Frequent Attenders – Breaking the Cycle in Primary Care

People who attend GP practices on a very regular basis are usually seen as one and the same ‘type’ – elderly, multiple conditions (co-morbidities), often including a mental health issue. Despite the person booking multiple 10 minute appointments (sometimes a week), often all they are offered are more 10 minute appointments. Clearly this isn’t working, so what does?

It will be no surprise that there isn’t a magic bullet, but there are a range of approaches that can help, could work and do work.

The first step is to know who these people are, at a level of detail that helps you classify them beyond the number of times they attend (though that’s a good starting point). Morriss et al (2012) found the top 3% of attenders are associated with 15% of all appointments, alongside increased in hospital visits and mental health indicators.

Start with data

So who are people that turn up all the time? Whilst you will have some ideas (and prejudices) sometimes it turns out its not who you think it is. Here is an example from one practice in our London Primary Care Quality Academy, where we found that the top 5% of patients may be using 20% of GP resources at the practice.

The practice may not be thinking in a joined-up way about how it is spending this resource.

Screen Shot 2018-06-05 at 18.23.23

Not only is the practice not meeting these people’s needs, they are spending a lot of money in the process, you can see in the next diagram how this practice is spending 1.5-3K on its Super Attenders, and if you take the people who attend every 3 weeks or more, over 5 years this practice has spent £1million on a service that’s not working.

Screen Shot 2018-06-05 at 18.24.31

Now if you look at who these people are in this practice we had a surprise, as you can see its not all mental health, or old people – it’s a range of people with a range of conditions – so what’s going on?

Screen Shot 2018-06-05 at 18.25.14

The next step is to conduct a deep dive into a range of these people individually. In this case it looks like the problem is ‘trouble with life’ i.e. these people have conditions that other people are coping with, but their context is much more messy and complex and they just can’t cope. Here is a first review of the top 100 in one practice.

Screen Shot 2018-06-06 at 11.36.33Screen Shot 2018-06-06 at 11.38.18

These deep dives are Patient History Maps which are deliberately created manually. By having a summary history map, we can begin to look for insights into how services have interacted with the patient. Where there have been handoffs, where there has been failure demand, where education and other services have been effective. We seek to understand why services and systems act as they do, and the thinking behind it. In summary we seek to understand context and how perhaps sometimes services treat presentations, but not slow the decline in health. They complement the quantitative data captured above. These maps present professionals and senior management with the vital opportunity to do their own enquiry – creating a normative learning loop (Downham 2018).

It is likely in your frequent attender group that you have a range of people, which we have categorised differently as they need different responses:

  1. People with multiple needs
  2. People with increasingly complex physical needs
  3. People with increasingly complex mental and physical needs
  4. People with extremely complex situations which means they can’t cope with their physical/ mental condition.

You can also take a needs based approach to discover the people who are likely to become super attenders – the ones in the low end of the frequency spectrum who have chronic conditions that are relatively stable, but are at risk of becoming unstable (the frailty index for older people would be a good starting point).

Determine the type of need

Clearly going round and round the system isn’t working, and we know that often multiple attendances in general practice also equates to multiple attendance in A&E, which in turn equates to the burden of multimorbidity which is independently associated with social deprivation (Hull, 2018).

The next step is to work through the list and choose from a range of interventions for this cohort of primary care users as follows:

  • People with multiple conditions, which are chronic but stable.

These people (often older in terms of prevalence, but they can be any age) with multiple conditions where a 10 minute appointment only addresses one of their multiple concerns. Here the evidence is that continuity of clinician and longer less frequent appointments scheduled regularly and self-bookable by the person is the best solution[1] (Deeny et al 2017). In terms of best practice, it is considered to be an initial consultation of circa 1 hour[2], and from then on the clinician and person decide how much time the follow-up appointments need, reducing over time as able. Overall this signals that the practice is offering a more tailored consultation approach to meet needs (see log on Reducing Demand in Primary Care part 1 and 2), and so this does need to be part of the change in how the GP system works with triage, e-consult, diversifying the workforce, and offering walk-in and bookable appointments, as this generates the headroom and appointment space to be able to offer the longer appointments.

