The next PM...

[The Accountant, OBE, KC]

But how is that going to work as the whole point about people not attending appointments is that they ... err ... do not attend the appointment so aren't going to be able to have any conversation with the receptionist because ... err ... they aren't there.

The fine for repeat offenders, as  per my suggestion in my post, would be payable  before you can get another NHS appointment including seeing your GP. It should be logged against your NHS number in the system and the booking system should prevent booking an appointment until it has been paid. The idea is that rather than chasing people to pay, people would be trying to pay the NHS  so they can get an appointment. Same way they pay if they want a doctor’s note from the GP. They can fill in a form to apply for a refund If their reason for missing appointment  falls within certain set criteria for refunds eg a death of close family member, illness etc and if they can provide evidence.

The system can also automate sending reminders to pay. I got text reminders about Covid vaccines, flu vaccines, so the majority of people would get their payment reminders by text or Whatsapp or email with a link or QR code to pay by card or Paypal. People who don’t have access to electronic communication can be sent a letter or be reminded to pay over the phone when they call to try to book an appointment.

This would allow Good Samaritans to pay fines for others if they have the payment link/ reference number and patient’s details. But I don’t think it’s meant to be a money-making idea - it’s supposed to have a deterrent effect to change behaviour. Some gyms do this. You get a penalty if you don’t attend a class you booked and you did not cancel your booking. You can’t book a new class or activity or gym session until you pay the penalty. It’s a small amount and I paid it at my gym as I had a family matter to deal with so couldn’t attend, but it gave me the incentive to try to be better organised for the future.

[ProfessorDavey]

Still don't think it would work. All those initiatives for hospital appointments assume that everybody lives well-ordered lives. It just isn't so, unfortunately.

The proposal is that "reasonable excuses" would be exempt.

Who decides what is a reasonable excuse?

So from my direct experience of managing reception areas in a hospital, which of these are reasonable:

My washing machine flooded.

My daughter started being sick.

My wife took the house keys.

and my personal favourite:

My girlfriend had a very heavy period and I couldn't leave her.

How do you decide if the excuse is reasonable and furthermore do you go one step further and in effect accuse them of lying?

I'm sure some of the people I dealt with in the past were not telling the truth, but it wasn't my job to alienate them from the healthcare they had been referred for.

I just do not see it being feasible.

As I said it sounds appealing and a nice easy win. It isn't.

I agree - there are many people whose lives are chaotic or have medical conditions that make it difficult to remember appointments or to get to them. I don't think fining people is the way forward at all, as I suspect the people most affected will be disproportionately the most vulnerable.

The other problem I have with this is a nasty undercurrent which is appearing to blame the difficulty in getting an appointment with a GP on people not turning up (you could have had their appointment). So blaming other patients for the poor service so many people are currently facing in terms of seeing their GP.

Now the data I've seen suggests that only one in 20 or one in 25 GP appointments is a 'no show', which isn't really a very high level and certainly not sufficient to explain not being able to get a routine GP appointment for three weeks (or more). No the reason is that the system is creaking through underfunding and lack of staff, not because occasionally someone doesn't turn up to an appointment.

And you can see where this is going - first it will be fining people for not attending and when that doesn't work the tories will move onto changing people a 'small amount to visit their GP, just to make sure they show up'.

[ProfessorDavey]

The fine for repeat offenders, as  per my suggestion in my post, would be payable  before you can get another NHS appointment including seeing your GP. It should be logged against your NHS number in the system and the booking system should prevent booking an appointment until it has been paid.

So someone rings up to a get an appointment for something that might be really serious and they won't be given an appointment until they've paid a fine for some missed appointments in the past where they might have a perfectly reasonable reason why they didn't attend. Some people simply don't have the money - what are you going to do then.

The system can also automate sending reminders to pay. I got text reminders about Covid vaccines, flu vaccines, so the majority of people would get their payment reminders by text or Whatsapp or email with a link or QR code to pay by card or Paypal. People who don’t have access to electronic communication can be sent a letter or be reminded to pay over the phone when they call to try to book an appointment.

This would allow Good Samaritans to pay fines for others if they have the payment link/ reference number and patient’s details. But I don’t think it’s meant to be a money-making idea - it’s supposed to have a deterrent effect to change behaviour.

We already have a Good Samaritan system to pay for other people to access medical services - it is called general taxation.

