Stemming the flow: Counting the cost of missed NHS appointments

Anyone working in healthcare understands the frustration when a patient misses an appointment and new research by Esendex has revealed the huge cost to the NHS of ‘DNAs’ (did not attend).  

There are many reasons why someone would fail to attend their scheduled appointment and these factors vary massively depending on the type of healthcare setting, organisation and region. 

Among the most common reasons for patients to miss an appointment are difficulty in arranging carers at the time of the appointment, transport issues, and difficulty taking time off work. 

These all highlight the complexity of getting people to the right place at the right time, and are factors which are often outside of the control of the organisation and patient. 

Other common factors are much more frustrating for everyone concerned. Many patients report being unaware of an appointment or having simply forgotten about it, while some also point to unclear or incorrect information or to having difficulties cancelling or rescheduling. 

At Esendex we work with healthcare providers including dentists, physiotherapists and GPs, to implement automated SMS solutions which have huge potential to drive down the number of missed appointments.

The cost of missed appointments

To uncover the true cost of missed appointments across the UK, our team issued requests to all NHS trusts across the UK under the Freedom of Information Act, asking how many scheduled appointments or DNAs were missed at their hospital sites over the last five years. 

The NHS’s data shows that every missed hospital appointment costs £160, so we combined the data to reveal the overall cost to the health service. 

The results are stark. Our analysis shows that, on average, each NHS trust has recorded more than 250,000 missed appointments over the last five years. For the 102 NHS Trusts who responded to our FOI request, this totalled more than 25 million appointments. 

The cost of these missed appointments was almost £41 million per trust. Across the trusts we surveyed, this represented a total cost of £4.1 billion for the NHS. 

When we extrapolate this research across the 229 trusts in the NHS, missed appointments have cost the health service a total of £9.3 billion over the last five years. 

