General Practice and Primary Care

This research aimed to address the problem of multiple missed appointments and low uptake of care offers in health care, described as "missingness".

This is an under-researched area, disproportionately affects the most marginalised groups in society and is associated with high levels of premature mortality. Our research sought to more fully understand the drivers of missingness, its consequences, the populations who are most at risk, and to develop targeted interventions to address it.

The study was undertaken in three overlapping stages.

1. The first was a review of the existing literature and knowledge pertaining to missingness. This was used to create a "programme theory" about the known causes of missingness in different contexts across identified at-risk groups, and about the kinds of interventions which may target these causes to address missingness.
2. The second involved refining this programme theory by gathering knowledge, through in-depth interviews, with two groups with a deep understanding of missingness; "experts-by-experience" who have missed multiple appointments in the past, and professionals and practitioners who work with people who have experienced missingness across health and social care settings. This research was undertaken with a sample of thirty people from each of these populations across Scotland and England.
3. The third stage drew on the knowledge accrued across the previous two stages to develop targeted interventions tailored towards different causes of missingness across these at-risk populations.

Illustration by Jack Brougham

An important part of the project was to invite individuals with professional or lived experience of "missingness" in healthcare to be part of a Stakeholder Advisory Group. During a series of four meetings, this group discussed and gave feedback into the two main aspects of our project: to understand the causes of missingness; and to develop complex interventions to address the issue.

Stakeholder advisory group

The research was funded by the National Institute for Health and Care Research (NIHR), with members of the research team based at the University of Glasgow, University of Oxford, University of Bath and Homeless Network Scotland. Ethical approval for the study was obtained from University of Glasgow's College of Medical, Veterinary and Life Sciences Ethics Committee (project number 200220187).

The full study protocol can be found on the NIHR website.

• Williamson, Andrea E. , Baruffati, David , Lindsay, Calum , Mackenzie, Mhairi , O'Donnell, Catherine , Wong, Geoff, Simpson, Sharon A. , Ellis, David A. and Major, Michelle (2025) Developing Interventions to Address Missingness in Healthcare. Project Report. University of Glasgow. doi:10.36399/gla.pubs.366491

• Mackenzie, M. , Baruffati, D. , Lindsay, C. , O'Donnell, K. , Ellis, D., Simpson, S., Wong, G., Major, M. and Williamson, A. (2025) Fundamental causation and candidacy: harnessing explanatory frames to better understand how structural determinants of health inequalities shape disengagement from primary healthcare. Social Science and Medicine, 374. doi: 10.1016/j.socscimed.2025.118043

• Baruffati, D. and Williamson, A.E.W. (on behalf of the Missingness in Healthcare Team) MISSINGNESS: Understanding Missingness in Healthcare. Part of a downloadable report published by the South Asian Health Foundation, editors Ali, S. et al.

• Lindsay, C., Baruffati, D., Mackenzie, M. et al. Understanding the causes of missingness in primary care: a realist review. BMC Med 22, 235 (2024). https://doi.org/10.1186/s12916-024-03456

• Lindsay, C., Baruffati, D., Mackenzie, M. et al. A realist review of the causes of, and current interventions to address ‘missingness’ in health care. NIHR Open Res 2023, 3:3

• Andrea E Williamson, Inclusion health and missingness in health care: dig where you stand. Editorial, British Journal of General Practice 2023; 73 (735): 436-437.  doi: https://doi.org/10.3399/bjgp23X734985 

Applying a missingness lens to healthcare, VHS, April 2025

Following on from a presentation by Andrea Williamson at the 2024 Voluntary Health Scotland Annual Conference, an engagement event was held in March 2025. This follow up session aimed to find out from members what they could achieve when they applied a ‘missingness lens’ to close the health inequalities gap. This blog post summarises the ideas which emerged from these discussions.

FEANTSA newsletter, summer 2025

Andrea Williamson has written an article for FEANTSA, the European Federation of National Organisations Working with homeless people. It explores Inclusion Health, with a particular focus on missed healthcare appointments among people experiencing homelessness, emphasising the importance of applying a missingness lens to healthcare. 

Enlighten blog post

This blog post published in the NHS 2048 section of the Enlighten website, is a summary of the background epidemiological work and causes of missingness. 

Missingness presentations

These presentations are the short and longer versions of presentations given by members of the project team:

Missingness in healthcare short slide deck

Missingness in healthcare long slide deck

Any questions about the "Missingness Interventions" project should be addressed to the Missingness Interventions email.