Frankly you are looking for a solution where there isn't a problem - I know when you look at the headline figure (about £200million) as the cost of missed appointment this sounds like a lot - but in the context of the NHS budget of about £200billion it represents about 0.1% of that budget. And fining people won't reduce that cost fully (indeed I doubt it would reduce the cost significantly) as the suggested fines are lower than the cost of an appointment and you'd have to factor in the cost of administering the fines, processes of appealing against a fine etc (which would probably be greater than the suggested £10 cost), plus those who appeal successfully. Finally the increased burden on other, likely more expensive, parts of the NHS as patients start heading to A&E rather than their GP.

And at around one in 20/25 appointments being missed, it is hardly the reason you can't get an appointment at your GP, is it.

[The Accountant, OBE, KC]

So someone rings up to a get an appointment for something that might be really serious and they won't be given an appointment until they've paid a fine for some missed appointments in the past where they might have a perfectly reasonable reason why they didn't attend.

Yup. If they have been issued reminders to pay and have not managed to find the time to pay, here is the perfect opportunity to pay and get their appointment for something that might be really serious.

Some people simply don't have the money - what are you going to do then.

And many people do have the money to pay and don't feel bad about not showing up for appointments as there are no financial penalties. Like I said, it can be like food banks where people really don't have the money to eat - if people really, really don't have £10 and they can convince the many generous good samaritans all over the place to support the NHS and pay the fine on their behalf, then they will still get the appointment about something that might be serious.

Let's face it, it's not like you currently get lightening service about potentially serious health issues now on the NHS - though it depends on the service you are trying to access and on the whole I personally have had a good experience.

We already have a Good Samaritan system to pay for other people to access medical services - it is called general taxation.

I don't think taxation has quite the deterrent effect this penalty is trying to achieve.

Frankly you are looking for a solution where there isn't a problem - I know when you look at the headline figure (about £200million) as the cost of missed appointment this sounds like a lot - but in the context of the NHS budget of about £200billion it represents about 0.1% of that budget. And fining people won't reduce that cost fully (indeed I doubt it would reduce the cost significantly) as the suggested fines are lower than the cost of an appointment and you'd have to factor in the cost of administering the fines, processes of appealing against a fine (which would probably be greater than the suggested £10 cost), plus those who appeal successfully. Finally the increased burden on other, likely more expensive, parts of the NHS as patients start heading to A&E rather than their GP.

And at around one in 20/25 appointments being missed, it is hardly the reason you can't get an appointment at your GP, is it.

Sure - if the number-crunchers do the maths and decide it is not an issue worth pursuing or this is not the solution, then fine with me.

[ProfessorDavey]

Yup. If they have been issued reminders to pay and have not managed to find the time to pay, here is the perfect opportunity to pay and get their appointment for something that might be really serious.

You do understand that the group most likely by far to miss multiple appointment (in other words the group you'd want to fine) are the over 90s.

Other factors that predispose towards regular non attendance include being in the poorest socio-economic groups (almost perfect correlation).

[ProfessorDavey]

And many people do have the money to pay and don't feel bad about not showing up for appointments as there are no financial penalties.

Unevidenced assertion. Data please to back up your claim.

[ProfessorDavey]

Like I said, it can be like food banks where people really don't have the money to eat - if people really, really don't have £10 and they can convince the many generous good samaritans all over the place to support the NHS and pay the fine on their behalf,

As I've already said - we already do this, support the NHS - it is called general taxation. Your analogy to a food bank run as a charity isn't relevant.

[The Accountant, OBE, KC]

You do understand that the group most likely by far to miss multiple appointment (in other words the group you'd want to fine) are the over 90s.

Other factors that predispose towards regular non attendance include being in the poorest socio-economic groups (almost perfect correlation).

Not seeing the problem. Have an exemption for over 90s if that is a valid reason for missing appointments.

If being poor is also a valid reason to miss NHS appointments, again have an exemption for people on benefits.

This would be something for the NHS staff and voters to work out as they are the ones directly affected by the behaviour of missing appointments and its impact on waiting lists - if the number-crunchers don't see fines as a viable option, that's fine with me. On the other hand, if it works then great. Like I said before, I thought we already had a system where they kick you off the clinic list and your GP has to start the referral process again if you miss 2 NHS clinic appointments.

Also, see current policy for NHS dentists - they can't charge if you miss your first appointment but can decline to see you again. They can however curtail your course of treatment if you are part way through a course of treatment and you miss an appointment. They would then charge you again if you come back to their practice and want to have the course of treatment they curtailed.
https://forums.moneysavingexpert.com/discussion/6327739/dentist-charging-for-missed-nhs-appointment

[The Accountant, OBE, KC]

Unevidenced assertion. Data please to back up your claim.

