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Non-attendance rates among patients attending different grades of psychiatrist and a clinical psychologist within a community mental health clinic

DOI:10.1192/pb.28.1.5
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Ronan J Mcivor at South London and Maudsley NHS Foundation Trust
Ronan J Mcivor
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Aims and Method To examine non-attendance rates in patients seen by psychiatrists of different grades and a consultant clinical psychologist. Rates were obtained from the patient administration system over a 21-month period. Results A planned linear contrast showed that the clinical psychologist's patients had the lowest rate of non-attendance (7.8%), followed in turn by those of consultant psychiatrists (18.6%), specialist registrars (34%) and senior house officers (37.5%). Clinical Implications Factors such as continuity of care, perceived clinical competence and the provision of non-medical interventions might have an impact on attendance rates. These results indicate the difficulty in reconciling the training needs of junior doctors with the provision of continuity and quality of care for patients. Reminder systems for people seeing training doctors might be an effective way of reducing non-attendance rates.
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or iginal paper s
Psychiatric Bulletin (2004), 28,5^7
RONAN McIVOR, EMMA EK AND JEROME CARSON
Non-attenda nce rate s a mong p atient s at te nding di ffer ent
grades of psychiatrist and a clinical psychologist within
a community mental health clinic
AIMS A N D M ET HO D
To examine n on- attendance rates in
patients se en by ps ychiatrist s of
different grade s and a consult ant
clini c al psy ch olo gis t. Rate s wer e
obtained from the patient
admin is tratio n sy s tem ove r a
21- month period.
RESULTS
A planned linear contrast showed
that the clinical p sy ch ologis t ’s
patient s had the lowe st rate of
non-attendance (7.8 %), followed in
turn by thos e of consultant ps ychia-
trists (18.6 %), sp ecialist re gistrars
( 34% ) and senior h ous e of fic er s
(37.5%).
CLINIC AL IMPLICATIONS
Fac tors such as continuit y of care,
perc eived c linical competence and
the provision of non -medic al
inter vention s might have a n impa c t
on attendance rate s.Thes e results
indi cate t he di f f i cul t y i n re c on cilin g
the training ne e d s of ju nior do c t or s
with the provision of continui ty and
qualit y of c are f or patient s. Reminder
sy s tems f or people seeing training
doc tors might b e a n ef fec tive way of
reducing n on- attendance rate s.
Non-attendance by psychiatric ou t-patients has an
important impact on clinical and e conomic outcomes. The
national rate for non-att endance at all types of out-
patient clinic in t he UK has been reported as 12% (Sharp
& Hamilton, 2001), with rates varying depending on
setting and spe ciality (Chen, 1991; Gatrad, 2000).
Non-attenders are more likely to be young men from
deprived socio-economic backgrounds who have had to
wait a long time for their appoint ment (Lloy d
et al
,1993;
Beauchant & Jones, 1997; Killaspy
et al
, 2000). Rates of
non-attendance at psychiatric out-patient clinics are
thought to be double those seen in other medical
sp ecialities (Killaspy
et al
, 200 0 ), with thos e not attending
being more unwell, having great er social impairment and
being more likely to require hospital admis sion. This may
result in increased risk to self or others (Steering
Commit tee of the Confidential Inquiry into Homicides and
Suicides by Mentally Ill People, 1996). The initial
asses sment appointment seems to be of importance in
determining whether a pati ent returns, reflecting
confidence in the therapist and satisfaction with therapy
(McGuff
et al
, 1996). Missing subsequent psychotherapy
appointments has been related to withdrawing from
treatment (Berrigan & Garf ield, 1981). Simply forgetting
an appointment accounts for almost a quarter of
non-attendance (Sparr
et al
, 1993; Killaspy
et al
, 2000).
Little research has been conducted into differences
in patient non-attendance rates among professions and
between different grades of medical staff. Delk &
Johnson (1975) found that patients seeing medical
students were more likely to withdraw from treatment
compared with those seeing staff members, and Pang
et
al
(1996 ) showed that, in a Hong Kong setting, being
seen by a mor e senior member of st aff increased
attendance rates. In light of this, we examined whether
there were differences in no n-attendance rates between
different grades of medical staff, and between medical
staff and a consultant clinical psychologist. It was
predicted that non-attendance rates would be highest for
junior medical staff.
