Should Patients Pay For Missed Appointments?

Why fining patients might miss the point…

The clock ticks fifteen minutes past four. You scroll up… your four o’clock patient still hasn’t arrived. After a final glance down at your watch, you give in and put another mark next to this week’s tally of missed appointments.

Before leaving office, Rishi Sunak surfaced the idea of fining patients £10 for missed GP and hospital appointments as an incentive to motivate behaviour change amongst patients. Whilst the proposal was quickly dropped, the idea has persisted amongst certain circles in an attempt to take the economic pressure off a struggling NHS, whilst addressing the growing waiting lists.

Every year 7.2 million people miss their GP appointments and in the hospital setting, 6.4% of the 122 million appointments were unattended in 2021/2022. Each GP appointment costs an average of £30, meaning that the missed appointments cost the NHS approximately £216 million a year.

When viewed in the context of the whole £200 billion NHS budget, a £10 per missed appointment fee may feel insignificant, especially when the costs associated with building and maintaining the system needed to recover the payment are factored in. Some may argue that focusing on the nominal figure is to misunderstand the policy as its aim is to create a deterrence for missing appointments in the first place.

Always Asking Why?

Missed appointments often trigger a unique type of frustration for the healthcare provider. This frustration doesn’t just stem from lost time, but a perceived disregard for the value of NHS care amongst some patients.

Some people believe there is a sense of complacency about the privilege of free, universal healthcare. Inevitably, this reason may hold true in some cases - but not all. To evaluate a potential policy, is to consider all possibilities. So why do some patients miss appointments?

We know from evidence that non-attendance is not randomly distributed across the patient population. There are key determinants of health that will indicate a patient is more likely to miss an appointment:

Living in a deprived part of the country, suffering with a mental health condition, having sensory impairment, mobilising difficulties or living in rural areas with poor transport routes. Penalising these groups further could be problematic.

Realistically, any policy to charge for missed appointments in the UK would acknowledge this by factoring in exceptions for groups such as those on welfare benefits, children, pensioners and chronically ill people. Any economic model would, therefore, have to factor this in when planning how much this scheme would raise for the NHS.

The Result We Want?

Of course the last thing the NHS needs is fines putting off patients from booking appointments in the future and paying their first visit to the NHS much later down the line when they need more serious (and expensive) secondary or tertiary intervention.

Then there’s the psychological shifts that may arise from patients paying for missed appointments. Could it lead to a sense of ‘ownership’ and further entitlement over appointments? Could it lead to a level of friction between the clinician and the patient if the public view doctors as the gatekeepers and enforcers of this magic penalty fine?

Feeling frustration and apathetic towards our health service is understandable. It takes a sense of maturity to try to factor in the legitimate reasons for struggling to make an appointment. Once these legitimate reasons are acknowledged, we can begin to have a conversation about how to curtail missed appointments, but for now the ‘fine’ system doesn’t seem to be one of them.

Kenneth Arrow - Healthcare Market vs Conventional Market

Ever heard of ‘supply & demand’? Well that conventional economic thinking doesn’t apply to healthcare. In fact, the healthcare market defies all the conventional thinking that we see in standard markets.

Kenneth Arrow pointed this out in 1963 claiming that uncertainty and trust shape the medical profession, which makes typical market models inadequate.

If I were to ask a fit and healthy individual when they think they will need to use the health service, they wouldn’t be able to tell me. Healthcare is unpredictable in a unique way. It’s not like booking a holiday or a car, we don’t know when we will fall ill or whether those treatments will eventually succeed.

This uncertainty destabilises market logic because consumers (or patients to you and me) don’t know in advance what they need. You can’t budget like you would for a normal purchase or evaluate what you are buying.

In other markets, if products fail, you can rush to the customer service desk and return it (whilst warning others). In healthcare, patients are rarely in a position to judge whether the care ‘worked’, and there’s no obvious place to leave a review.

On top of this, patient’s can’t easily critique what doctors know, creating a landscape of information asymmetry. Patient’s need to trust doctors to act in their best interests and not in the best interests of the nearest supplier.

Without this trust, healthcare as we know it collapses. It is for this reason why we created professional ethics, licensing and the NHS’s public model — because market forces alone can’t carry the moral and intellectual weight of our profession.

Does the NHS Have Too Many Managers?

Are NHS managers and consultants essential or an example of excessive bureaucracy?

Back in 2015, Sir Stuart Rose concluded in his review of NHS leadership that ‘the NHS is drowning in bureaucracy’. Many people still hold this view and associate bureaucracy with hospital managers.

