Frequent Attenders – Breaking the Cycle in Primary Care (1) Understand who turns up frequently
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.
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.
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?
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.
Circa 40% are Struggling with life
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:
People with multiple needs
People with increasingly complex physical needs
People with increasingly complex mental and physical needs
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).
Downham, N. (2018) Case History Mapping. London South Bank University.
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.