You want data for "many people" or data for many people possessing £10 in their bank account or wallet/ purse? How do you suggest I define "many" so I know the criteria for the data you require?

Here are some stats on average savings in the UK as a starting point:
https://www.raisin.co.uk/newsroom/savings/better-saving-money/
https://www.finder.com/uk/saving-statistics

Or you want data for many people not feeling bad about being financially penalised for missing appointments, since they are currently not financially penalised for missing an appointment?

I don't think it's a controversial suggestion - I suspect many people who are financially penalised by their NHS dentist for missing appointments, feel bad about being financially penalised for missing appointments.

[The Accountant, OBE, KC]

As I've already said - we already do this, support the NHS - it is called general taxation. Your analogy to a food bank run as a charity isn't relevant.

Yes but it seems the taxes aren't covering the costs. We could of course increase taxes but some voters do not agree due to the perceived inefficiency of the NHS. Some people don't want to be taxed more to cover NHS costs for all treatments, e.g. if they feel the treatment is for an issue that is self-inflicted or cosmetic or it is going towards funding inclusiveness policies and training rather than medical treatments.

If we pay for other people to eat despite being taxed to fund benefits for poor people to be able to afford to eat, is there any reason we can't start a charity similar to food banks to pay people's fines for missed NHS appointments so they can access health care again.

[ProfessorDavey]

You want data for "many people" or data for many people possessing £10 in their bank account or wallet/ purse? How do you suggest I define "many" so I know the criteria for the data you require?

Here are some stats on average savings in the UK as a starting point:
https://www.raisin.co.uk/newsroom/savings/better-saving-money/
https://www.finder.com/uk/saving-statistics

Nope

Or you want data for many people not feeling bad about being financially penalised for missing appointments, since they are currently not financially penalised for missing an appointment?

Kind of - I want evidence to back up your assertion that many people don't feel bad about missing an appointment because there is no financial impact. That seems to me to be an unevidenced assertion as you haven't provided evidence as to why most people miss appointments, nor how they feel about missing an appointment. Still less have you provided a causal link that the lack of a financial penalty is the reason why they miss the appointment and that they don't care because there is no financial penalty.

So over to you VG, or you could perhaps retract the comment if you cannot back it up.

[The Accountant, OBE, KC]

Nope
Kind of - I want evidence to back up your assertion that many people don't feel bad about missing an appointment because there is no financial impact. That seems to me to be an unevidenced assertion as you haven't provided evidence as to why most people miss appointments, nor how they feel about missing an appointment. Still less have you provided a causal link that the lack fof a financial penalty is the reason why they miss the appointment and that they don't care because there is no financial penalty.

I don't need to as it wasn't a suggestion to fine people who have valid reasons to miss appointments. I believe the suggestion is to fine repeat offenders who are just being disorganised or not prioritising the NHS appointment over other issues because they take healthcare for granted because it is free and it doesn't cost them anything to rebook. It's an opinion based on the use of financial penalties to change behaviour in other areas of society.

Some healthcare workers have even suggested that there are patients who see free healthcare as a right rather than a privilege, and they want to change that mindset by introducing charges for GP appointments. Presumably these could be waived or claimed back or paid by a charity for people on benefits. They currently do this for vet bills.

So over to you VG, or you could perhaps retract the comment if you cannot back it up.

Sure - be happy to look into it once you have retracted all the comments that you have made on this thread and haven't been able to back up. E.g. Sunak's penniless grandmother etc etc

[ProfessorDavey]

I don't need to as it wasn't a suggestion to fine people who have valid reasons to miss appointments.

But you have asserted that many people don't feel bad about missing an appointment because there is no financial impact. That's what you need to justify, which requires you to evidence why they are missing appointments and how they feel about that.

[The Accountant, OBE, KC]

But you have asserted that many people don't feel bad about missing an appointment because there is no financial impact. That's what you need to justify, which requires you to evidence why they are missing appointments and how they feel about that.

No, it doesn't require me to evidence why they are missing appointments.

My point was that financial penalties usually make people feel bad, so if there aren't financial penalties they are not going to feel bad due to financial penalties.

[ProfessorDavey]

No, it doesn't require me to evidence why they are missing appointments.

It does if your argument is that financial penalties would make people miss fewer appointments.

My point was that financial penalties usually make people feel bad, so if there aren't financial penalties they are not going to feel bad due to financial penalties.

It doesn't matter if is makes them feel good, bad or indifferent - if it doesn't make people miss fewer appointments then how they feel seems pretty irrelevant, doesn't it.

