Frequent Attenders – Breaking the Cycle in Primary Care (2) What are their needs?

In the first blog of this series we worked out who is turning up frequently. Here we work out what it is they need now that you have explored undertaking a ‘deep dive’ review of the case notes.

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.

Related Blogs Primary Care Reducing Demand Part one  and Part Two

And a good read here from The Health Foundation

[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

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.

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 baseThe BMJ Opinion. July 18 https://blogs.bmj.com/bmj/2017/07/18/social-prescribing-offers-huge-potential-but-requires-a-nuanced-evidence-base/

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.

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Reducing demand. Step 4 - Going Live

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Where to start in PCNs