If you put automated reminders into a clinic that did not have them, you will see your DNA rate fall. That is one of the better-established findings in appointment research. A systematic review published in the British Journal of General Practice found SMS reminders reduce no-show rates by somewhere between 25% and 38%, and clinic owners who make the switch usually see it in their own numbers within a couple of months.
So this is not an argument that reminders do not work. They do, and a clinic without them should fix that before anything else. It is an argument about what happens after they have worked, and about a specific disappointment that a lot of clinic owners run into roughly six months in: the DNA rate has genuinely improved, everyone can see it in the data, and the monthly revenue has not moved nearly as much as expected.
There is a straightforward reason for that, and it is worth understanding, because it changes what you should do next.
What a reminder actually changes
A reminder does one job. It gets an appointment back into the patient's attention before the appointment happens.
For the patient who had simply forgotten, that is the whole battle. They see the message, they remember, they turn up, and an appointment that would have been a DNA becomes an attendance. That is the clean win, and it is the mechanism most of the benefit runs through.
But there is a second group, and they behave differently. This is the patient who was never going to attend. They have a clash, they are unwell, their childcare fell through, or they have simply changed their mind about the treatment. The reminder does not change any of that. What the reminder changes is when you find out. Without one, they vanish on the day and you learn about it when the slot passes empty. With one, they read the message the evening before and reply to cancel.
That patient has moved from your DNA column to your cancellation column. Your DNA rate improves. Whether your revenue improves depends entirely on what happens to the slot they just released.
The conversion is real, and it is only half the job
This is the part that catches clinics out.
Consider an illustrative clinic running 400 appointments a month with a 10% DNA rate, so 40 lost appointments. It introduces reminders and the DNA rate drops to 6%. That is a good result, in line with what the evidence would predict.
But those 16 recovered appointments are not all patients who now attend. Some proportion of them are patients who now cancel in advance instead of vanishing. Say, for the sake of argument, that half genuinely attend who would not have, and half cancel with notice. The clinic has gained eight attended appointments, which is real money, and eight cancelled slots, which is real notice and nothing more until someone does something with it.
If those eight cancelled slots sit empty, the clinic has captured perhaps half of the benefit it thought it was buying. The DNA rate on the dashboard looks better than the bank statement does, and that gap is not a measurement error. It is the honest result of solving the attention problem and leaving the capacity problem untouched.
Worth being clear: converting a DNA into a cancellation is still a genuine improvement even if you fill nothing. You get the chance to fill it, which you did not have before, and you get a patient who behaved considerately rather than one you now have to have an awkward conversation with. But a chance is not revenue. It becomes revenue only if it is taken.
Why "we ring the waiting list" is not a plan
Most clinics do have a response to a cancellation, and it is usually some version of ringing a few people who wanted an earlier slot.
The problem is not that this is a bad idea. It is that it depends on someone at the front desk having ten spare minutes at the exact moment the cancellation arrives, which is precisely when they are least likely to have them. A cancellation lands during clinic hours, alongside arrivals, payments, a ringing phone and a practitioner who needs something. Filling a slot for tomorrow is important, but it never feels urgent in the way a person standing at the desk feels urgent. So it slips, and by the time the desk is quiet the slot has passed.
The result is that most clinics fill cancellations occasionally rather than reliably. Occasionally is worth something. It is just a long way short of what the freed capacity is actually worth, and the difference compounds every week.
There is also a measurement blind spot here that makes the problem hard to see. Clinics track their DNA rate, because it is a number their practice management system will show them. Very few track what proportion of their cancelled slots get refilled, because nothing calculates it for them. That means the half of the problem that reminders solve is highly visible and the half they do not solve is effectively invisible, which is a good explanation for why so many clinics conclude they have dealt with no-shows and then cannot work out where the expected money went.
The two problems, stated plainly
It helps to separate them, because they need different tools.
Problem one is attention. The patient would attend if they remembered, and they did not remember. This is what reminders solve, and they solve it well. If you have not yet got automated reminders running, that is the highest-return thing available to you, and our guide to ten proven ways to reduce patient no-shows covers it alongside the other prevention levers worth pulling, ranked by impact.
Problem two is capacity. The patient is not coming, for reasons no message will change, and there is now a paid-for hour in your diary with nobody in it. Reminders cannot touch this. What is needed here is a way of getting a suitable patient into that slot quickly enough to matter, which is a different discipline with different failure modes. That is the subject of our guide on how to recover revenue from cancelled appointments.
The clinics that get the full benefit are the ones running both. Prevention lowers how often a slot comes free. Recovery lowers how much it costs when one does. Doing only the first caps your result at whatever proportion of your losses were forgetfulness, and for most clinics that is well under half.
What to do about it
Three things, in order.
Find out what your fill rate is. Take last month. Count the appointments that were cancelled. Count how many of those slots were later booked by someone else. That percentage is the number nobody in your clinic currently knows, and it is the one that tells you how much of your reminder benefit is leaking away. If it is low, you have found real money.
Stop treating cancellations as bad news. They are the good outcome. A team that hears a cancellation and thinks "opportunity, act now" behaves very differently from one that thinks "shame, nothing to be done". This is a framing change more than a process change, but it determines whether anything else you put in place gets used.
Make the first move automatic. Not the decision about who gets the slot, and not the booking itself, which should stay with a person. Just the part that has to happen within a few minutes of the cancellation arriving, because that is the part a busy front desk will never do consistently. Our guide on how to fill a last-minute clinic cancellation sets out what that looks like in practice, including why contacting your whole waiting list at once causes problems of its own.
Where ShowUp fits
ShowUp started as an SMS reminder platform for UK private clinics, so this is a limitation we have watched from close range. Reminders do their job, clinics see their DNA rate improve, and then the conversation turns to the slots that come free anyway and what can be done about them.
That is what ShowUp is being built to address next. The principle is that a freed slot should trigger a considered approach to a suitable patient straight away rather than waiting for someone at the clinic to spot it, that accepting should take a single action on a phone, and that nothing reaches the diary without a person at the clinic confirming it. Prevention and recovery are two halves of the same problem, and treating them as one system is the point.
If you want to talk about how your clinic handles cancellations today, send us an email.
About the author
Will Kirk is the founder of ShowUp Software Ltd, a UK company that makes ShowUp: software that helps private healthcare clinics recover revenue from cancelled and missed appointments by offering freed slots to a waiting list by SMS, with automated appointment reminders included. ShowUp works alongside Cliniko. Based in Nottingham. ICO Registered: ZC159538. Company Number: 17228859.
Sources
- British Journal of General Practice: Text message reminders for healthcare appointments: a systematic review
- NHS England: Outpatient attendance and DNA data