Meth od
The study investigated patients of an inner-city commu-
nity mental health team in south London. The patient
administration system was used to obtain rates of atten-
dance and non-attendance for 482 patients seeing the
following members of staff: two consultant psychiatrists
(167 patients), two specialist registrars (111 patients), two
senior ho use officers (SHOs) (52 patients) and a consul-
tant clinical psychologist (152 patients). The consultant
psychiatrists and the clinical psychologist are permanent
members of staff, whereas the specialist registrars and
SHOs change every 12 months and 6 months, respectively
as part of a training rotation. Cancellations were not
included in the analysis, nor were non-attendance rates
among new re fer rals. Data were collected for a 21-month
McIvor
et al
Patient non- att endance rat es
5
period and analys ed using the Statistical Package for the
Social Sciences, version 10.
Res ults
Average non-atten dance rates varied from 7.8% for the
clinical psychologist to 37.5% for the SHOs (Table 1). The
hypothesis was tested using a planned linear contrast
(
F
=287.491, num. d.f.=1, den. d.f.=80,
P
50.001 ). The
non-attendance rate for the clinical psychologist was
significantly lower than the rates for the medical staff,
which increased progressively for consultant psychiatrists,
sp ecialist registrars and SHOs.
Discussion
Continuity of care, clinical competence and differences in
clinical style are hyp othe sis ed to be the main reas ons for
the significant differ ences in non -attendance rates
between groups. The consultant clinical psychologist and
consult ant psychiatrists saw most of the ir patients over
long periods, which allowed the development of a good
rapport and a positive, uninterrupted the rapeutic
relationship. Non-consultant medical s taff, on the ot her
hand, rotated every 6 or 12 months, resulting in inter-
ruption of clinical care. This change in medical staf f might
have adversely affected patients’ willingness to attend
their appointment.
W hy did the clinical psycho logist have a lower non-
attendance rate than the psychiatrists? A contributing
rea son might be that clinic al psychologists tend not to
see people who are acutely ill; non-attendance has been
shown to b e related to severity of illness for patients with
psychiatric problems (Lloyd
et al
, 1993 ; Killaspy
et al
,
2000). In addition, clinical psychologists are not involved
in mental health assessments for c ompulsory admission
or other practices perceived to be coercive, such as those
relating t o hospitalisation or medication. Psychology is
perceived to be less stigmatising and more acceptable to
the patient: the ‘poor image’ of psychiatry has been
reported by patients as one of the main reasons for not
attending appointments (Hillis & A lexander, 1990).
Furthermore, clinical style may be important, with
psychologists more likely to emphasise principles of
therapeutic alliance, collaboration and education, factors
that have been found to correlate positively with
appointment-keeping and pat ient satisfaction (Fiester &
Rudes tam, 1975). Although we did not measure
frequency or length of appointments, contact with the
psychologist might have been perceived as having a more
defined therapeutic focus, with longer and mo re frequent
(usually week ly) s essions encouraging engagement.
Overall, non-attendance rates for medical staff were
high, with rates significantly lower with greater seniority.
Experience and perceived clinical competence may be an
important factor in non-attendance rates. Less experi-
enced staff may not feel as competent in dealing with
complex patient issues. Quality of care might thus be
higher for patients seeing a consultant. In addition,
patients may feel they are being given a better service
simply by seeing a mor e senior memb er of st aff.
Stud y limit ations
We did not dire ct ly examine the reas ons behind our
findings. Frequent failures to attend by individual clients
were not controlled for, and it is possible that a small
number of patients who repeatedly failed to attend
skewed rate s. Furthe rmore, there may be differences
between the patients seen, with consultant psychiatrists
being more likely to see chronic attenders, and junior
me dical staff seeing patients with a range of clinical
profiles, involving short-term interventions or longer-
term work. As the stud y wa s con ducted in a deprived
inner-city area, it is possible that the findings are not
representative.
Implic ations
Non-attendance rates have a significant impact on clinical
and economic outcomes. If continuity of care and level of
experience are possible factors influencing non-attendance
rates, our findings reinforce the dif ficulty in reconciling
the needs of medical training with the provision of
patient care. Training doctors have to rotate between
sub-spec ialities in order to gain necessary experience,
and it is no t possible for consultants to s ee everyone.
Ideally, the same professional should see clients fo r the
duration of their treatment, but clearly this is not always
possible.