Video

This video shows excerpts from the April 2024 Deep End conference held in Glasgow, and includes Prof Andrea Williamson talking about aspects of the Missingness research projects (on YouTube, produced by Edward Sharp-Paul). It gives a good overview of the conference themes - joy, inclusivity, advocacy, kindness and hope - including contributions from other keynote speakers.

Scottish Government's Population Health Framework

The Scottish Government's recently published Population Health Framework sets out their long-term approach to improving Scotland’s health and reducing health inequalities for the next decade, and the associated report, mention the concept of "missingness" as defined in this study ("Equitable health and care" section).

CMO Scotland annual report for 2023-24 'Realistic medicine - Taking care'

This report (August 2024) discusses how to deliver the overarching aim of Realistic Medicine, to deliver better value care for patients, and for our health and care system. The report includes the idea of "missingness" which is discussed in Chapter 1 and mentioned in Chapter 4.

Scottish Government report 'Inclusion health action in general practice: early evaluation report'

This report into the Inclusion Health Action in General Practice programme (IHAGP) draws on previously published research from the Serial Missed Appointments research and ideas from the Missingness Interventions project, along with work done by other organisations in the field of Inclusion Health, to encourage general practices to look at ways to address this theme.

"Missingness" is mentioned in the Introduction (with a link to the Serial Missed Appointments 2021 paper) and in particular in Case Study 4.

Articles linked to/discussing missingness research

• A column in the Scotsman by Karyn McClusky (chief executive of Community Justice Scotland), published 13/01/25, discussing the importance and relevance of the concept of "missingness" to the field of criminal justice
• Mention of "missingness" work in Deep End International Bulletin No 12, November 2024
• An online article on healthandcare.scot by Frankie Macpherson, published 7/7/24. 'Researchers: policy needed for patient ‘missingness' 
• An article in the Herald (behind a paywall) by Helen McArdle, published 29/06/24. 'Why do people miss GP appointments - and how can we fix it?'

To contact a member of the research team directly, follow the link to their profile or organisation page. For contact about the project in general, you can email: missingness@glasgow.ac.uk 

Principal Investigator

Prof Andrea Williamson 
Professor of General Practice and Inclusion Health (General Practice and Primary Care, University of Glasgow) 

Co-Principal Investigator

Prof Kate O’Donnell
Professor of Primary Care Research and Development (General Practice and Primary Care, University of Glasgow) 

Other team members

• Dr Calum Lindsay
  Research Associate (College of Medical, Veterinary and Life Sciences, University of Glasgow) 
• Ms Elspeth Rae 
  Research Administrator (until 31/05/25, College of Medical, Veterinary and Life Sciences, University of Glasgow) 
• Dr David Baruffati
  Research Associate (06 December 2022 to 28 November 2024) now Affiliate Researcher (College of Medical, Veterinary and Life Sciences, University of Glasgow) 
• Dr Geoff Wong 
  Associate Professor of Primary Care (University of Oxford) 
• Ms Claire Duddy 
  Realist Reviewer and NIHR Pre-Doctoral Fellow (University of Oxford) 
  (01 December 2022 to 05 June 2023)
• Prof Mhairi Mackenzie
  Professor of Social Policy and Inequalities (Urban Studies and Social Policy, University of Glasgow)
  Associate Professor of Public Policy (School of Health and Wellbeing, University of Glasgow) 
• Ms Michelle Major 
  Impact Lead (Homeless Network Scotland) 
• Prof Sharon Simpson
  Professor of Behavioural Sciences and Health (MRC/CSO Social & Public Health Sciences Unit, University of Glasgow) 
• Prof David Ellis 
  Professor of Behavioural Science (University of Bath) 

• Pathways of Hope - Lived experience of drug + alcohol dependence and recovery is a public information comic which brings together personal stories and insights from people in recovery from drug and alcohol dependence, medical students and doctors. The comic was developed through conversation cafés at the University of Glasgow, hosted by the Humanising Healthcare initiative. It was co-created with the recovery communities to capture their stories authentically.
• Serial missed appointments in the NHS
• Asrar Aldadi recently completed her PhD titled Factors influencing repeated non-utilized healthcare appointments from patients’ and healthcare providers’ perspectives in a Saudi Arabian hospital Outpatient Department: A qualitative study having explored the global qualitative literature about repeated non utilised appointments in a qualitative systematic review. Asrar's work has extended our understanding of the patient and health service factors that drive missingness and potential solutions in the Saudi Arabian context.