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Independents' Day

Referral, diagnosis and management of dysphagia

Toddler brought in as extra for the third time



Your last extra tonight is James, 13 months old. He looks hot and miserable and is clearly not in the mood to be examined. His mum also appears strained. Looking at the computer you note that he has already been seen twice as an extra in the past four days. Dr Melanie Wynne-Jones discusses.

Why do patients present as extras?

Extras can be defined as those patients who are added to already fully-booked surgeries because they cannot or will not wait for the next available appointment. They are an increasing problem for many practices, but both patient and practice factors are involved.

The 24-hour society means that patients are increasingly expecting their needs or wants to be met immediately. This has changed many people's definition of what constitutes a medical emergency, and is putting round-the-clock pressure on health services.

Many people feel they have a right to see their GP without taking time off work. This can skew demand to the end of the day or to out-of-hours services.

Another common phenomenon is the parent who has collected a sick child from childcare. Working parents often feel both anxious and guilty. They have not been able to observe the child over the day, or are worried about whether they will be able go to work tomorrow.

Like non-working parents they may be inexperienced in minor childhood illness and have no relatives to advise them. Or they may be frightened by media health scares.

How do practices trigger extras?

Clearly a practice that does not offer enough routine appointments is likely to be faced with large numbers of extras. This may be confirmed by feedback from the practice's patient survey1,2.

However, comparisons with the average consulting rate are becoming less useful as there are now many other ways that patients can 'consult' the NHS including seeing their GP or practice nurse, seeking advice by letter, telephone or e-mail or using NHS Direct, walk-in centres or out-of-hours services.

Solutions include mapping demand against supply, formal adoption of Advanced Access3 (although a 48-hour wait to see a GP may be too long) and 'working smarter' (see box, left).

How would you approach James?

You will get more and better information by talking to his mum before pouncing on James, and he may see you as less of a threat and be more co-operative when you finally do examine him. Suggesting mum gradually undresses James while you ignore him may also save a battle later.

However, as you talk you can make several useful observations, such as his colour, degree of lethargy, respiratory rate and effort, pain on movement, or the presence of neck stiffness or photophobia (toddlers can often be interested in a torch waved casually around, so long as it doesn't appear to be a deliberate attempt on their personal space).

Take the history again from scratch rather than relying on the previous notes; a small feature, or the way mum relates the story, could be the crucial clue. Why exactly is she so worried ­ has James's condition deteriorated and how?

Did she feel inadequately reassured last time, has someone else or some previous event worried her, or has she come back because she is obeying 'safety-net' advice given at the last consultation? Are her concerns appropriate, or falsely based on inexperience, lack of confidence, or unrealistic expectations?

Only now should you examine James, but if he is struggling or screaming despite your best efforts, you may not be able to examine him as fully as you would wish.

What should you do now?

If you are certain that you have all the information you need, and that this is genuinely a case of the 'worried slightly-unwell', then you can share your findings with mum and discuss the next steps plus any red flags for consulting again.

Telling patients off for inappropriate consulting is rarely productive. Changing their behaviour while maintaining a good relationship is more likely if you:

·elicit and acknowledge their concerns

·praise and reinforce what they have done well (for example giving fluids and antipyretics)

·give health education including when (and when not) to seek advice

·are supportive and empathic rather than critical.

However, if you are unsure, or cannot adequately assess James, it's worth remembering the Rule of Three ­ patients who consult three or more times for apparently minor symptoms may have a serious condition that you have missed, or which is presenting in an unusual way.

Most GPs can give examples where admitting the patient to hospital for this reason alone turned out to be the right decision. It would be sensible to request a second opinion from the paediatrician if you have any doubts.

Melanie Wynne-Jones is a GP in Marple, Cheshire

Working smarter could include:

·Adjusting the proportion of routine/emergency appointments

·Adjusting for the effects of partner absence

·Increased delegation to the practice nurse

·Increased use of telephone consulting/triage/follow-up

·Reducing doctor-initiated follow-up appointments

·Actioning hospital letters and results proactively rather than waiting for patients to make appointments

·Reviewing the appropriateness of 'safety-net' advice given in consultations4

·A firm but safe policy for dealing with requests from extras administered consistently by suitably trained staff

Key points

·Demand for appointments depends on both patient and practice behaviour

·Appointment supply and demand must be actively managed to balance resources, workload, patient safety and patient satisfaction

·Avoid preconceptions when assessing patients who consult repeatedly about the same problem; the clue may lie in their ideas, concerns and expectations

·Remember the Rule of Three


1 The General Practice Assessment Questionnaire is available with full instructions at

2 The Improving Practice Questionnaire is available at

3 Advanced Access Achieving and sustaining improved access to primary care, Department of Health, 2002 Trusts/PrimaryCareTrustsArticle/fs/en?CONTENT_ID=4016138&chk=gvOn07

4 The inner consultation: how to develop an effective and intuitive consulting style, Roger Neighbour (Paperback 2004) Radcliffe Medcial Press.

ISBN 1 85775 679 7

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