DNA By Design

Are patient Did Not Attends designed into the way services are delivered? Or is it all the patient’s own fault?

“If they were motivated to change, they would attend their appointments”

I’ve been hearing this phrase, and variations of it, from professionals for over 25 years. Blaming patients for their failure to attend appointments.

The apparent logic goes something like:

  • Billy has been referred to me because Billy has a problem, and because I am an expert in that kind of problem
  • Billy needs to be motivated to change in order to change
  • A sign of Billy’s motivation is that he attends his appointments with me
  • Billy doesn’t attend his appointments
  • Therefore Billy isn’t motivated to change
  • And I can’t help Billy if he is not motivated to change his problem
  • So I will discharge Billy

In some areas of health and social care – especially psychiatry – this logic is so apparent, so obvious, that it is taken as Universal Truth.

Barriers to Change

When the sole determinate of Billy’s motivation is his Did Not Attend (DNA) ratio, we fail to account for any barriers that stand between him and his desired state.

And there can be loads of barriers – many of them erected by the very service that is supposed to be helping him.

Public transport and/or Car Parking

Many mental health services are now clinic based, and these clinics aren’t always in the most accessible of locations. This means that the responsibility to get to the appointment falls on the party with the fewest available resources.

Staff get paid to attend appointments, patients don’t. Staff get mileage allowances, patients don’t. Staff nearly always have their own cars – decent, reliable cars. Patients are often reliant on public transport. Staff often have access to parking. Many patients don’t.

One clinic I know has a car park that they share with many other services. The only available spaces for patients and staff alike are marked with a blue dot. Staff get there are 9am, filling all the available spaces. Patients then have to park half a mile away, pay at a meter and walk back to the clinic. If all of this makes them late, then well that’s just tough.

A CAMHS service I know requires patients from the most deprived part of its catchment area to catch three buses to get there – taking over two hours to travel 6 miles. The buses are one an hour. Attending a 45 minute appointment is therefore an entire day out of work/school. But miss one of those buses and you miss your appointment. Sorry, no more services for you.

But rarely is access for those with the most barriers to travel factored into service design.

Timing of Appointments

Whilst we’re supposed to be able to exercise choice over appointments, this is limited to times when the service is available. And timing of appointments rarely factors in barriers to attending at those times – often only between office hours.

People with specific work or child care arrangements may not be able to take the time out of their lives to race across town for an appointment.

That’s assuming they are in any fit state for doing so. It is well researched that people with depression have their lowest mood earlier in the day. So why are they being offered appointments at 9.30am, when they are more likely to be feeling at their most awful?


People have other commitments. They’re not sitting at home waiting for their service to be available. They’ve got shit to do. Kids to drop off/pick up from school and club, meals to make, work to go to, elderly relatives to look after.

We can’t be expecting people to re-juggle all these commitments so they can take 2-3 hours out of their day to come to an appointment on the other side of town. DNA’s are designed into a service by prioritising the needs of the service above of the needs of the people using it.

Health and Social Care Problems are Demotivating

All professionals know (or should know) that health problems, issues with social care, and mental health problems are often in and of themselves demotivating. Being depressed doesn’t make one leap out of bed eager to rush excitedly to your therapy appointment.

And yet the characteristics of the people services are there to support are often not factored into the design of that service. It’s as though we only want people who aren’t depressed to come to our depression clinics.

Confidence in the Professional

This is possibly the most over-looked of all the reasons why people don’t attend appointments. Professionals are, by definition, experts. And they are experts in the very thing that their patients need help in. So, there is no way they can be part of the problem. Is there?

Like many people, I know many, many professionals who are awe inspiring, skilled, compassionate and empathic. I know other professionals who I wouldn’t trust to look after my cats.

The process of becoming a great professional involves reflection and introspection. Looking inside and wondering how you can be better.

Blaming patients for not attending is the antithesis of reflective practice. It is an attitude that moves professionals towards institutional arrogance. I can’t be wrong. I’m too much of an expert to be wrong.

