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The annual survey by Developing Patient Partnerships (DPP) found that almost 20 million appointments with practice nurses and GPs were missed in the UK over the last 12 months.

The charity estimates that each time a patient fails to show up, it costs the NHS £21. The problem is estimated to have wasted £421 million of NHS cash since July 2006.

Despite the introduction of directed enhanced services for access across the UK to improve access to GP services, the number of DNAs rose from 11 million in the 12 months to August 2006 to 13.5 million in the past year.

Missed appointments with practice nurses also spiralled, from 5 million to 6.5 million, the DPP found. In 2003, just over 250,000 were missed.

A total of 41 per cent of the 557 GPs surveyed backed calls for patients who did not turn up to be removed from the patient list, the DPP survey revealed last week. Almost three quarters of patients agreed.

When asked if they felt a £10 fine was more appropriate, two thirds of GPs agreed.

DPP chairman Dr David Wrigley said removing patients was a last resort but the issue was uniting patients and GPs.

'What is clear is the level of frustration felt by GP practices and clearly the public don't look too kindly on people missing appointments either,' Dr Wrigley said.

'We've campaigned fiercely to raise awareness of the impact of missed appointments and the public now realise they will bear the brunt of it.'

Almost all practices said missed appointments raised waiting times for other patients.

The majority of patients who missed appointments on a regular basis were aged 16-34; almost 10 per cent of appointments with these patients are missed. Overall, 6 per cent of appointments are missed, a DPP spokeswoman told GP.

GPC chairman Dr Laurence Buckman said: 'Removing a patient from a list should be absolutely the last resort, after the patient has had an opportunity to explain what happened.

'The majority of GPs do not support charging patients who miss appointments. We have repeatedly voted against the idea at the LMCs conference.'

Some 77 per cent of the public and 46 per cent of health staff said 'forgetting' was the main cause of missed appointments.