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Background: Missed appointments are common in primary care, contributing to reduced clinical capacity. NHS England has estimated that there are 7.2 million missed general practice appointments annually, at a cost of £216 million. Reducing these numbers is important for an efficient primary care sector., Aim: To evaluate the impact of a system-wide quality improvement (QI) programme on the rates of missed GP appointments, and to identify effective practice interventions., Design and Setting: Practices within a clinical commissioning group (CCG) in East London, with an ethnically diverse and socially deprived population., Method: Study practices engaged in a generic QI programme, which included sharing data on appointment systems and Did Not Attend (DNA) rates. Fourteen out of 25 practices implemented DNA reduction projects, supported by practice-based coaching. Appointment data were collected from practice electronic health records. Evaluation included comparisons of DNA rates pre- and post-intervention using interrupted times series analysis., Results: In total, 25 out of 32 practices engaged with the programme. The mean DNA rate at baseline was 7% (range 2-12%); 2 years later the generic intervention DNA rates were 5.2%. This equates to a reduction of 4030 missed appointments. The most effective practice intervention was to reduce the forward booking time to 1 day. The practice that made this change reduced its mean DNA rate from 7.8% to 3.9%., Conclusion: Forward booking time in days is the best predictor of practice DNA rates. Sharing appointment data produced a significant reduction in missed appointments, and behaviour change interventions with patients had a modest additional impact; in contrast, introducing structural change to the appointment system effectively reduced DNA rates. To reduce non-attendance, it appears that the appointment system needs to change, not the patient., (© The Authors.)