Non-attendance at psychological therapy appointments

Pages231-248
Date12 September 2016
Published date12 September 2016
DOIhttps://doi.org/10.1108/MHRJ-12-2015-0038
AuthorJames Binnie,Zoe Boden
Subject MatterHealth & social care,Mental health
Non-attendance at psychological
therapy appointments
James Binnie and Zoe Boden
James Binnie is a Lecturer in
Counselling Psychology at the
Psychology Department,
London South Bank University,
London, UK.
Zoe Boden is based at the
London South Bank University,
London, UK.
Abstract
Purpose Research demonstrates that non-attendance at healthcare appointments is a waste of scarce
resources; leading to reduced productivity, increased costs, disadvantaged patients through increased
waiting times and demoralised staff. The purpose of this paper is to investigate non-attendance and
implemented interventions to improve practice.
Design/methodology/approach A mixed methods service audit took place in a primary care
psychological therapies service. Existing service guidelines and reporting systems were reviewed.
A cross-sectional design was used to compare a years cohort of completers of cognitive behavioural therapy
(CBT) (
n
¼140) and drop-outs (
n
¼61).
Findings Findings suggestedcontrasting guidelines and clinically inaccurate reporting systems. The overall
service did not attend(DNA) rate was 8.9 per cent; well below ratessuggested in the literature. The drop-out
rate from CBT was 17 per cent. The most influential factor associated with CBT drop-out was the level of
depression.The level of anxiety, riskratings and deprivation scoreswere also different betweencompleters and
drop-outs.The main reasons given fornon-attendance were forgetting,being too unwell to attend,having other
priorities, or dissatisfaction with the service; again these findings were consistent withprior research.
Originality/value A range of recommendations for practice are made, many of which were implemented
with an associated reduction in the DNA rate.
Keywords IAPT, Psychological therapy, Non-attendance, Service audit
Paper type Research paper
Introduction
Non-attendance is an aspect of service delivery that has been affecting health services generally and
mental health and psychological therapy services in particular for decades. In the UK up to one in ten
outpatient appointments are missed (The Information Centre for Health and Social Care, 2006) with
a calculated cost of £600 million a year (Dr Foster Research Limited, 2009). Non-monetary costs of
non-attendance include longer waiting times, wasted resources and poorer clinical outcomes (Stone
et al., 1999). Non-attendance has also been associated with having a negative emotional impact on
healthcare professionals (Tweed and Salter, 2000). Although focusing on failure to attend
appointments (i.e. DNA rates) is important, patients can still have successful treatment despite
missing the occasional session. Therefore also focusing on the drop-out rate or non-completion of
treatment is important. Drop-out can be defined as when patients leave treatment sessions early in
an unplanned manner before treatment has finished; patients stop attending without prior
agreement (Westbrook and Kirk, 2005). Because of the implications of non-attendance within health
services there has been a governmental focus on this area for several years. Within the National
Health Service (NHS), ensuring attendance at psychological therapy appointments is an important
part of meeting many Department of Health recommendations (Department of Health, 1999, 2000)
and guidelines (e.g. National Institute for Clinical Excellence, 2004, 2005).
Received 11 December 2015
Revised 20 May 2016
Accepted 30 June 2016
DOI 10.1108/MHRJ-12-2015-0038 VOL. 21 NO. 3 2016, pp. 231-248, © Emerald Group Publishing Limited, ISSN 1361-9322
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MENTALHEALTH REVIEW JOURNAL
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PAG E 23 1
Non-attendance and drop-out
From studies commissioned by UK governmental departments DNA rates varied in general
outpatient healthcare settings from an average of 8.5 (Department of Health, 2010) to 10 per cent
(The Information Centre for Health and Social Care, 2006) and non-attendance rates (DNA and
cancellations) were found to be almost 20 per cent (The Information Centre for Health and Social
Care, 2013). In their review paper Mitchell and Selmes (2007) explored the issue of engagement
with psychiatric services arguing that up to 20 per cent of appointments in psychiatric services
are missed (DNA), which is twice that of other medical specialities. Initial appointments are more
likely to be missed than follow ups, and 50 per cent of patients who miss appointments are likely
to drop-out from treatment.