Effective strategies to reduce non-attendance rates
include the use of telephone or postal reminders (Rusius,
1995; Read
et al
, 1997; Hardy & Furlong, 2001); offering
patients a choice of time and date (Read
et al
, 1997); and
wr iting a personal letter rather than a standard
appointment card (Hillis & Alexander, 1990). Such inter-
ventions have reduced non-attendance by up to 60%
(Read
et al
, 1997). These strategies should be targeted at
people seeing staff below consultant grade. If non-
attendance persists, a number of options are available to
the team, including contact with the general practit ioner,
or an acknowledgement that the patient does not wish
to be assessed or seen. If there is concern about the
patient in relation to mental state or risk, then a home
visit is indicated. The use of assertive outreach or
assertive community treatment, if available, may be
us eful in this regard, although such programmes tend to
focus on those with severe and enduring mental illness
rather than those attending out-patient clinics only.
McIvor
et al
Pati ent non - at te ndance rate s
original
pap ers
Table 1. Monthly non-attendanc e rate s for the different
professions over a 21-month per iod
Profession
(Patient
n
)
Mean
(%)
Mini-
mum (%)
Maxi-
mum (%)
Clinical psychol ogist (
n
=52) 7.8 2 19
Consultant psychiatrists
(
n
=167)
18.6 6 28
Specialist registrars (
n
= 111) 3 4 2 8 51
Senior house officers (
n
=52) 37.5 21 59
6
However, assertive outreach can facilitate contact with
patients who are hard to engage (Lehman
et al
, 1997),
and the development of such services has been
encouraged in the UK (Department of Health, 1999).
Future research will e xamine non-attendance rates in
patients seen by psychologists of different grades and by
other members of the community me ntal health team.
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STEERING COMMITTEE OF THE
CONFIDENTIAL INQUIRY INTO
HOMICIDES AND SUICIDES BY
MENTALLY ILL PEOPLE (1996)
Report of
the Confidential Inquiry into Homicides
and Suicides by Mentally Ill People
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London: Royal College of Psychiatrists.
*Ronan McIvor Consultant Psychiatrist, Maudsley Hospital,103 Denmark Hill,
London SE5 8 AZ, Emma Ek Trainee P s ycho logist, Jerome Carson
Consultant Clinical Psycholo gist, South Londo n and Maudsley NHS Trust, London
7
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... Gleichzeitig stieg die Wahrscheinlichkeit einer präziseren Vorhersage der Sitzungszahl mit höherem Ausbildungsgrad (Mueller und Pekarik 2000). Eine andere Studie berichtete weniger Therapieabbrüche bei klinischen Psychologen im Vergleich zu Assistenzärzten (McIvor et al. 2004). Sowohl die fachliche Ausrichtung (Schöttke et al. 2017;White et al. 2010;Xiao et al. 2017) als auch die Effektivität und Effizienz eines Therapeuten (Banham und Schweitzer 2016) wiesen keinen Einfluss auf. ...
... Das Verzerrungsrisiko der eingeschlossenen Studien kann überwiegend als gering bewertet werden. Von den 23 Studien wiesen 2 Studien ein hohes Verzerrungsrisiko auf (McIvor et al. 2004;Philips et al. 2017). In einer Studie wurden ausschließlich die Abbruchraten von 8 Therapeuten berichtet, ohne Angaben über die Zielpopulation oder zu den Therapeuten (McIvor et al. 2004). ...
