Intended for healthcare professionals

Views & Reviews From the Frontline

Frequent attenders are getting poor care

BMJ 2014; 348 doi: (Published 13 January 2014) Cite this as: BMJ 2014;348:g208
  1. Des Spence, general practitioner, Glasgow

Shocking headlines have revealed that a small number of patients attend emergency departments as many as 50 times a year.1 This was suggested to be a waste of resources and a failure of primary care. Perhaps reporters should ask the same questions of general practice. Our waiting rooms are full of familiar faces, who wave as we walk by, some attending more than 50 times a year. GPs are criticised for having appointments that last only 10 minutes, but we spend hours each year in the company of some patients. What leads patients to consult so often? It is not the illness they think it is.

In my experience, almost all frequent attenders, also known as “heartsinks,” have abnormal health seeking behaviours and health anxiety. These seem to be learnt behaviours, transferred through generations, often occurring in family clusters. These behaviours are also fanned by the type of healthcare system: frequent attenders are the cash cows in a private insured care. These patients tend to present with multiple vague, complex, and unrelated medically unexplained symptoms—for example, fatigue headache, body pain, urinary problems, numbness, palpations, chest pain, breathlessness, and sleep disorders. And their problems are confusing, contradictory, and exasperating for doctors.

The traditional medical model of care is spectacularly inadequate when dealing with frequent attenders, leading to needless referrals, investigations, and, by sheer weight of contact, spurious labels and diagnoses. The usual suspects of psychoactive drugs are often prescribed. The only certainty is that investigation, referral, and labels make frequent attenders worse not better.

Of course, this is why continuity is so important, and the medical art of doing nothing with style a core clinical skill. I might refer frequent attenders for NHS homeopathy because patients receive care but without harm. Is this all just mere anecdotal ramblings of a cynic?

Research indicates that 3% of patients in general practice generate 15% of the workload (and this seems like an gross underestimate).2 Frequent attenders receive five times more drugs and five times more referrals,3 do indeed exist in family clusters,4 and do respond to complementary treatments.5 These numbers and patterns may well be mirrored in hospital practice. So a conservative estimate is that frequent attenders consume a staggering £15bn of the NHS budget annually,6 enough to fund NHS London and bigger than the divisive proposed cuts to welfare.7

This is not just about wasted resources, because these patients are also receiving harmful and poor medical care. Almost no recent research has considered this fundamental quality and resource problem. Britain does not need more healthcare—just better medicine.


Cite this as: BMJ 2014;348:g208


  • Competing interests: I have read and understood the BMJ Group policy on declaration of interests and have no relevant interests to declare.

  • Provenance and peer review: Commissioned; externally peer reviewed.

  • Follow Des Spence on Twitter @des_spence1


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