The NHS trusts with the most missed appointments

Hospital Trust	Region	DNA: 2019	DNA: 2020	DNA: 2021	DNA: 2022	DNA: 2023	Total DNA	Total Cost of DNAs
Mersey Care NHS Foundation Trust	North West England	271,916	219,195	241,436	238,069	225,998	1,196,614	£191,458,240
Manchester University NHS Foundation Trust	North West England	235,251	172,551	220,539	223,285	232,838	1,084,464	£173,514,240
Barts Health NHS Trust	London	208,620	154,911	190,360	241,242	229,812	1,024,945	£163,991,200
University Hospitals Birmingham NHS Foundation Trust	West Midlands	233,684	192,678	182,984	203,897	206,673	1,019,916	£163,186,560
Guy’s and St Thomas’ NHS Foundation Trust.	London	203,625	166,129	168,901	203,081	162,007	903,743	£144,598,880
King’s College Hospital NHS Foundation Trust	London	156,401	127,679	155,423	167,706	119,951	727,160	£116,345,600
Northern Care Alliance NHS Foundation Trust	North West England	168,849	111,785	121,598	125,322	118,033	645,587	£103,293,920
Mid and South Essex NHS Foundation Trust	South East England	119,183	81,221	99,982	118,547	122,564	541,497	£86,639,520
Liverpool University Hospitals NHS Foundation Trust	North West England	36,790	99,235	130,539	117,132	121,711	505,407	£80,865,120
Leeds Teaching Hospitals NHS Trust	Yorkshire and the Humber	108,203	76,393	107,114	106,854	100,237	498,801	£79,808,160
Nottingham University Hospitals NHS Trust	East Midlands	84,463	74,082	96,132	107,713	115,358	477,748	£76,439,680
Sandwell and West Birmingham Hospitals NHS Trust	West Midlands	84,046	82,289	92,911	97,803	104,036	461,085	£73,773,600
London North West University Healthcare NHS Trust	London	97,206	71,282	86,668	91,313	94,691	441,160	£70,585,600
St George’s University Hospitals NHS Foundation Trust	London	84,437	63,453	75,370	94,410	93,665	411,335	£65,813,600
Barnet, Enfield and Haringey Mental Health NHS Trust	London	97,638	51,467	74,967	90,266	94,584	408,922	£65,427,520
Barking, Havering and Redbridge University Hospitals NHS Trust	London	86,104	57,781	80,665	88,665	94,769	407,984	£65,277,440
Chelsea and Westminster Hospital NHS Foundation Trust	London	94,438	61,517	75,020	88,283	88,546	407,804	£65,248,640
University Hospital of Derby and Burton NHS Foundation Trust	East Midlands	90,934	61,306	75,356	84,662	83,672	395,930	£63,348,800
Lewisham & Greenwich NHS Trust	London	93,587	63,648	70,723	76,165	84,359	388,482	£62,157,120
The Royal Wolverhampton NHS Trust	West Midlands	79,692	58,885	69,872	81,263	90,811	380,523	£60,883,680
University Hospitals of North Midlands Trust	West Midlands	81,037	66,260	77,917	78,578	70,407	374,199	£59,871,840
South Tees Hospitals NHS Foundation Trust	Yorkshire and the Humber	Not provided	Not provided	Not provided	Not provided	Not provided	360,161	£57,625,760
Hull University Teaching Hospitals NHS Trust	Yorkshire and the Humber	55,480	54,750	74,273	81,929	70,926	337,358	£53,977,280
University Hospital Southampton NHS Trust	South East England	60,645	53,867	69,634	69,071	67,037	320,254	£51,240,640
East Kent Hospitals University NHS Foundation Trust	South East England	66,338	52,037	58,503	68,164	66,135	311,177	£49,788,320
University Hospitals Bristol and Weston NHS Foundation Trust	South West England	61,549	51,131	64,397	68,436	65,284	310,797	£49,727,520
Coventry and Warwickshire Partnership NHS Trust	West Midlands	69,336	64,192	60,856	46,019	53,619	294,022	£47,043,520
East Suffolk and North Essex NHS Foundation Trust	East of England	58,269	46,419	58,283	56,548	53,273	272,792	£43,646,720
Bolton NHS Foundation Trust	North West England	58,620	43,841	49,171	58,642	55,474	265,748	£42,519,680
Royal Berkshire NHS Foundation Trust	East of England	53,885	45,323	53,213	56,497	54,334	263,252	£42,120,320
Tees, Esk and Wear Valleys NHS Foundation Trust	North East England	55,523	51,478	53,520	48,344	52,633	261,498	£41,839,680
East Lancashire Hospitals NHS Trust	North West England	49,264	43,818	54,328	58,961	50,658	257,029	£41,124,640
Homerton Healthcare Foundation Trust	London	54,712	40,076	50,776	57,871	53,296	256,731	£41,076,960
Gloucestershire Hospitals NHS Foundation Trust	South West England	48,971	42,651	52,933	56,480	51,460	252,495	£40,399,200
North West Anglia NHS Foundation Trust	East of England	55,786	43,154	47,084	55,731	48,707	250,462	£40,073,920
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust	Yorkshire and the Humber	55,290	39,116	48,663	52,750	53,697	249,516	£39,922,560
Lancashire Teaching Hospitals NHS Foundation Trust	North West England	47,802	43,229	46,809	52,863	56,783	247,486	£39,597,760
North Bristol NHS Trust	South West England	49,834	41,222	51,485	54,044	47,720	244,305	£39,088,800
St Helens and Knowsley Teaching Hospitals NHS Trust	North West England	49,879	39,169	42,666	52,803	53,880	238,397	£38,143,520
Rotherham Doncaster and South Humber NHS Foundation Trust	Yorkshire and the Humber	53,282	39,423	44,699	46,870	51,697	235,971	£37,755,360
Sussex Partnership NHS Foundation Trust	South East England	45,022	44,734	48,168	47,985	48,198	234,107	£37,457,120
Croydon Health Services NHS Trust	London	43,402	39,800	56,116	48,546	45,513	233,377	£37,340,320
Berkshire Healthcare NHS Foundation Trust	South East England	51,074	41,923	45,003	46,952	46,848	231,800	£37,088,000
University Hospitals Dorset NHS Foundation Trust	South West England	54,843	36,802	42,683	48,576	42,025	224,929	£35,988,640
Whittington Health NHS Trust	London	49,670	34,006	39,418	47,621	52,785	223,500	£35,760,000
University Hospitals Of Morecambe Bay NHS Foundation Trust	North West England	48,350	31,760	46,211	46,482	44,946	217,749	£34,839,840
West Hertfordshire Teaching Hospitals NHS Trust	East of England	39,633	35,438	46,085	47,342	40,506	209,004	£33,440,640
Bradford Teaching Hospitals NHS Foundation Trust	Yorkshire and the Humber	46,429	30,260	36,211	47,425	46,342	206,667	£33,066,720
Wrightington, Wigan and Leigh NHS Foundation Trust	North West England	40,219	30,029	42,737	49,123	41,580	203,688	£32,590,080
Northampton General Hospital NHS Trust	East Midlands	42,665	33,962	44,379	42,295	38,248	201,549	£32,247,840

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Mersey Care NHS Foundation Trust was found to have the most NDAs of those who responded to our Freedom of Information request. 