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Hintergrund: Bisherige Forschungsarbeiten berichten wenig einheitliche Befunde zum Einfluss von Therapeutenmerkmalen auf Therapieabbrüche (Drop-outs). Zudem mangelt es an vergleichbaren Operationalisierungen von Therapieabbrüchen. Fragestellung: Ziel des Review war die Identifizierung von einflussreichen Therapeutenmerkmalen, die mit Therapieabbrüchen zusammenhängen. Weiterhin wurden die Operationalisierungen von Therapieabbrüchen in den vergangenen 20 Jahren untersucht. Material und Methode: Die Literatursuche erfolgte via PsycARTICLES, PsycINFO, PSYNDEX und OVID MEDLINE. Extrahiert wurden die Operationalisierung des Konstrukts Therapieabbruch, Abbruchquoten, die erhobenen Therapeutenmerkmale sowie die verwendeten Erhebungsinstrumente. Das Verzerrungsrisiko der Studien wurde anhand des Tools Quality in Prognostic Studies (QUIPS) analysiert. Ergebnisse: Es konnten 23 relevante Studien mit 20.034 Patienten und 1826 Therapeuten identifiziert werden. Das Alter, das Geschlecht und die therapeutische Erfahrung hatten keinen Effekt auf den Therapieabbruch. In einigen Studien zeigte sich ein Einfluss ethnischer und kultureller Variablen. Psychologische Therapeutenvariablen wie Persönlichkeitseigenschaften wurden bislang wenig untersucht. Die dahingehenden Ergebnisse können noch nicht abschließend beurteilt werden. Eine einheitliche Operationalisierung für Therapieabbrüche existiert nicht. Schlussfolgerung: Zukünftigen Untersuchungen wird empfohlen, die Auswahl an möglichen Prädiktoren umfassender zu gestalten und sowohl Therapeuten‑, Patienten- als auch Prozessvariablen zu berücksichtigen. Zudem sollte sich nicht auf eine Operationalisierung des Konstrukts Therapieabbruch festgelegt werden, sondern stattdessen sollten mehrere Varianten gleichzeitig verwendet werden, um die Effekte der Operationalisierung auf das Ergebnis in Sensitivitätsanalysen zu untersuchen.
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Objective: Engagement in mental health treatment is low, which can lead to poor outcomes. We evaluated the efficacy of offering patients financial incentives to increase their mental health treatment engagement, also referred to as contingency management. Method: We meta-analyzed studies offering financial incentives for mental health treatment engagement, including increasing treatment attendance, medication adherence, and treatment goal completion. Analyses were run within a multilevel framework. All study designs were included, and sensitivity analyses were run including only randomized and high-quality studies. Results: About 80% of interventions incentivized treatment for substance use disorders. Financial incentives significantly increased treatment attendance (Hedges' g = 0.49, [0.33, 0.64], k = 30, I2 = 83.14), medication adherence (Hedges' g = 0.95, [0.47, 1.44], k = 6, I2 = 87.73), and treatment goal completion (Hedges' g = 0.61, [0.22, 0.99], k = 5, I2 = 60.55), including completing homework, signing treatment plans, and reducing problematic behavior. Conclusions: Financial incentives increase treatment engagement with medium to large effect sizes. We provide strong evidence for their effectiveness in increasing substance use treatment engagement and preliminary evidence for their effectiveness in increasing treatment engagement for other mental health disorders. Future research should prioritize testing the efficacy of incentivizing treatment engagement for mental health disorders aside from substance use. Research must also identify ways to incentivize treatment engagement that improve functioning and long-term outcomes and address ethical and systemic barriers to implementing these interventions. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
... Drop-outpercentages binnen de forensische gezondheidszorg variëren tussen de 46% en 70% (McMurran & Theodosi, 2007;Rosch e.a., 2016). De no-showpercentages liggen tussen de 25% en 41% (Dalton, Major & Sharkey, 1998;Feitsma, Popping & Jansen, 2012;Hambridge, 1990;Hornsveld e.a., 2008), afhankelijk van de onderzochte setting, behandeling en toegepaste analysemethodes (McMurran & Theodosi, 2007;Rosch e.a., 2016 Van Merode, & Arntz, 2007;McIvor, Ek, & Carson, 2004). ...
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... Persistent attendance is one of the most basic components of therapeutic change in psychotherapy. 50 Attendance rates have a significant impact on clinical and economic outcomes, 51 and many interventions are targeted to increase attendance rates in mental health settings and services. 52 Attendance is often cited in the context of engagement and is associated with positive treatment outcomes. ...
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Full-text available
  • Sep 2017
Setting: Programmes that integrate mental health care into primary care settings could reduce the global burden of mental disorders by increasing treatment availability in resource-limited settings, including Rwanda. Objective: We describe patient demographics, service use and retention of patients in care at health centres (HC) participating in an innovative primary care integration programme, compared to patients using existing district hospital-based specialised out-patient care. Design: This was a retrospective cohort study using routinely collected data from six health centres and one district hospital from October 2014 to March 2015. Results: Of 709 patients, 607 were cared for at HCs; HCs accounted for 88% of the total visits for mental disorders. Patients with psychosis used HC services more frequently, while patients with affective disorders were seen more frequently at the district hospital. Of the 68% of patients who returned to care within 90 days of their first visit, 76% had a third visit within a further 90 days. There were no significant differences in follow-up rates between clinical settings. Conclusion: This study suggests that a programme of mentorship for primary care nurses can facilitate the decentralisation of out-patient mental health care from specialised district hospital mental health services to HCs in rural Rwanda.