Confidence in the “therapy”

It’s pretty obvious to state that not everyone is the same. So why do mental health services default to shoehorning people into a narrow range of therapeutic models?

Of all services, I would expect mental health to have the broadest range of available options for people. But we have CBT and we have Things That Aren’t Called CBT But Realistically They Are Just CBT By Another Name.

Diversity of service provision is key to finding an approach that is compelling to the person experiencing it. If it is compelling, then they are more likely to want to move heaven and earth to get there. So if they’re not getting there, what does this say about the type, and also the quality, of the services on offer?


Playing the Blame Game

It would appear that the answer is to blame Billy for not attending – he is not motivated, he doesn’t care, he can’t be bothered to remember. So the solution is to issue him with a sanction – discharge him, remove him from lists or even fine him.

Examples of blaming the patient can be found all over the place – in posters on clinic walls, appointment letters, texts , news articles. and even in Government petitions

The message is clear – patients should be held to account for wasting valuable public resources.

It’s as if services believe that, by simply existing, they are doing the public a favour, and the public should be damned grateful.

I get that professionals feel frustrated when people don’t attend appointments. They’re human too and they come to work to make a difference to people’s lives. But we shouldn’t allow our frustration to become blame. Because in that direction, we only seek solutions that widen the gap between us and the people we exist to serve.

And anyway, it’s simply not working. Because despite this onslaught of blame, the problem persists. Is this because of the flaws in the public or because of the flaws in the system?

A Neat Sidestep

There is an onus on paid providers to create services that are accessible and compelling. But by blaming patients for DNAs, services neatly sidestep any consideration of their own role in erecting significant barriers to access and engagement.

The inverse care law also comes into play with DNAs. This is the evidence that the people most in need are the least likely to receive or benefit from a service.

Simply blaming patients out-of-hand does nothing to understand how inequalities may be impacting on service access. Do patients who miss appointments tend to come from particular backgrounds? Is there a dominant demographic profile? Do they tend to live in particular kinds of neighbourhoods? What public transport routes are available?

If we don’t even ask these questions or analyse this data, then how can we be so certain that we are not contributing to our own DNA rate?

Many services are designed with a “one door fits all” approach. It’s often called “Single Point of Access” or something similar. It is the same route of access for everyone, so that is fair. That’s equality.

Only is isn’t. It’s as equal as saying “my shop has the same massive step for everyone, so that’s fair” and failing to acknowledge that this massive step will be easier for some people, and harder for others.

DNA by Design

All systems are perfectly designed to achieve the results they get. Therefore, if a service gets poor results, this is because it is perfectly designed to get poor results.

If you want to change the results, we have to change the design. But attitudes towards DNAs don’t even come close to considering service design as a factor. Instead, all the responsibility is shifted onto those who experience the service, not those who are paid to deliver it.

In a study I did with mental health patients a few years back, we explored the value of simply narrating your story and having someone – in our case, an artist – listen to that story andand reflect it in a work of art.

The feedback was astonishing, with one participant stating “I’ve been in mental health services for 18 years and this is the first time I’ve ever told my story”

The study had over 100 participants attending a total of over 600 sessions and a DNA rate of 0%.

If the reason people DNA is because of some inherent fault that lies inside them, then this should have been impossible.

But we designed the study in partnership with the very people who would be joining. We explored and found ways to overcome their barriers to access. We worked around people’s lives instead of expecting them to work their lives around us. We paid particular attention to what would make it compelling.

In short, we asked: how do people want to experience this Thing? And how can we design it to guarantee that experience?

So when the conclusion is: We have a high DNA rate, because our patients are a bunch of irresponsible shits; then the answer is to issue fines, discharge them and send out snotty texts.

But when the conclusion is: We have a high DNA rate because we are perfectly designed to have a high DNA rate, then the answer is experience—based design, user engagement and co-production.

Which one do you think is going to be more effective?