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How I...targeted persistent frequent attenders

Dr John Havard explains how he and his colleagues tackled the problem of patients who attend too often

Dr John Havard explains how he and his colleagues tackled the problem of patients who attend too often

The problem

Every practice has a group of frequent attenders who never seem to get better.

This relatively small cohort of patients take up a lot of time over the years and often somatise themselves into the full tapestry of outpatient clinics and inpatient procedures.

Most GPs can identify several of these patients if asked but we are not very good at developing strategies to deal with them.

This all came to a head in our practice after we appointed a new partner. Initially the other four GPs in the practice were delighted with the decrease in their workload but six months later they were saying they seemed to be just as busy and yet there had been no increase in patient numbers. A quick look through our IT system identified an increase in both face-to-face consultations and the consultation length of our frequent attenders.

What we did

We looked more closely at our most frequent attenders over the previous year to discover what overt pathology had come to light. There were predictably some terminal care and chronic disease patients who we felt were using the service appropriately. But there remained an obvious group of patients for whom the attendance pattern had been chronically high for years, apparently defying all attempts of problem resolution. This became our target group.

We decided to write to them, but needed to be really careful that the letter was one of support, not rebuke. There was inevitably going to be a feeling of being ‘discovered' or of ‘abusing the system'. The letter had to make the observation that they attended frequently but put the blame on us for failing to identify the full nature of their problems. (To see a copy of the letter go to www.pulsetoday.co.uk/clinical.)

On the whole the letter was received positively. One patient was upset and complained, but her attendance has since dropped off immensely.

The letter offered a surgery consultation for up to an hour with the manager of our local MIND resource centre. The plan was to identify the patients' core anxieties and problems and then to signpost the patient to local groups or services.

For MIND, the challenge was to see people who did not regard themselves as having a mental health problem and so would not otherwise have come through their doors.

Results

Nine patients out of the 20 we wrote to attended the special one-to-one appointments. The meetings were felt to be useful by both parties and the historical need to attend the surgery was discussed. Resolutions involved a range of ideas including volunteer work, subsidised reflexology, anxiety groups and subsidised counselling.

The main attraction of this project was the possibility of a dramatic reduction in our workload but the implications of somatisers for secondary care are significant and raised some commissioning possibilities.

Outcome

We continue to log surgery attendances and the early crude figures suggest the intervention has been effective.

These patients still get acute illnesses but we have monitored both consultation frequency and consultation length.

Both parameters have been positively affected.

Anecdotally, patients have commented that they feel calmer and more in control of their lives since attending the MIND centre.

Next steps

We are now going to work our way further down the frequent attender list and target the next 40 patients. This time, though, we are going to sit down and discuss in more detail which patients are most likely to benefit from MIND signposting. The next tranche may include patients who we have perceived to have had a physical illness for some time.

The project has shown us all that something meaningful and effective can be achieved for frequent attenders.

Of course cardioversion can sometimes only give temporary resolution so I will be keeping my finger on the pulse and looking closely at those consultation figures…

Dr John Havard is a GP in Saxmundham, Suffolk

Frequent attenders form a small core of patients but can take up a lot of time Frequent attenders form a small core of patients but can take up a lot of time Letter sent to frequent attenders Letter sent to frequent attenders

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