The Contribution of a Music and Arts Rehabilitation Program to the Creative Identity, Well-Being, and Community Integration of People With Mental Health Conditions
Article
The United Nations highlighted the importance of promoting the rights of people with mental health conditions (MHC) to education, employment, and citizenship. One related initiative in Israel is the Garage pre-academic music and arts school for individuals with musical and artistic abilities coping with MHC. This process–outcome study examined whether and how the Garage contributes to participants’ creative self-concept, mental health, alleviates loneliness, and promotes postsecondary education and work integration. It also probed the participants’ initial expectations and the extent to which these were fulfilled. Using a single-group pretest–posttest design, quantitative data on the outcome variables were collected, along with mid-test data on process variables from the Garage students ( N = 44). Supplementary qualitative data were collected at pretest on the students’ expectations. The results suggest a significant increase in creative personal identity and mental health, a decrease in loneliness, and promotion of postsecondary education and work integration. These findings were associated with persistent attendance, basic psychological needs satisfaction, and expectation fulfillment. A merged analysis indicated that the students’ qualitative expectations were generally congruent with the quantitative results. Overall, the findings show how the program corresponds to humanistic values, targets service users’ needs and rights, and promotes personal recovery and community integration.
Intensive Cognitive Behaviour Suicide Prevention for Males in Custody: A Pilot Feasibility Case Series
Article
  • May 2022
Background Retention of participants to programs of psychological therapy in a prison setting is problematic. Intensively delivered therapy has emerged in recent years, in contrast to the traditional format of weekly sessions of psychological therapy. Method This study aimed to evaluate the feasibility of an intensive program of cognitive behavior suicide prevention therapy within a male prison, for the first time. Thirteen participants consented to take part. Up to 10 h of therapy was offered, across five sessions, within a 3-week delivery window. Outcome measures were completed at baseline and follow-up. Results Program completion and client satisfaction with the intensive program were high. Outcomes related to suicidal distress were assessed, with effect sizes reported. Large and statistically significant effect sizes were found for suicidal ideation and emotional regulation when comparing baseline to follow-up. Small and non-significant effects were found for social support and problem solving when comparing the same. Conclusion The study holds promise for the feasibility and efficacy of delivering an intensive cognitive behavior suicide prevention therapy for people in prison. Further exploration on a larger scale is warranted [Clinical Trial ID: NCT03499548].
Improving out-patient attendance using postal appointment reminders
Article
Full-text available
Previous studies have demonstrated high rates of non-attendance among new referrals to psychiatric out-patient clinics. Consistent factors which distinguish non-attenders have not been shown. Forgetting an appointment contributes towards non-attendance and offers potential for its reduction. The effect of sending patients an appointment reminder three working days prior to the appointment date was examined. The rate of attendance of those sent a reminder improved significantly.
Rejection of psychiatric treatment
Article
Full-text available
The growing realisation that health care resources are limited has led to increasing concern about the wastage caused by the failure of patients to keep their psychiatric appointments. Generally, non-attendance following psychiatric referral is particularly high (e.g. Baekland & Lundwall, 1975), although in the north-east of Scotland the rate is roughly similar to those reported by other specialties (Alexander & Hillis, 1989). However, little effort has been made to elicit the views of non-attenders themselves or to consider what aspects of the referral system may contribute to this failure to attend.
Prospective controlled study of psychiatric out-patient non-attendance: Characteristics and outcome
Article
  • Feb 2000
Background Psychiatric clinics have high non-attendance rates and failure to attend may be a sign of deteriorating mental health. Aims To investigate why psychiatric out-patients fail to attend, and the outcome of attenders and non-attenders. Method Prospective cohort study of randomly selected attenders and non-attenders at general adult psychiatric out-patient clinics. Subjects were interviewed at recruitment and severity of mental disorder and degree of social adjustment were measured. Six and 12 months later their engagement with the clinic and any psychiatric admissions were ascertained. Results Of the 365 patients included in the study, 30 were untraceable and 224 consented to participate. Follow-up patients were more psychiatrically unwell than new patients. For follow-up patients, non-attenders had lower social functioning and more severe mental disorder than those who attended. At 12-month follow-up patients who missed their appointment were more likely to have been admitted than those who attended. Conclusions Those who miss psychiatric follow-up out-patient appointments are more unwell and more poorly socially functioning than those who attend. They have a greater chance of drop-out from clinic contact and subsequent admission.