Average attrition rates or drop-out rates from psychological therapy vary according to the
methodology of the study (naturalistic, clinical or combined) and the definition used. Royal
College of Psychiatrists (2011) calculated the drop-out rate to be 25 per cent, with the median
number of sessions attended before drop-out being 2. This is comparable to the findings of
Westbrook and Kirk (2005) who calculated the drop-out figure to be 22.5 per cent in a large
sample from a routine clinical practice receiving cognitive behavioural therapy (CBT). Although,
much lower attrition rates (5.6 per cent) have been reported for CBT in controlled trials (Butler
et al., 2006). Meta-analytic approaches combining naturalistic and clinical trials include Wierzbicki
and Pekarik (1993), who found a mean drop-out rate of 46.86 per cent, and more recently by
Swift and Greenberg (2012) who found a rate of 19.7 per cent (669 studies 83,834 subjects).
Grant et al. (2012) investigated attrition from psychological therapy in regards to the stage of
treatment. Using a retrospective case note audit of four months of referrals (n¼497), 32 per cent
failed to opt in to the service after referral, 26 per cent opted in but failed to attend their first
appointment, 34 per cent attended therapy sessions but dropped out, 8 per cent did attend
assessment but were deemed unsuitable for the service and were referred elsewhere. It therefore
seems that drop-out can occur throughout the care pathway, not just in active treatment.
Factors associated with non-attendance tend to focus on demographic, patient and service
causes. In general healthcare settings young men (15-44 years old) are most likely to miss
appointments (The Information Centre for Health and Social Care, 2006); with young men almost
twice as likely to DNA compared to women of the same age (The Information Centre for Health
and Social Care, 2013). A history of non-attendance (Neal et al., 2005) and poorer levels of health
(Akhter et al., 2012) are associated with non-attendance. The service factors associated with
non-attendance include the way in which appointments are booked, clerical errors or
communication failures (NHS Institute for Innovation and Improvement, 2008). In secondary care
mental health settings being younger, having a history of self-harm, higher levels of social
deprivation (Hillis et al., 1993), higher levels of mental disorder (Killaspy et al., 2000) and the
method of invitation to the appointment (Hillis and Alexander, 1990) are all influential in
determining non-attendance. For psychological therapy settings minority racial status (Wierzbicki
and Pekarik, 1993), low education (Keijsers et al., 2001; Wierzbicki and Pekarik, 1993), being
younger (Saxon et al., 2010; Jones et al., 2008), low socio economic status (Wierzbicki and
Pekarik, 1993), higher levels of social deprivation (Grant et al., 2012; Self et al., 2005), having a
diagnosis of personality disorder (Schindler et al., 2013; Swift and Greenberg, 2012) or eating
disorder (Swift and Greenberg, 2012), greater psychological distress (Saxon et al., 2010), higher
levels of measured agoraphobic avoidance (Lincoln et al., 2005), high depression scores (Jarrett
et al., 2013), lower motivation (Keijsers et al., 2001) and being seen by a trainee therapist (Swift
and Greenberg, 2012) are all related to increased drop-out. No significant differences have been
found in drop-outs rates between psychological therapy approaches (Grant et al., 2012;
Hembree et al., 2003), however the nature of the therapeutic relationship has been suggested to
correlate to psychotherapy drop-out (Sharf et al., 2010).
Reasons given for non-attendance at general and secondary care mental healthcare
appointments are remarkably similar. Forgetting is given as the most frequent reason
(Neal et al., 2005; Akhter et al., 2012; Killaspy et al., 2000), apathy (Murdock et al., 2002), illness
(Akhter et al., 2012; Killaspy et al., 2000; Lever Taylor et al., 2013), work commitments (Hillis and
Alexander, 1990) and clerical errors (Killaspy et al., 2000) are also reported. Reasons unique to mental
health settings are being unhappy with the referral (Killaspy et al., 2000; Lever Taylor et al., 2013),
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