Dealing with patients who default from review

Patients are often required to return for a review of their health condition. This could be to re-evaluate medication or symptoms, or for further discussion and treatment following a test result. The reasons for a review should be clearly communicated to the patient so they understand its importance and how failing to attend could impact their health.

Problems can arise if a patient defaults from review, and doctors may be uncertain about who takes responsibility for this.

Related topic: www.mddus.com/resources/publications-library/gpst/gpst-issue-13/failure-to-comply

Basic considerations

It is important to identify the reason why a patient has defaulted from attending. Have they had trouble booking an appointment within the time frame suggested? Do they have issues getting to the surgery? Are they anxious about something in particular? Each patient is different and in the majority of cases there will be a valid reason for not attending a review appointment. Taking into consideration the individual patient’s needs, you should agree a plan which may reduce the chance of them defaulting again.

The GMC requires that you take all necessary steps to prescribe safely. This includes agreeing a treatment plan with the patient, who should have an understanding of the clinical reasoning and also the importance of follow-up and review. If a patient defaults from their review appointment, it may not be safe simply to refuse to prescribe their medication. You should make attempts to explore the reasons for them defaulting and aim to agree a plan that provides safe care while taking into consideration the patient’s needs. The GMC’s Good Medical Practice, paragraph 49 states that: “you must work in partnership with patients, sharing with them the information they will need to make decisions about their care.”

In Good practice in prescribing and managing medicines and devices the GMC also states: “You must make sure that suitable arrangements are in place for monitoring, follow-up and review.” Both you and your patient should agree on the treatment proposed, and understand the arrangements for monitoring, follow up and review, any further investigations needed, any proposed changes to medication doses and the issuing of repeat prescriptions. This plan should be clearly documented in the patient’s medical records.

Common pitfalls

• Failing to ensure that patient contact details are up to date. Take the opportunity to update a patient’s contact details when agreeing a new management plan or when an infrequent attender presents at the practice.
• Failure to explore all avenues for contacting the patient. First line contacts include telephone and text messages and posted correspondence. Consider whether a signed-for or hand-delivered letter is necessary.
• Failure to provide adequate advance notice of a review. Ensure that practice staff understand the importance of review appointments and are proficient with the systems in place to notify patients
• Failure to document. Keep records of all communication with patients regarding their condition and the importance of follow up. Any attempts to contact a patient who failed to attend a review should also be recorded.

Key points

• Keep patient contact details up to date.
• Ensure your practice or clinic has a protocol for making appointments and dealing with missed appointments.
• Staff training is essential to ensure compliance with this protocol, and review regularly to adapt to the practice’s needs.
• Inform patients about how to make appointments and the consequences of missing appointments. Make this information readily available, such as publishing on your practice website.
• Consider and explore any underlying reasons for a patient’s non-attendance.
• Provide patients with the information they need to know in a way they can understand. Making a treatment plan without discussing the pros and cons with the patient is likely to result in non-concordance and defaulting on reviews.
• Keep clear records of the steps taken to investigate the reason for missed appointments and attempts made to inform the patient of the importance of attending.

Further guidance

• GMC. Good Medical Practice: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/good-medical-practice/domain-3---communication-partnership-and-teamwork#paragraph-46
• GMC. Good practice in prescribing and managing medicines and devices: https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/prescribing-and-managing-medicines-and-devices
  
  MDDUS Training & CPD resources:
  www.mddus.com/resources/publications-library/gpst/gpst-issue-13/failure-to-comply