  • People with mental and physical health problems.

Here the Intermountain approach could work, where the introduction of team based assessment and care reduced hospital admissions, (Reiss-Brennen et al 2016). This approach is to:

  1. Assess the person’s mental health severity, physical health and life situation/social factors to build a holistic picture of their health and complexity of the context they operate in.
  2. Review the assets available within the person’s own context (family / friends) and build the team needed to meet that person’s needs including the person’s own assets.
  3. Develop an integrated team response for this person.
  • People who lack confidence, are undervalued, lack meaning.

These people need to use their skills and make a contribution to feel valued. All the work on coproduction shows that people who are seen to be the most ‘needy’ by the institution, have amazing capabilities to offer, and if used it brings phenomenal self-efficacy (e.g. Coproducing Leeds). Taking a partnership approach with communities to develop new ways of bringing people together (an asset based community type approach), where the practice invites people to work with them to support the health and wellbeing of communities, and co-develops and co-provides a number of activities that regain people’s creativity and fun, and tackles the social determinants of poor health. Healthier Fleetwood is a great example of this, as is the Health Champions approach of Altogether Better. Although as Husk 2017 whilst all good sense tells us that these approaches work, the evidence lags behind practice, and there is no specific evidence for people who attend frequently. We are finding that (and its early days with a very few people so not reliable yet) where the people who are attending regularly become an asset bringing their talents and gifts to the practice and community, their need for appointments reduces.

  • People with complex needs tipping into instability, but who are currently stable.

Here you need to convene the MDT, which will need clear agreements about integrated decision-making and a devolved budget. The job here is to prevent escalation.

Look after your infrequent attenders

All of these expensive 10 minute appointments are of course being paid for from a list that includes people that don’t attend at all or very much. Without them the practice can’t afford to provide services for those that need it. The per-head budget relies on the practice having a mixed list. So what happens when one of your infrequent attenders needs an appointment and there is a wait, or they don’t get through on the phone? Well they could take their business elsewhere. We encourage practices to look after their low attenders, partly to keep them as customers, and partly because prevention starts with these people. Most teenagers and young people don’t have any contact with primary care. Treating complex health needs starts with helping people to reduce their likelihood of developing them in the first place.

You can find out more about the London Primary Care Quality Academy here

Related Blogs Primary Care Reducing Demand Part one  and Part Two

And a good read here from The Health Foundation

References

Deeny, S., Gardner, T., Al-Zaidy, S., Barker, I., Steventon, A. (2017) Briefing: Reducing Hospital Admission by Improving Continuity of Care in General Practice. The Health Foundation, London.

Downham, N. (2018) Case History Mapping. London South Bank University.

Hull, S., Homer, K., Boomla, K., Robson, J., Ashworth, M. (2018). Population and patient factors affecting emergency department attendance in London: Retrospective cohort analysis of linked primary and secondary care records. British Journal of General Practice, 68.

Husk, K.(2017) Social prescribing offers huge potential but requires a nuanced evidence base. The BMJ Opinion. July 18 https://blogs.bmj.com/bmj/2017/07/18/social-prescribing-offers-huge-potential-but-requires-a-nuanced-evidence-base/

Morriss,R., Kai, J., Atha, C., Avery, A., Bayes, S., Franklin, M., George, T., James, M., Malins, S., McDonald, R., Patel, S., Stubley, M., Yang, M. (2012) BMC Family Practice 13:39.

Reiss Brennen, B., Brunisholz, K,D., Dredge, C., Briot, P.,Grazier, K., Wilcox, A., Savitz, L., James, B. (2016) Association of integrated team-based care with health care quality, utilization, and cost, JAMA, 316(8):826-834.

[1] People aged 62-82 had 6% fewer hospital admissions where they saw the same GP more consistently (same GP 2 more times out of every 10).

[2] This is primarily tacit knowledge

2 thoughts on “Frequent Attenders – Breaking the Cycle in Primary Care

  1. Great blog as always, I have found that these regular patients that practices do not look after are the increasing demand on local EDs. There is a growing number of patients in the 18-30 age range that are simply using ED as their first contact as they simply can not get a quick primary care appointment.

    Like

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