Quality Improvement Project Exploring the Factors in Non-attendance at an NHS Musculoskeletal Outpatients Department


In NHS digital’s annual report into Hospital Outpatients Activity 2018-2019, physiotherapy had the highest did not attend (DNA) rate when compared to other specialities. It reports that for every 10.4 attendances one service-user DNA (9.6%). High DNA rates increase costs and waiting times. This improvement project aimed to identify the factors involved in DNA rates of a musculoskeletal (MSK) physiotherapy outpatients departmen


This work is supported by the Clinical Improvement Scholarship Programme run by Brighton and Sussex University Hospitals NHS Trust. The project used the service improvement framework known as “A3 problem-solving”. Data was gathered to understand the current situation. Firstly, the monthly DNA rate was calculated retrospectively between September 2018-August 2019. Secondly, service-users who DNA their appointments were surveyed by telephone using closed questions. Service-users were asked for the reason for their DNA, whether they had experienced difficulties cancelling their appointments and whether they were aware of the department’s open appointment policy. Finally, the department’s staff took part in a process mapping activity. Current approaches adopted by the department were discussed as well as describing a service-user’s journey from the initial appointment to follow-up including the cancellations process. Following data collection, the department’s staff conducted a root cause analysis to identify the top contributing factors and then developed an action plan.


Results: There were 13865 appointments booked between September 2018-August 2019 of which 4074 were new and 9791 were follow-ups. There was a higher rate of DNA for follow-ups (14.7%) than new appointments (9.3%). 32 service-users were surveyed. The most frequent reasons for DNA were: 10 forgot, 7 were unwell and 4 had attempted to cancel. 17 out of 32 service-users reported difficulty in cancelling their appointments. 26 out of 32 service-users were not aware of the open appointment policy. The process mapping activity identified that the department uses text reminders, information posters and reminder calls to reduce DNA. The staff identified two potential contributing factors. Firstly, physiotherapists do not routinely offer an open appointment because of a lack of confidence in communicating the option and the time constraints within consultations. Secondly, there are limited ways in which a service-user can contact the department to cancel. The department’s action plan was to implement a cancellation email, to investigate how administrative staff can better meet cancellation demands and to investigate how to support clinicians to have better conversations about open appointments.

Conclusion(s): The project found that the department had a higher DNA rate than the national average as reported by NHS digital and that it was higher in follow-up appointments. Staff and service-users identified problems with cancelling appointments. Clinicians felt that communication about open appointments could be improved. Future work is required investigating other contributing factors and implementing and measuring the outcomes of the action plan.

Cost and savings

The project was free to run and set-up. There is no data currently available on savings made by this work


This work is an example of a quality improvement approach in MSK outpatients which could be implemented in other departments. It is important for physiotherapy departments to have good communication infrastructure to allow service-users to easily cancel and rebook appointments.

Top three learning points

No further data 

Funding acknowledgements

This work was not funded.