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Breaking the cycle

A practice describes its scheme to help reduce the burden of frequent attenders

Research has shown that up to a quarter of people attend medical care for psychological reasons, with frequent attendees (12+ visits per year) accounting for around 15% of a practice’s workload.

A growing evidence base shows there are social factors associated with frequent practice attendance and recent NICE guidance on behaviour change (2007) has also recognised this problem.

In order to address this, in Bradford we have been piloting a ‘social prescribing’ service in general practice. This service allows GPs to refer frequently attending patients to ‘health trainers’ who can develop action plans to tackle their non-medical psychological needs and help them achieve their health goals, such as losing weight or giving up smoking.

What we did

In 2008 the Bradford S&W PBC alliance used pooled freed-up resources to provide health trainers in all 23 practices in the alliance area to help to address the health inequalities among our patient population, make a significant difference in these patients lives and longer-term to save money and time to the NHS both in GP time and in secondary care costs.

Over time, if we were able to demonstrate the value of the health trainers in delivering improved health outcomes for these needy patients and cost savings for the PCT then the funding will be adopted longer term by the PCT once the freed up resources have dried up.

How the scheme works

GPs or practice nurses are able to refer patients directly into the health trainers weekly clinic slots, with the aim of keeping waiting times to a minimum (normally two weeks or less). Consultations are one hour in duration; the patient has four sessions on average and is followed up at three, six and 12 months.

The benefits for patients are improved health and wellbeing and the support to make sustained health and lifestyle changes. This leads to improved self esteem and confidence.

The system works well as the health trainers are able to devote more time to support each patient, compared with a GP, and they have a detailed specialist knowledge of all the facilities, clubs and voluntary organisations in the local area that could benefit the patient.

The health trainers go on accompanied visits with their patients when they first go to join a gym or some other form of club or activity as it is often this level of social support that they need in order to get involved with such activities.


This service has provided a number of benefits to the GP practice, including a reduction in frequent practice attendance.

The age range of the patients seen is evenly spread between 16 and 75 with a slight predominance in the 26-35 age range. The majority of patients referred in to the system (50%) are those with mental health issues, 20% are patient with social isolation issues and others are for work, family or financial reasons.

It provides the practice with access to a vastly increased range of services to refer patients into and establishes far better links with voluntary and other community organisations in the area. The service also helps the practice in encouraging and supporting patients to take responsibility for their own health and develop a better awareness of self care.

By using the health trainer as a link into community activities and leisure facilities we have the confidence that the patient will be guided and supported through this transition and not referred into a ‘black hole’. Overall we are able to see demonstrable improvement in both patients’ health and wellbeing.

Following consultation patients from our practice have been signposted to 20 different organisations including Volunteering Bradford, MIND Drop-in, MIND Crafts Group, Yoga Group, Access Bus, Italian Senior Citizens’ Association and the Dry Stone Walling Association, including a number of accompanied visits.

Overall the scheme is viewed as a good success providing an excellent resource for GPs to refer to when there are few other realistic options for this needy group of patients.

It took longer to get the service established and running smoothly than we would have liked – this was due to delays and issues with the PCT provider arm in getting the health trainers recruited, trained and embedded into the practices in which they work.

It has also taken a while for some practices to get used to using the service and remembering among everything that the resource is there to be used, but looking at our appointment system the next two weeks clinics are fully booked with vacancies available on the third week, which is how we like to see the demand managed.

Nick Nurden is a business partner at the Ridge Medical Practice, Bradford

Nick Nurden is the Business Partner for the Ridge Medical Practice