What are we missing? Reflections on the 'problem' of missed appointments in the UK

Tackling missed appointments has become a prominent part of conversations about the 'recovery' of the UK NHS from the COVID-19 pandemic. With long waiting lists, delays in access to primary care, and overburdened staff, it seems logical that efforts should be made to reduce the time lost to unused appointment slots. Yet care needs to be taken to reflect on how and why missed appointments have become an area of focus, and to be transparent about what this means for patient care and health inequalities. This article provides a critical perspective on the current mainstream approach to missed appointments in policy, research and practice.

The study applies Bacchi's "what is the problem represented to be" method of policy analysis to provide critical commentary on findings from a realist review of 253 documents; interviews with 61 'key informants' whose personal and professional experiences relate to missingness; and a series of co-design workshops with a Stakeholder Advisory Group of 16 professionals and experts-by-experience. It also includes an informal analysis of national news media and NHS news pieces covering missed appointments since 2015.

Analysis identified a consistent approach to missed appointments across research, practice and media and policy statements. This approach focuses on the impacts of missed appointments for services; places responsibility on the shoulders of patients; and limits interventions to things that seek to alter their behaviours in pursuit of a service-wide reduction in missed appointments. The hegemony of this approach is sustained by research that has failed to adequately engage with the most marginalised patients; failed to explore causes in depth; and failed to include an inequalities lens in its approach to interventions. We propose an alternative viewpoint - applying a missingness lens - built from an alternative evidence base that combines critical literature review, qualitative interviews, and participatory methods with those experiencing missingness and with key professionals.

Embedding an alternative perspective in practice and in research has significant potential as a non-stigmatising, inequalities-based and effective approach to understanding and addressing missed appointments.