Frequent attenders – a

family systemic approach

Dr Venetia Young

GP, Bishopyards Surgery

(now the Lakes Medical Practice)

Penrith, Cumbria, England

UK

Bishopyards, Penrith

Small market town – population 20,000

5500 patients. 5 doctors (3 WTE), 2 nurses, pharmacist

Consultations of more than 5 in Jan-March 2007 with GP in surgery

163 patients 1025 appointments. 3% of list

25% on antidepressants

Top 50 33% on antidepressants

Only one child

High proportion middle aged women

Frequent attenders audit

Top 5 – 3 major mental illness in contact

with mental health services, one severe

eating disorder, one social problem

10 with depression and anxiety.

2 with severe illness (both died)

7 with straightforward physical illness

26 multiple symptoms in which stress

played a part.

Sheffield (UK) Study

Waller and Hodgkin 2000

9 practices

1.3% patients generated 8.3% of consultations (20pa)

3.6% patients generated 17.6% of consultations (15pa)

42% on antidepressants 20pa cf 9% of population

22% of FA had no chronic disease

1/3 repeated behaviour the next year

How was this managed?

Discussed with GPs

10 patients in referral process for PCMH team

CMHT contacted re top 3

Eating disorder patient admitted

Social problem family seen jointly at scheduled appointments as there were multiple medical problems

Remaining frequent attenders noted and 15 worked with by VY alone: genogram, ICE elicited, stress cycle and hyperventilation explained, breathing exercises taught, HADS, depression treated where appropriate,

3 patients offered regular routine follow up.

continued

Training – all staff on stress management and

health related anxiety

2 GPs, pharmacist and HCA on Positive Mental

Training- self-hypnosis CDs

Regular meetings with HV

Better focus with PCMH team

Change in appointment system

Cultural shift - Active management

Less use of locums

One year on in Penrith

44 patients seeing GP 5 or more times, compared with 163

1 consulted 10 times compared with 11

Less than 1% of list, compared with 3%

18 male 31 female

18 not on Chronic Disease register

19 Hypertension, 4 Mental health, 2 DM, 2 cancer

8 under 20, 6 in 20-40, 5 in 41-50, 9 in 51-60, 8 in 61-70, 8 in 71-80.

Saving 200 appointments over 3 months

Some cases

Margaret

62 Divorced.

Pain in head, neck, shoulders, knees and back. Dyspepsia. Migraine. Hypertension. Carer

Genogram

Reading self help leaflets

Stress cycle explained

Breathing and relaxation technique

Solution focussed questioning

Regular follow up: 5 appointments 120 minutes in all.

Case 2

Hilda 65

Type 2 DM on oral medication – poor control HbA1c 8.8

Barrett’s oesophagus

Severe anxiety disorder

CBT

Work with her and daughter

Medication – low dose escitalopram

Breathing and relaxation

Regular FU

Hilda 2010

DM well controlled for 2 years, HbA1c 6.6 reduction in medication

Barrett’s oesophagus improving endoscopically, no dyspeptic symptoms

Appointments every 8 weeks

Anxiety gone: no panic attacks for 2 years, no worries about hypos, no anxieties about endoscopy

Coping strategies: taking a step back from family dynamics, breathing, exercise

Patient comments

Rachel 35 - pleased to have diagnosis of

ME and not to have to pester the doctors

any more

Jo 68 - phoning doctors was a sign of not

being well

Mark 45 – phone number not near phone

Liz – 32 finally referred for psychotherapy

What are the patients’ needs?

Medically unexplained symptoms

Distress – relationships, work, school, money,

housing.

Depression and antidepressants

Anxiety disorders especially health related

anxiety need recognition.

Major mental illness

Good quality self-help literature

Appropriate referrals

Skill implications for whole team?

Active management not reactive

Good assessment

Eliciting patients’ backgrounds

Explaining stress and its effect on the body

Explaining hyperventilation

Managing affect in consultation and on phone

Diagnosing sub-syndromal depression

Therapeutic skills for watchful waiting

Noticing the frequent attender

Noticing the medication abuser

Using self-help materials

More advanced skills

BATHE

SFBT

CBT

Hypnotherapy

NLP

EFT (Tapping)

Human Givens approach- enhanced CBT

Systemic (Family Therapy)

The Primary Care Team and the

wider community

Community resources: young mothers,

middle aged women, lonely elderly

Mental health organisations

Social care organisations

Third sector

Further updates

Two practices have merged, with different frequent attender problems

GP trainees and medical students given data to interpret

PCMH meetings monthly in practice: school nurse, health visitor, community psychiatric social worker, primary care mental health worker.

Plan to start a group for 45-60 yr old women who are beginning to attend frequently.

MIND – charitable organisation – developed a sound recovery focus

Menopause evening – 50 women plus nurses and doctors

Training afternoon for 95 patients with COPD

Systemic Training in all 11 practices in locality on genograms, breathing and stress cycle

Training for all staff on personality disorders

‘A pain in the neck?’

The use of a systemic lens helps the clinician to

understand that if a community is not meeting

the needs of groups of its people, then they will

present in bigger numbers with multiple

symptoms to their primary care organisation.

The same applies to families failing to meet

emotional needs of their members

Clinicians will have frequent attenders if they

can’t explain MUS

References

Waller and Hodgkin: General Practice -demanding work 2002 Radcliffe

Asen, Tomson, Tomson and Young: 10 minutes for the family, Routledge 2004

Larivara et al 1996 developing a family systems approach to rural healthcare: dealing with the heavy user problem. Families, Systems and Health 1996 14; 291-302

Kroenke and Mangelsdorf 1989 American Journal of Medicine 86 262-266

McDaniel et al 2004 Family Oriented Primary Care Springer Verlag