Policy-makers’ conception of patient non-attendance fees in specialist healthcare: a qualitative document analysis

OBJECTIVES: Patients missing their scheduled appointments in specialist healthcare without giving notice can undermine efficient care delivery. To reduce patient non-attendance and possibly compensate healthcare providers, policy-makers have noted the viability of implementing patient non-attendance fees. However, these fees may be controversial and generate public resistance. Identifying the concepts attributed to non-attendance fees is important to better understand the controversies surrounding the introduction and use of these fees. Patient non-attendance fees in specialist healthcare have been extensively debated in Norway and Denmark, two countries that are fairly similar regarding political culture, population size and healthcare system. However, although Norway has implemented a patient non-attendance fee scheme, Denmark has not. This study aimed to identify and compare how policy-makers in Norway and Denmark have conceptualised patient non-attendance fees over three decades. DESIGN: A qualitative document study with a multiple-case design. METHODS: A theory-driven qualitative analysis of policy documents (n=55) was performed. RESULTS: Although patient non-attendance fees were seen as a measure to reduce non-attendance rates in both countries, the specific conceptualisation of the fees differed. The fees were understood as a monetary disincentive in Norwegian policy documents. In the Danish documents, the fees were framed as an educative measure to foster a sense of social responsibility, as well as serving as a monetary disincentive. The data suggest, however, a recent change in the Danish debate emphasising fees as a disincentive. In both countries, fees were partly justified as a means of compensating providers for the loss of income. CONCLUSIONS: The results demonstrate how, as a regulative policy tool, patient non-attendance fees have been conceptualised and framed differently, even in apparently similar contexts. This suggests that a more nuanced and complex understanding of why such fees are debated is needed.