But hey ho, clearly you aren't going to justify your assertion.

[ProfessorDavey]

Good response from the BMA on the matter.

https://www.bma.org.uk/bma-media-centre/charging-patients-for-missed-appointments-is-not-the-answer-to-tackling-the-nhs-backlog-says-bma

Also great article from the Independent from a few years ago on the related topic of charging for GP appointments, which is justified by the same, faulty, arguments that if you pay for something you will value it more and be less likely to miss an appointment.

https://www.independent.co.uk/life-style/health-and-families/features/5-reasons-why-you-shouldn-t-have-to-pay-to-see-your-gp-a6838501.html

[Udayana]

 Obviously none of this is about doing anything to help the NHS practically or elsewise. It's just about trying to drum up votes - all the proposals will be ditched straight after Sept 5th.

Personally, I think he might have been better off proposing £10 compensation each time you turn up for an NHS appointment and are left waiting for over 30 mins after the time given!

(Yes, I know this completely impractical)

 
   

[ProfessorDavey]

Obviously none of this is about doing anything to help the NHS practically or elsewise. It's just about trying to drum up votes - all the proposals will be ditched straight after Sept 5th.

Personally, I think he might have been better off proposing £10 compensation each time you turn up for an NHS appointment and are left waiting for over 30 mins after the time given!

(Yes, I know this completely impractical)

It is just classic tory diversionary non-sense.

So which is more likely to mean you cannot get a GP appointment for weeks:

1. One in 20 appointments is a no-show or
2. That there are 105,000 staff vacancies in the NHS

Answers on a post-card. But in the tory mind better to shift the blame onto patients, and not just all patients (research suggests a typical no-show is most likely to be very old, over 90, from a very low socio-economic group and likely have complex multiple health-care needs), rather than take responsibility for under funding the NHS and creating a staffing nightmare via brexit.

[ProfessorDavey]

Obviously none of this is about doing anything to help the NHS practically or elsewise. It's just about trying to drum up votes - all the proposals will be ditched straight after Sept 5th.

Personally, I think he might have been better off proposing £10 compensation each time you turn up for an NHS appointment and are left waiting for over 30 mins after the time given!

(Yes, I know this completely impractical)

Actually I think there is more truth in this than you think.

There is certainly evidence that if you pay for something up from, e.g. a fee for a GP consultation that patients expect more, and would certainly expect their appointment to be on time.

So if patients get fined for being late of not attending, then surely the flip-side should apply - patients should be compensated if their appointment is late or cancelled.

[The Accountant, OBE, KC]

It does if your argument is that financial penalties would make people miss fewer appointments.

My argument is that some people would be deterred from missing appointments by fines - probably the same people who are deterred by fines from parking in places where they are obstructing traffic or waiting in yellow box junctions. Of course, there are other people who rack up lots of parking tickets and other PCNs and are not deterred by fines. 

It doesn't matter if is makes them feel good, bad or indifferent - if it doesn't make people miss fewer appointments then how they feel seems pretty irrelevant, doesn't it.

I would trial a fine system and see how it works out for the NHS. It might take a while for people to learn to take personal responsibility but I think it is something to work towards. While there are of course genuine cases of hardship that led to missing an appointment, there are also people who are immature or disorganised, or who have not been taught to take personal responsibility, or who make excuses and the fines would probably be doing them a favour as currently they have no reason to not miss an appointment - if it will get re-booked at no cost to them. The fines would help them prioritise and learn some self-discipline, for which they would eventually be grateful even if they don't acknowledge it as it's not much fun learning lessons.

But hey ho, clearly you aren't going to justify your assertion.

Good you're finally catching on. I suppose it's a bit like you arguing that Sunak's grandmother was penniless without evidence or you arguing that Sunak's mother's pharmacy business did not help pay for school fees, again without any evidence.

[ProfessorDavey]

My argument is that some people would be deterred from missing appointments by fines - probably the same people who are deterred by fines from parking in places where they are obstructing traffic or waiting in yellow box junctions. Of course, there are other people who rack up lots of parking tickets and other PCNs and are not deterred by fines.

Again poor analogy.

If you get a FPN or PCN for a parking offence, or blocking a box junction, or speeding etc - it is precisely because those things are offences. Not turning up to an appointment isn't an offence last time I looked. Are you planning on making missing a GP appointment an offence VG?