In 2023, it recorded 225,998 missed appointments and more than 1.1 million since 2019. The cost of these NDAs is calculated to be more than £191 million. 

Barts Health NHS Trust and University Hospitals Birmingham NHS Foundation Trust were the organisations with the next highest level of missed appointments, with more than one million each. 

Average DNA per NHS trust – 2019 – 2023

2019	53,669
2020	42,653
2021	50,616
2022	54,599
2023	52,700

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Our data did reveal that, despite the huge cost of missed appointments, the number of no-shows has remained relatively consistent over the last five years. 

In 2020, the COVID-19 pandemic meant that missed appointments dropped to 42,653, but since then, levels have remained between 50,000 and 55,000 per year per trust. 

How do different regions compare?

NHS trusts in the West Midlands have faced the highest cost of missed appointments, with almost £80 million generated between 2019 and 2023. 

The West Midlands was closely followed by London, with trusts in the capital facing costs of more than £60 million due to missed appointments. 

London was also highly prevalent in the trusts with the most missed appointments, with eight of the top 20 trusts (40%) based in the capital. 

	2019 – Missed appointments per trust	2020 – Missed appointments per trust	2021 – Missed appointments per trust	2022 – Missed appointments per trust	2023 – Missed appointments per trust	2019 – 2023 – Missed appointments per trust	Total cost of missed appointments per trust
East Midlands	50,436	39,987	50,520	54,644	55,232	250,820	£40,131,200.00
London	84,446	62,339	74,911	85,759	80,981	388,435	£62,149,560.00
West Midlands	107,721	89,092	95,465	99,819	102,439	494,535	£79,125,653.33
East of England	35,497	28,272	35,053	37,707	35,442	171,970	£27,515,200.00
North East England	37,152	29,595	34,946	35,962	32,973	170,628	£27,300,440.00
North West England	21,631	17,412	20,891	22,344	21,725	104,003	£16,640,540.95
South East England	25,610	22,892	25,985	34,379	35,852	167,281	£26,764,910.00
South West England and Gibraltar	39,057	32,017	38,102	39,707	36,982	185,864	£29,738,256.00
Yorkshire and the Humber	27,501	19,506	23,615	25,814	24,852	121,289	£19,406,181.82

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What can healthcare organisations do to reduce missed appointments? 

There’s no doubt, given the huge cost of missed appointments, that healthcare providers need to find new ways to reduce no-shows. 

Research shows that SMS open rates are as high as 98%, with an average response time of 90 seconds. In addition, 90% of people read a text message within the first three minutes of receiving it. 

All of this research shows that SMS reminders and confirmations are a vital tool for healthcare providers to deliver the information patients need and to reduce the risk of no-shows. 

While letters and emails are easily lost or left unread, automated SMS reminders can alert patients about upcoming appointments, scheduled tests or prescription collections, and give them the option to reschedule or cancel well ahead of time. 

Recommended reading: How to reduce no-shows with appointment reminders

SMS surveys can also enable healthcare providers to gather invaluable feedback to inform planning and improve patient experiences. By sharing test results, after-care support and other reminders, healthcare organisations can also offer further support to their patients while reducing overheads. 

Commenting on the findings, Chris Gorman, Head of Professional Services at Esendex, said: 

“Missed healthcare appointments are hugely frustrating for everyone in healthcare – not least for organisations like the NHS which has to shoulder the financial and administrative burden of no-shows. 

“There are a huge number of reasons which might explain why someone misses a healthcare appointment, whether that’s difficulty in taking time off work, being unable to arrange care at the time of the appointment, or transport challenges that prevent people from getting there.  

“Perhaps the most frustrating factor is when patients are unaware of a scheduled appointment, have the wrong information, or simply forget about it. While many healthcare providers rely on letters or emails to update patients about their appointments, these can easily be missed, lost or left unread, so it’s clear providers need to find new ways to reduce no-shows. 

“With data showing that most people read a text message within the first three minutes of receiving it, SMS solutions have a huge potential to drive down the number of missed appointments across the NHS. Rich messaging also enables providers to support two-way conversations on devices most of us carry with us at all times, making it a convenient, cost-effective and reliable method of contact.”

To find out more about SMS solutions for the healthcare industry, please visit: https://www.esendex.co.uk/industries/healthcare/ 

Methodology

Esendex issued FOI requests to hospital trusts asking how many missed scheduled outpatient appointments or ‘DNAs’ (did not attend) there were at their major hospital sites across the past five years. With every missed hospital appointment costing the NHS £160 (own NHS data), we then calculated the total DNA figure by £160 giving us the total cost of missed appointments to each NHS hospital trust.