So how many staff are actually employed as managers? The actual number of people in the NHS formally employed in a full-time managerial position is 51,000. This includes some doctors and nurses who do full time management roles. In total therefore, managers make up around 4% of the total NHS workforce. Suddenly, this number does not seem as large when you consider that managers make up 10% of the UK workforce overall. 

A Bit On The Side

The classic archetype of a suited NHS manager sitting in an office in the far corner of the hospital misses the true reality. Breaking down staff into managers vs non-managers is too simplistic. In reality, there is a significant middle ground. A large proportion of NHS management is done by doctors themselves. Many hospital consultants, for example, take on service leadership or departmental oversight as part of their role.

What NHS managers do is another common question: they lead on service improvement, manage budgets, manage demand and capacity, investigate complaints, manage staff, work with regulators, assess risk and monitor targets and performance.

Not Your Classic Consultant

Lurking in the background of many significant decisions made in the NHS lie the external management consultants who aim to increase efficiency and introduce reform. These are professionals from private firms—like McKinsey, Deloitte, and KPMG, brought in to offer strategic advice (often with a heavy price tag).

The North West London ICB can be one of our examples, where KPMG was paid £652,000 to help implement a strategy creating 'same day access hubs' for all 2.1 million residents in North West London. The aim was to centralise triage for low-complexity cases. From the moment it was implemented the scheme faced significant opposition from GPs and patients, who raised concerns about safety and its logistical feasibility. Eventually, the scheme was abandoned (don’t worry - KPMG got the pay out).

There is no doubt that you may be able to find examples of successful collaboration between the NHS and these firms, but how frequent are these examples? Research published in Public administration examined four years of data from 120 hospitals in England. They found that hiring management consultants created an interesting feedback loop where trusts that used consultants once were more likely to keep doing so, regardless of whether performance improved.

It also failed to find a link between consultancy use and improved efficiency. You would think that trusts who doubled down on management consultant spending should see a gain in productivity but that was not the case. Why are we so loose with our rules here? Oversight bodies need to monitor effects and prevent repeated engagements with firms when there is no measurable benefit observed.

Too Many Managers?

Since the 2010 coalition government, the NHS has faced significant cuts to NHS management. We now spend less on management than countries like France or Germany, and there has been an 18% reduction in NHS managers since 2010. Ironically, further cutting internal management capacity could drive even greater reliance on external consultants, who cost far more and deliver less consistent results.

So is the NHS is overrun with full-time managers? The evidence doesn’t seem to suggest so.

“The "GCS 16" on CT requests never fails to get me - Has the patient unlocked a new level of consciousness?”

“9:20 Cardiology WR - Patient had a cabbage last year”

“To do the FRCPath Part 2 examination, you have to fork out £1531 in 2025. Where does this money go? In actuality, it just about covers the cost of the exam once you factor in examination development, staff costs, venue hire, statistics advisors, examiner training, part 2 meetings etc etc. See this breakdown from the RCPath.”

“For first year doctors, It is hard to judge how much you have learned/developed until you compare yourself with the new resident doctors arriving in august”

“Man in T2RF who we were explaining why we needed to start NIV because his CO2 levels were too high. Without missing a beat he says: ‘I knew I should have voted for the green party’.”

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Some things to review when you’re off the ward…

The GMC earns a tidy number through the PLAB exam. The income directly from the PLAB examination increased from £4 million in 2017 to £25 million in 2024.

The measure of inflation greatly impacts how resident doctors’ pay changes over time. This Nuffield Trust article shows how the picture shifts depending on what measure of inflation you use, RPI or CPI.

The BMA’s Scottish GP committee has formally declared a dispute with the Scottish Government over persistent underfunding of general practice. Nearly half of GPs report their practices are “precarious or not sustainable,” with many planning industrial action. (Pulse)

The SynHG project has been launched to develop a synthetic a human chromosome. Whilst potentially revolutionary for genetics and therapies, it raises ethical concerns and long-term implications for human biology. (Welcome Trust)

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Too Old To Learn? Labour’s Student Loan Crackdown

Should anyone be able to enter medicine, no matter their age? Well the idea of late bloomers making a career switch to medicine has taken a large hit in recent times.

An interesting ‘loophole’ at the heart of the student finance system is set to be reversed by the Labour government. Labour is set to ban over 60s from accessing student loans to fund their degrees. In 2024, over 1,000 students over the state pension age took money from the student loan company to cover their fees. The prospect of these individuals ever earning enough to fully pay back these fees is incredibly slim. The Department For Education has called this grossly unfair at a time where younger students become more buried under student loan debts by the day.

So should people over 60 be eligible for student loans? One camp will tell you it is financially ludicrous for the government to provide loans to people who are unlikely to ever repay it, whilst the other will say that we should live in a society where everyone should have the means to pursue education, no matter the age.