Classification and organisation of guidelines

Most guidelines contained an inception and/or policy implementation date, were general in nature and applied to all paediatric services. We found only one aimed at diabetes DNAs and three for Child and Adolescent Mental Health Services. All referred to other documents (legislation, regulatory review, statutory guidance, clinical guidelines, research) to contextualise their advice. Thirteen provided flow diagrams to aid decision making and three included sample letters to parents. Guidelines varied in the steps to take when an appointment is missed. For example, the guideline from one mental health trust (MHT5) invites the family to attend another appointment after a first DNA. After two, a letter is sent but no further appointment offered. Another guideline (MHT7) adopts a similar approach but makes reference to the child's right to receive healthcare and the need to inform other services and partners about non-attendance. Most guidelines do not specifically define DNA and associated terms, other than stating that DNA means ‘did not attend’.

Safeguarding advice to HCPs

Risks of non-attendance are described generally as risks to well-being. We identified only one referring to a specific condition (diabetes). The advice on how to deal with non-attendance was broadly similar across the sample, though in some the advice was general, in others more prescriptive with specific steps suggested depending on risk and/or perception of risk. These steps fall into five categories:

1. Reflection and review: consider whether the appointment is necessary and the child's health needs are being met; review records and other data to check address and contact details are correct and ascertain the level of risk; consider making a referral to CSC;

2. Direct interaction with the family: offer another appointment; attempt to make contact with the family; send a letter to the family;

3. Indirect interaction with the family: attempt to contact wider family members and/or neighbours;

4. Liaison with internal colleagues: seek advice from safeguarding leads in own organisation;

5. External referral: liaise with/contact other professionals outside own organisation including general practitioners (GPs); make a referral to CSC; contact the child's social worker; contact the police; issue a missing family alert.

Recording of activities is emphasised in all the guidelines.

Other findings

Some guidelines describe potential barriers to attendance by reference to the social determinants of health, service access and use. For example, the authors of MHT2's policy observe that: “Service users are often embedded in complex multiple pressures and demands, including poverty, discrimination, social exclusion, and multiple personal burdens…” (p. 4).

Some acknowledge that DNAs may or may not be a problem: “The missing of a health appointment on its own may be of no concern, or one missed health appointment may be very significant“ (CCG2, p. 5).

Managing information flows: gathering, processing and recording

Respondents described information gathering and processing as having a number of functions, including helping them identify a ‘true’ DNA. ‘True’ DNAs were those where a child had been booked into the appointment, expected to attend and the family were aware of this but the child had not attended. ‘False’ DNAs were the result of the organisation's mistake: So we would look…is it a true DNA, have we rearranged the appointment because sometimes that happens? You rearrange clinics, you send letters out, they don't receive them in time. (Service manager, safeguarding children role, Acute Trust)

Information was also used to demonstrate that the ‘correct’ actions had been followed, such as recording non-attendance.

Several respondents expressed anxiety about not knowing what is happening to a child and whether failure to attend an appointment represented a risk or not. For a child already ‘known’ to CSC, either because they were on a child protection plan (CPP) or had previous interaction with CSC, information might be held by social workers. However, since most children who miss appointments are not on a CPP, trying to establish the level of risk was difficult.

Seeking help and support from others

All respondents reported that they could seek help from others and being well supported within their organisations in managing DNAs.

When dealing with colleagues outside their own organisation, respondents sometimes referred to the challenges that different professional practices presented, including higher thresholds in CSC than those in their own organisation. Most respondents spoke about ‘multiagency’ working, and managing information flows between organisations was central to this.

The child at the heart of the policy: supporting children and families

As noted earlier, respondents recognised that not all DNAs are ‘true’ DNAs. Where non-attendance was established as a ‘true’ DNA, understanding non-attendance was important because this determined the type of support needed. While respondents talked about having systems in place to support families, these tended to be general rather than specific to a family's needs. One spoke about "….focusing on families that need extra support to get them to appointments. We have looked at that and we have put transport on …" (service manager, CCG).

Yet, while HCPs talked about supporting families, their concerns were primarily with the child and their unmet needs. One described non-attendance as children's rights issue, and the prospect of a child missing out on healthcare and possibly suffering was a concern, evident in respondents’ references to issues being ‘flagged up’, the imperative to ‘spot problems’ and the dangers of children ‘slipping through the net’.

Negotiating the difficult terrain between supporting families and focusing on the unmet needs of children was a delicate balancing act requiring sensitivity. Though, as another respondent pointed out, a narrative built on the premise that parents always work in the best interest of the child is not always helpful: …actually if the child [is]…not getting healthcare…then that's neglect whether you're a lovely [parent] or not a lovely [parent], really your loveliness doesn't come into it. (Safeguarding paediatrician, Acute Trust)

For professionals, the task is to ensure the child's health needs are met without damaging the professional–family relationship. Respondents recognised that heavy handedness could be counterproductive. There was a perception that a referral to CSC, or even the suggestion of it, could be damaging.

Wider risk discourses and events

Respondents were aware of wider societal anxieties and preoccupation with risk. Some referred to high-profile deaths and serious case reviews, as well as target setting. This awareness was strongly linked to the first theme—the imperative to collect and record information to demonstrate the ‘right’ steps had been taken. Just as the HCP is concerned with assessing the needs of the unseen child, she/he is also subject to scrutiny and accountability including providing assurance of adherence to central and local policies.