But back to your argument - where is your evidence that fining people for missing appointments or changing a fee for an appointment will make them not miss appointments. There are plenty of other countries that have tried your 'experiment' largely through charging for GP appointments - as the article I linked to suggests it doesn't change behaviours. Indeed Germany tried this (fees for GP appointments) in 2004, but scrapped them in 2012 because they didn't change behaviour but imposed a significant administrative burden on their healthservice - actually rather more than the theoretical cost of all the missed GP appointments in the UK.

[ProfessorDavey]

I would trial a fine system and see how it works out for the NHS. It might take a while for people to learn to take personal responsibility but I think it is something to work towards. While there are of course genuine cases of hardship that led to missing an appointment, there are also people who are immature or disorganised, or who have not been taught to take personal responsibility, or who make excuses and the fines would probably be doing them a favour as currently they have no reason to not miss an appointment - if it will get re-booked at no cost to them. The fines would help them prioritise and learn some self-discipline, for which they would eventually be grateful even if they don't acknowledge it as it's not much fun learning lessons.

Yup that's right - let's blame the feckless - that'll teach em!!!!

Alternatively we could actually fund the NHS properly and stop blaming patients for problems that aren't caused to any significant degree by one in 20 appointments being missed, costing (even using the theoretical cost) about 0.1% of the NHS budget, when the NHS has a staffing crisis with 105,000 vacancies.

[SteveH]

Yup that's right - let's blame the feckless - that'll teach em!!!!

Alternatively we could actually fund the NHS properly and stop blaming patients for problems that aren't caused to any significant degree by one in 20 appointments being missed, costing (even using the theoretical cost) about 0.1% of the NHS budget, when the NHS has a staffing crisis with 105,000 vacancies.

Well, it's not either/or, is it? We could (and of course should) massively increase the NHS's funding (and if that means a rise in tax or national Insurance, that's fine by me), AND charge for missed appointments. I think the latter is impractical, and would probably cost more to administer than it brings in, as others have suggested, but there's nothing wrong with the idea ethically.

[ProfessorDavey]

Well, it's not either/or, is it? We could (and of course should) massively increase the NHS's funding (and if that means a rise in tax or national Insurance, that's fine by me), AND charge for missed appointments. I think the latter is impractical, and would probably cost more to administer than it brings in, as others have suggested, but there's nothing wrong with the idea ethically.

Yup you could do both I guess, but I don't think fining people for non-attendance at appointment should happen for practical reasons, but I guess also on principle, which you might consider to be ethical.

Not sure I agree with you that there aren't ethical issues, and the BMA certainly thinks there are - from their response to the proposals:

"Charging patients for missed appointments would not only undermine the essential trust between doctor and patient, but ultimately threaten the fundamental principle that the NHS delivers free care at the point of need, for all. The BMA has always stood firmly against the idea of charging patients for missed appointments.

While it is frustrating when patients do not attend, the reasons why this happens should be investigated rather than simply resorting to punishing them. Financially penalising patients inevitably impacts the poorest and most vulnerable in the community. This may discourage them from rebooking, exacerbating already worsening health inequalities and costing the NHS more."

I would have thought that doctor/patient trust is fundamental medical ethical issue. As is justice (one of the four cornerstones of medical ethics along with autonomy, beneficence and non-maleficence). Bringing in something that would disproportionately impact the poorest and most vulnerable in the community seems to me to be a clear medical ethical issue around justice.

[The Accountant, OBE, KC]

Again poor analogy.

If you get a FPN or PCN for a parking offence, or blocking a box junction, or speeding etc - it is precisely because those things are offences. Not turning up to an appointment isn't an offence last time I looked. Are you planning on making missing a GP appointment an offence VG?

No I wouldn't make it an offence. I think we should just trial the principle of fines for missing 2 appointments and see what effect it has. I think in Scotland NHS dentists can fine you for missing appointments. I have not had time to look into the data to see the effect it has had

But back to your argument - where is your evidence that fining people for missing appointments or changing a fee for an appointment will make them not miss appointments. There are plenty of other countries that have tried your 'experiment' largely through charging for GP appointments - as the article I linked to suggests it doesn't change behaviours. Indeed Germany tried this (fees for GP appointments) in 2004, but scrapped them in 2012 because they didn't change behaviour but imposed a significant administrative burden on their healthservice - actually rather more than the theoretical cost of all the missed GP appointments in the UK.

If you are referring to the Independent article you linked to, I could not read it as not a subscriber. I thought Germany requires everyone to take our state or private health insurance, and the cost of premiums are partly paid by the employee from their salary and partly paid by employers. The self-employed also pay premiums. Not sure what happens if you are unemployed in Germany. I think everyone still has to pay a fee for the first visit to a doctor in every quarter.