Is frequent attending a problem? Exploring the feasibility and acceptability of a practice-level intervention for frequently attending patients in primary care

Problem

Primary care practices are currently struggling to meet the demand for their services. Patients who consult with their GP most frequently use considerable NHS resources without necessarily gaining benefit and may even be harmed. Staff at a local primary care practice developed an intervention aimed at better meeting the needs of these patients. An in-service evaluation found the intervention was viewed positively by both staff and patients and had the potential to reduce health care resource use.

Approach

We conducted a pilot cluster randomised controlled trial and mixed methods process evaluation which aimed to explore the feasibility and acceptability of implementing the intervention beyond the original practice. The intervention consisted of three key components: use by the GP of a psychosocial consultation technique called BATHE (Background, Affect, Trouble, Handling, Empathy); increased continuity of care with a named GP; and increased use of telephone consultations. Six practices were recruited (4 intervention, 2 control). The top 3% frequently attending patients were identified using a search of the electronic health records. Patients were excluded if their level of attendance was, in the GPs opinion, appropriate for their health status. The main outcome of interest was GP consultation rate during the 12 month intervention period. Qualitative data collection included video recording (and later conversation analysis) of BATHE consultations, observations of appointment making and staff training, and semi-structured interviews with patients, GPs and reception staff.

Findings

GPs were generally positive about the BATHE technique and the way it enhanced the consultation focus by, for example, helping patients to identify what was Troubling them the most. However, implemention of the technique proved challenging often due to time pressure in consultations. GPs also resisted the wholesale use of BATHE on frequent attenders instead preferring to selectively apply BATHE at times they considered appropriate. Changes to continuity of care with a named GP and use of telephone consultations was also limited, due to lack of flexibility in the appointment making system and GP availability. Patients were positive about the study but noticed little change in their care over the intervention period. Continuity of care remained an important issue for patients and in some, but not all practices, difficulty getting to see their preferred doctor was a source of frustration.

Consequences

GPs, practice staff and local commissioners are enthusiastic about the study and keen to try any initiatives to help manage demand in primary care. However, although motivation for improving the management of frequent attenders is high, implementating change was difficult. The study underlines the additional benefits of conversation analysis and observational approaches to feasibility work ahead of a definitive trial.