Rethinking ‘did not attend’

We should ask why patients miss appointments, not just blame them  

My husband is obsessed with cruise control. He simply cannot wait to get on a decent stretch of road and fiddle with the little buttons, setting his speed at one kilometre over the limit (sometimes two, if he is feeling particularly daring). He relaxes back into the driver’s seat, an air of calm settling over him. For about 30 seconds.

Because cruise control is all well and good on a well-functioning Autobahn with perfectly maintained verges and drivers who are accustomed to getting from A to B efficiently.

But trying to set your expectations on Ireland’s roads is frequently futile. You have some hope on a motorway, but on a standard road you cannot blithely cruise along at 101km and expect everyone else to do the same. Of course, everyone should drive their car at the speed appropriate for the road – not faster, not slower. Goldilocks behaviour. Each car should find its place seamlessly in the chain of other vehicles on the road, and everyone could tootle along at a sensible pace, then indicate correctly and veer off smoothly when their junction comes up.

Never in our wildest dreams is this ever going to happen. A tractor is going to pull out of a field. A Yaris is going to slow from 60 to 40 while its driver tries to decide if it’s the post office they’ll go to first, or will they do that after Mass instead. A D-reg tourist is going to go like the clappers, then realise they want to look at the beautiful Wild Atlantic Way view (and take a snap for Instagram).

My aforementioned husband is a sociologist and many years ago he explained the concept of ‘collision culture’ to me. This is where massive changes in Irish society over the years have resulted in the sudden bringing together of incompatible ways of living. Deadline-focused BMW entrepreneurs share the road with the old fella heading reluctantly to the nursing home to visit his wife. Conservative Catholics who are still pretty convinced about hell are bombarded with images of ungodly acts on their television. Young men find that the traditional role of provider and protector are now being derided by women who have no need for either provision or protection.

There are many examples of collision culture in healthcare, where the system works at a set speed in a given direction and everyone else has to either fall into line, or crash out. “Your appointment is at 9am on Monday in Mallow.”

Right, but I can’t get to Mallow for 9am on Monday.

“I’ll have to reschedule you so, to 2027.”

There is always a sense that you should be so grateful for the care that you are being given, that you should never ever imply that it simply doesn’t suit you. You get what you get and you don’t get upset. And yet, if you meekly accept the service as it is offered, you will often find yourself worse off than the bolshy complaining middle-class types who have the resources and confidence to advocate for themselves.

Services are planned in the eternal and futile assumption that everyone will behave the way we want them to. People will arrive at the outpatient department at 2pm and sit meekly until whatever random time the doctor picks up their chart from the massive pile. At the end of the afternoon, the massive pile will not have disappeared. There will be around a fifth of the charts still sitting there, because those people will not have shown up. A big scrawly DNA [did not attend] will be written across their notes.

“For God’s sake, it’s a disgrace, do they not know about our waiting lists? Someone else would have given their only arm to take that place.”

And we begrudgingly send them out another dictatorial appointment, at the same time on the same day of the week in six months’ time, and are doubly disgusted if they don’t show up then either.

Some wiser heads than me have suggested that we change the acronym from DNA to CNA – ‘could not attend’. The person was unable to meet our strictly enforced and inflexible timetable. This might prompt us to think a little bit deeper about why that might be and maybe even consider alternative ways of making our services available for those who need to use them.

Healthcare services can continue to insist on driving to a schedule that suits them, but only a few people will be able to keep up. The others will either choose a different route, or crash out entirely.