to the wrong problem?

The dust now starts to settle on the spending review. While additional funding is welcomed (with important caveats), there will always be those who question whether funding health care solely through taxation is the right model - the Economist recently discussed ‘how little Britain raises privately for health care, suggesting that there is scope for more patient charges’.

One of the most commonly put forward options for charging is penalties for those who miss health care appointments. Where charging for anything else in the NHS is usually off limits, this idea seems to provoke more support.

According to recent polls, only 15% of the public support the idea of a £10 charge to visit a GP, whereas 61% of those surveyed were content with the idea of a £10 fine for missed appointments. Perhaps where charges for revenue-raising alone are unpalatable, a charge designed to also incentivise a change in behaviour (attendance at appointments) can be justified by many as being for the greater good.

Some will also argue that charging is a necessary solution to a very real problem. NHS England suggests that more than twelve million GP appointments are missed each year in the UK, costing in excess of £162m per year. Age of austerity or not, that’s not a figure to be sniffed at.

Whenever this issue makes its appearance, it raises three basic questions for me - questions which should ideally feature in any policymaker’s ‘ABC of policy’ book:

1. What do we know about the problem we are trying to solve?
2. Will this solution solve the problem?
3. Are there better alternatives?

Those arguing in favour of charges are likely to answer these questions with:

1. ‘People are being reckless and missing appointments for no good reason’,
2. ‘A charge will act as an incentive for good behaviour’,
3. ‘It’s the only way to show we mean business on this’.

If this is the case, the argument for fines would appear to have some merit.

However, if we consult the evidence base, the story is not quite so straightforward.

Question number 1: What do we know about the problem we are trying to solve?

Like many things health policy related, we actually don’t know a huge amount about what really drives missed appointments. Systematic reviews churn up very little other than ‘more research is needed’. Where studies do exist (often from the States), however, they point to forgetfulness (Sagepub.com, Pubmed.govI, Wiley.com, NCBI.com, Bristol.ac.uk), administrative problems  (e.g. never received the appointment letter), ‘chaotic lives’(often associated with vulnerability), or access issues related to transport as some of the more likely reasons.

This seems to contradict the underlying assumptions about what problem charging would be there to solve. If a penalty is the answer, this assumes that some form of reckless behaviour is the cause, so a punishment is one solution. However, wilfully choosing to waste taxpayers’ money isn’t backed up in the existing evidence for why people are actually missing appointments.

Question number 2: Will this solution solve the problem?

Even if you take a hard line and say ‘forgetfulness’ is indirectly being reckless so fines would make people be more responsible, charges might not be the best way to do this.

Again, there is limited evidence on the effectiveness of fines as a solution to this or similar problems. In some experiments in other sectors, fines have even been associated with an increase in the behaviour that the intervention was trying to reduce. People thought that the alternative became excusable if they paid the fine. It crowded out any intrinsic motivation that people had to ‘do the right thing’.

More worryingly, we also already know that where user charges do get implemented in health care, they tend to affect the poorest and sickest in society disproportionately more than others. Given that most missed appointments correlate with demographic factors including deprivation, this type of fine is likely to do the same - generally not the approach aimed for within an NHS which has traditionally taken pride in a principle of fairness.

Question number 3: Are there better alternatives?

So the problem might not be the one we thought it to be, and either way, the proposed solution might not even work anyway. Is it all we’ve got to go on, so potentially worth giving it a go?

There are alternative options to charging which have shown potential at going some way to help with the problem, without quite so many of the negative side effects that charging brings. Granted, like charging, the evidence base on some of these alternatives is still emerging and none represent a magic bullet. But results can be worth consideration nonetheless.

Examples include text or telephone appointment reminders (to help with the forgetfulness point), self-booking of appointments or even the application of some techniques from behavioural science such as commitment devices (e.g. getting people to write their own appointment details down) and / or nudge techniques which play to people’s social consciences about waste in the NHS or a desire to be part of the ‘majority’ who do attend on time.

More detailed analysis of the costs and benefits is needed for all of these options, but there are some promising signs. Recent Randomised Control Trials undertaken by Imperial College suggested that moving from the existing appointment reminder system to one which also includes a message about the cost to the NHS of people missing appointments would result in 5,800 fewer missed appointments per year in the Trust in question, at no additional cost. Whilst not comparing like for like, some cautious optimism for such alternatives to fines could be permitted considering that estimated revenue from charges for missed outpatient hospital appointments total about £55m, but this is before administrative costs, appeal costs and exemptions, which would bring this figure down in reality.

So pose a few basic questions, get a basic answer: before jumping into charging for missed appointments, let’s pause to question if that is the right solution to the right problem.

Any policy based on a misdiagnosis of the problem is at best naïve but at worst harmful. As well as raising questions about good practice in policymaking, there is ultimately a fundamental ideological point here too: is the risk worth taking in light of the principles of fairness that the NHS stands on? If we’re going to plump for any intervention based on a leap of faith about what it will achieve, aren’t the less regressive, probably cheaper to implement, less politically volatile ones a more attractive place to start?

Natalie is a Policy Fellow at the Health Foundation - you can follow Natalie on Twitter @NatalieBerryTHF