A Randomized Trial of Assertive Community Treatment for Homeless Persons With Severe Mental Illness
Article
Background: This experiment evaluated the effectiveness of an innovative program of assertive community treatment (ACT) for homeless persons with severe and persistent mental illnesses. Methods: One hundred fifty-two homeless persons with severe and persistent mental illness were randomized to either the experimental ACT program or to usual community services. Baseline assessments included the Structured Clinical Interview for DSM-III-R, Quality-of-Life Interview, Colorado Symptom Index, and the Medical Outcomes Study 36-Item Short Form Health Survey. All assessments (except the Structured Clinical Interview) were repeated at the 2-, 6-, and 12-month follow-up evaluations. Results: Subjects in the ACT program used significantly fewer psychiatric inpatient days, fewer emergency department visits, and more psychiatric outpatient visits than the comparison subjects. The ACT subjects also spent significantly more days in stable community housing, and they experienced significantly greater improvements in symptoms, life satisfaction, and perceived health status. Conclusions: Relative to usual community care, the ACT program for homeless persons with severe and persistent mental illness shifts the locus of care from crisisoriented services to ongoing outpatient care and produces better housing, clinical, and life satisfaction outcomes.
Socio-economic and demographic factors in patient non-attendance
Article
  • Jan 1997
Explores demographic and socio-economic factors behind patient non-attendance at outpatient clinics. Part of a wider series which can be found at http://www.hcaf.biz/2010/Publications_Full.pdf
A multivariate analysis of early dropout process
Article
  • Sep 1975
Performed principal-component factor analyses on patient input (demographic and pretherapy expectations), therapist input (demographic), and patient perspective therapy process variables that significantly differentiated 71 early dropout from 110 nondropout outpatients at 2 community mental health centers. At 1 setting results confirm (a) the presence of selection factors in the intake process whereby the more disturbed patients, who subsequently drop out, are assigned to lower level trained therapists and (b) the proposition that many patients unilaterally terminate despite the perception of the initial session as being an overall positive experience. Findings at the 2nd setting support the more traditionally held view of "dropout" as related to patient dissatisfaction with received services. Differences in the dropout process at the 2 settings were attributed to empirically demonstrated differences in the therapists' theoretical approach to the initial interview. The proclivity of earlier investigators to conceptualize dropouts as being characteristic of a single type of patient seems to be another unfounded homogeneity myth. (22 ref)
Noncompliance in Community Psychiatry: A Review of Clinical Interventions
Article
A substantial number of psychiatric patients seen in community settings fail to comply with treatment. Noncompliance takes many forms, including failure to keep initial appointments, to complete outpatient referrals from emergency services, to keep aftercare appointments following hospitalization, to remain in treatment, and to take prescribed medication. The author reviews the literature on noncompliance in community settings and discusses interventions that have been found to reduce noncompliance. Based on the review, four general recommendations for improving patient compliance are given; they are scheduling appointments before release from inpatient treatment, shortening the waiting period for appointments, using prompts in the form of letters and telephone calls to encourage patients to keep their appointments, and offering orientation and education about treatments and medications.
Relationship of missed psychotherapy appointments to premature termination and social class
Article
The problem of missed appointments in psychotherapy has received little empirical study. Consequently, this problem was studied in relation to several demographic and actuarial variables. Lower socio-economic status was found to be related to missed appointments and to premature termination. Missing appointments was also found to be related to dropping out of treatment. Possible reasons for these findings are discussed and suggestions offered for reducing premature termination.
Non-attendance at Outpatient Clinics: Is It Related to the Referral Process?
Article
  • Jul 1993
Non-attendance at outpatient clinics is a complex problem and previous studies have concentrated on hospital-related factors. It has been suggested that non-attendance might be related to the referral process, including the selection of patients for referral and the quality of communication between GP and patient. These issues are examined in a study of 1492 patients given first-time appointments at ENT and gastroenterology clinics. Non-attendance rates were 26 and 20% respectively. Non-attendance was not related to the nature, severity or duration of the patients' presenting problems at the time of referral or to their perception of the need for referral. Resolution of symptoms did not appear to be a major reason for non-attendance. Patients were significantly less likely to attend if they had been unable or only partly able to discuss their health problem with their general practitioner. Those who had requested referral were equally likely to default.