It used to be a nightmare.

Within two weeks of receiving the GP's referral letter, a patient had to be given an appointment date at an outpatients' clinic.

Getting patients involved - Colchester General Hospital's outpatients' manager Pat Wood with her appointments staff. Picture: TERRY WEEDEN

That date could have been nine months or even a year down the line, but, hey, that was the way things were done.

"It was not effective," said Pat Wood, outpatients' operations manager for Essex Rivers Healthcare Trust, "and it certainly didn't prove efficient. Patients forgot, consultants left, appointments had to be changed numerous times and clinics were cancelled. It was not ideal, to say the least."

She believes the system contributed big time to the growing number of DNAs. This is hospital-speak for "did not attend", applicable to those who don't show up for their outpatients' appointments and, for whatever reason, don't phone in with an apology.

Four years ago it was bad. Nearly 20,000 people in north Essex were classed as DNAs. That's 20,000 lost appointments at a time when trusts were being pushed harder than ever before to bring down outpatients' waiting lists.

As Mrs Wood pointed out, had some of the 20,000 rung to cancel there would have been quite a dent made in those waiting lists.

A qualified nurse, she had been operations manager for less than a year when the figures showed there was something not quite right with the appointments system. It wasn't just a question of patients being bad-mannered. Many genuinely forgot; others turned up at the wrong time.

"It became easy to see what the main problem was patients were being given their appointment dates much too early. Things had to change."

They did. A new system came in, one which put the emphasis on negotiation and patient-involvement.

"Now, when we receive the referral letter from the GP, we write to the patient saying we have the letter and we will be in contact at a later date to negotiate a time for the appointment," Mrs Wood said.

That is usually between six and eight weeks before the patient nears the top of the waiting list.

"We don't write, we ring. Then we do everything we can to ensure the patient gets a suitable appointment date."

That could mean within a month. Thanks to this much-shortened wait time from knowing the appointment date to it actually coming round, DNAs have dropped. Getting patients involved from the outset was a good move, too.

But outpatients' clinics were not the only ones hampered by DNAs. Essex's GP surgeries were also suffering but, unlike outpatients' clinics, their figures are not improving.

Colchester is a prime example. Judy Watts is practice manager for Dr Withnall and Partners. The practice has 11,500 patients, four full-time GPs, two nurse practitioners, three nurses, a midwife and a phlebotomist, surgeries in Mersea Road and Creffield Road and an area which takes in the entire Maldon Road area through to Monkwick.

In the three months from September to date in November, 15,132 appointments have been made with the practice. Out of those, about 1,000 have been DNAs.

This is a high proportion, but it is in keeping with the national average. Neither is it a new phenomenon. Posters encouraging patients to phone their surgeries and cancel if they can't make appointments have been around forever.

"The situation is not getting any better, particularly when whole families don't turn up," said Mrs Watts. "That can be half-an-hour of a professional's time which has been put aside and, because no one phoned to cancel, (has been) wasted."

Many patients book three or four weeks in advance to make routine appointments. These are extremely susceptible to DNAs.

"If we get habitual non-attenders for example, not turning up three or four times and not letting us know then I will write to them, pointing out their actions are a waste of an NHS resource and, if they persist, they will be asked to leave the practice."

She stresses there are cases where patients do forget, but they are a very low percentage of overall DNAs.

"Yes, there are genuine ones, but they are overwhelmed by those who simply do not care. If only they would realise that a quick phone call to cancel means their appointment can be used by someone who really needs it."

Back at Essex Rivers, Pat Wood is pleased with the Trust's new appointments' system. As far as she is concerned it is working. In the trust's financial year 1999-2000 there were about 17,500 DNAs out of 250,000 appointments. Last year - which had a similar number of appointments - saw a drop to 15,000.

Everyone who makes an outpatients' appointment receives a card almost begging them not to be a DNA. The card scheme was launched when DNAs hit their peak in the mid-1990s, and has been effective.

The nightmare may be far less gloomy, but it isn't a sweet dream yet.

Published Thursday December 6, 2001