Frequent attenders are getting poor care

Des Spence gets it right again. This is a problem of elephantine proportions for our entire health economy, made steadily worse by an increasing predilection amongst our politicians and the public for rapid access to any GP, investigation or treatment facility. The inexorable trend of super-specialisation within secondary care adds to the general mix. Where we don't quite agree is over research. Here in the UK, we have already carried out some of the most important research on the subject in the world, with names such as Dowrick, Creed, Guthrie, Salmon, Stone, Morriss, Wessely, to name but a few, covering as they do an array of medical specialties.

No, the lack is not in primary research, it is in the application of that research into daily practice. The answer lies not in simply throwing IAPT at it, but in understanding our patients' ideas, concerns, fears and health beliefs, enabling them to trust us, making sure we really listen (and check that they think so too). We must also enable a new shared understanding about the problem to develop between primary care generalists and secondary care specialists, utilising recognised and evidence based therapeutic approaches when patients are ready, and expert advice & input from psychiatric colleagues in liaison and psychotherapy. Our experience of putting together a pilot of this kind proves that it can work. The question is, is the system now ready to allow itself to deal with this elephant in the room?

Dear Editors

Dr Spence yet again started another timely discussion of a highly relevant topic: dealing patients who are frequent attenders of healthcare.

The "heartsinks" attending emergency department and general practices tend to tie up significant NHS resources and yet does not appear help reduce their need to seek medical attention. Dr Spence did not specifically attempt to dissect the types of patients or situations that resulted in the phenomenon of frequent attenders.

My opinion is that there are certain traits and character in both the patient profile and healthcare delivery that have resulted in this situation. This level 5 evidence considers the following:

1. Patient personality profile consisting of one of the following

Normal reasonable, Normal uninformed, Attention seeking, Unhappy with most things in life, Manipulative and distorted sense of entitlement (exists mostly in nationalised health system)

2. Patient actual health status consisting of one of the following:

Fit and Healthy, Unfit but no actual illness, minor/transient ailment of no major significance, major treatable illness, terminal condition (other than life itself)

3. Diagnosis/labelling made to explain complaints

Correct diagnosis made, Incomplete (partial) diagnosis made, wrong diagnosis made, no diagnosis made

4. Treatment recommendation

Correct treatment plan, incomplete/inadequate treatment plan, incorrect treatment plan, no treatment

5. Patient adherence to treatment

Complete compliance, partial or non compliance only as due to actual socio-economic inability to comply, partial or non compliance due to patient's lack of ownership or determination/commitment, conscious deliberate decision not to comply inspite of lack of barrier to do so.

Taken in any combination above any patient can turn into heartsinks but I generally find in my 25 year involvement in healthcare that a frequent attender is likely to be one of the following:

1. Normal personality, actual disease, incomplete/incorrect/no diagnosis, incorrect or no treatment, good compliance

2. Normal personality or normal uninformed, actual disease, correct diagnosis, correct treatment, partial compliance due to socio-economic issues (unable to change living or working condition, unable to afford foodstuff or products not fully paid for by national healthcare)

3. Attention seeking/ Consciously manipulative, actual disease, correct diagnosis, correct treatment, deliberately partial or complete failure to comply

4. Attention seeking/ Unhappy in life/ consciously manipulative, minor ailment or unfit but healthy, correct or no diagnosis, correct or no treatment, deliberate non compliance or partial compliance lack of ownership

It is the latter 2 that is the hardest to look after. It is important that we identify group 1 or 2: group 1 is likely to benefit from complete back to square one reassessment or a second or even third opinion, doctors looking after group 2 patients should access allied health assistance who may be more versed in negotiating the complex maze of healthcare/social support schemes particularly in national healthcare system like Australia with different jurisdiction held by federal vs state agencies plus NGOs.

It is the latter 2 that is the hardest to look after.

Group 3 and 4 will require ancillary services including counsellors and psychologist as well as community nurse coordinators as their first port of call or case managers. There are unlikely to attain permanent state of "feeling well" as normal people but hopefully with adequate contact and monitoring, we can deflect any unfounded automatic attempt to head for the nearest NHS health facility and reduce unnecessary attendance for healthcare service.

Perhaps Dr Spence was writing tongue in cheek when he suggested referring such patients to NHS Homeopathy practitioners. However I will be horrified if there is any element of true intent by Dr Spence to do so, as the action condones the practice of homeopathy and allows the continued funding of this aspect of NHS service by increasing referrals. Furthermore homeopathic practitioners will showcase their success stories “where conventional medicine failed" while the bulk of the non-responders (who will remain on the books of these practitioners) will continue to seek attention from GPs and ED.