Five steps to reducing demand for appointments from frequent attenders
Dr John Havard advises GPs on how to launch a practice-level initiative to reduce inappropriate repeat attendance
Many GPs would acknowledge that relatively few patients registered at their practice take up a majority of the staff’s time and energy. The Pareto Principle (the idea that, for many events, roughly 80% of the effects come from 20% of the causes) applies here, in that 20% of our patients take 80% of our time. There a few places in the world where a citizen can command as much professional time as they want without any personal cost.
Some GPs are more empathic than others and some struggle more trying to keep to time. Do not waste a career trying to change this but try to control the menu rather than the speed of eating.
This is how our rural Suffolk practice of 9,000 patients tackled the issue, laid out in five consecutive steps, which might take some of the hard work out of similar work at another practice.
1 Investigate the size of the problem, and identify frequent attenders
The main attraction of this project was the possibility of a dramatic reduction in our workload but the implications of somatisers in secondary care are significant and raised real commissioning concerns that are heightened in the current financial crisis.
We identified the 20 frequent attenders (FAs) who took up the most GP time by analysing appointment data. Exclude terminal care patients and patients with complex medical problems from the audit. Most GPs can identify several of these patients if asked – but we are not very good at developing strategies to deal with them.
We calculated the total face-to-face consultation rates of these 20 frequent attenders over a full year and compared these to our average in the practice. If all our patients consulted at the same rate we worked out we would need a staggering 58 whole-time equivalent GPs to cope – significantly more than the current five.
2 Draw up a final list and discuss at a GP meeting
FAs are usually well known patients to all the GPs and occasionally a chat about them with colleagues can reveal insights that can help them become stronger and more independent.
Partners will be no doubt be delighted that GP colleagues are coping with the needs of recognised ‘heartsinks’, and may also want to take the time to thank those GPs struggling with these patients.
Creating a supportive atmosphere will make looking closely at the behaviours of both patient and GP more acceptable.
Discuss the list between partners and identify 20 frequent attenders to target for an intervention designed to reduce attendance while the patient remains on your list.
If you do nothing else I suggest it is worth formally identifying the patients and simply bring their attendance rate up in the consultation. I would suggest asking if anything else could be done to help address their needs as the figures suggest no progress is being made at present.
3 Offer patients an intervention, including a counselling session
We offered our top 20 a series of counselling sessions (which we paid for) with the manager of our local MIND resource centre in an attempt to identify any issues that might be precipitating their dependency.
The plan was to try to identify the core anxieties and problems and then to signpost the patient to local groups or services.
We wrote to patients to introduce the intervention. This letter needed careful construction and focussed on our inability to address their fundamental needs rather than their activity swamping our organisation. See the end of the article for a copy of our letter template.
We had an agreement with the patient that for this exercise the counsellor would discuss the case with the GP involved to help determine a more constructive way forward for the future. The patient always had the right to ask the counsellor to keep certain facts confidential if they insisted.
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 management groups. and subsidised counselling.
Do not see patients during the intervention. We had a rule that, notwithstanding medical need, they would not make GP appointments during these sessions. This small move gave us a breather, and more than justified the cost of counselling. Patients seemed to accept this condition particularly as they were benefitting from a new, extra service for us.
4 Offer a GP appointment to produce a treatment plan with the patient
Monitor the early findings and be prepared to discuss with patients on the phone if necessary. Patients need to be impressed that this is a constructive intervention and that they are not being ‘palmed off’.
Consider coding patients with a local code or pop-up so if a telephone consultation is being done then the triage person is aware that they have been identified as a frequent attender, and may suffer from health anxiety.
We logged surgery attendances and the early crude figures from the first run of the project in 2007 suggested the intervention had been effective (see graph in the footnotes).
These patients still get acute illnesses but we have monitored both consultation frequency and consultation length and both parameters have been positively affected.
5 Re-audit after a year to see if old behaviours persist
Remember this exercise is primarily about getting patients the support they need. As we all get increasingly busy we have to ensure that the skill mix at our disposal is used as efficiently as possible. Just like cardioversion in AF, you will find that not every ‘heartsink’ will revert to normal rhythm – but there is still every reason to give them a shock.
There was inevitably going to be a feeling of being ‘discovered’ or of ‘abusing the system’ and any letters must to make the attendance observation but put the blame on us for failing to identify the full nature of their problems. This was largely successful but one patient was upset and complained at one of her many consultations - and yet her attendance dropped off immensely.
Making patients aware that you intend to monitor the problem is important and can occasionally yield positive reflection. The GP tone must always be one of inadequacy and frustration about not helping rather than accusatory – try hard here.
In most cases patients reverted to their dependency behaviours, but not all.
Ask your practice manager to present the latest data on the frequent attenders to a practice meeting a year after the initial work and put it in the diary now.
Dr John Havard is a GP in Saxmundham, Suffolk.
~[Patient Address Block]
We are continually looking at what we do to try to improve services for all of our patients. Recently, we have looked at our prescribing and referrals to hospital, which we discuss at practice meetings to see if we can do things better. We have also examined the service we provide to you, our patient, through appointments and visits. The results of a search through our appointments have surprised us all. A very small number of patients are being seen on a very frequent basis.
Certain chronic diseases need close monitoring and this is good use of medical time. Sometimes other services are needed to help you remain independent and manage your life, including the medical problems.
We feel that we are not meeting your needs and this is the reason for regular appointments. Maybe the benefit of these consultations is subtle and difficult to quantify. However, a GP may not be the right person to help you.
You are in the top 20 of patients attending the surgery and the frequency of your appointments suggests that we are not helping you to manage your problems effectively. We want to offer you something that we all feel will make you feel better in the long run. The aim is to help you to cope better with the challenges that life is setting you.
We have looked carefully at the resources available to us locally and we have come to the conclusion that we may be able to help you better if we assess your problems further. We have teamed up with Mind at The Willows with the intention of providing a comprehensive assessment. This will lead us to a plan, which will blend your care at the surgery with assistance from other health services in the area.
Our aim is to help you take control of your health. We feel that with a network of support, you may be able to manage life more confidently.
Please feel free to discuss this with the GP of your choice and we all sincerely trust that we will be able to tackle this problem together.
Saxmundham Health Group