Frequent AttendersFrequent AttendersA Family Systemic A Family Systemic

approachapproach

Dr Venetia YoungDr Venetia Young

Lakes Medical PracticeLakes Medical Practice

Penrith, CumbriaPenrith, Cumbria

Bishopyards SurgeryBishopyards Surgery

• Small market town – 20,000Small market town – 20,000• 5500 patients 5 doctors (3WTE) 2 nurses, 5500 patients 5 doctors (3WTE) 2 nurses,

pharmacistpharmacist• Consultations with GP in surgery 5 or Consultations with GP in surgery 5 or

more Jan –March 2007more Jan –March 2007• 163 patients 1025 appts 3% of list163 patients 1025 appts 3% of list• 25% ADT 25% ADT • Top 50 33% on ADTTop 50 33% on ADT• One childOne child• High proprortion middle aged womenHigh proprortion middle aged women

AuditAudit

• Top5 – 3 major Mental Illness all in Top5 – 3 major Mental Illness all in contact with CMHT, 1 severe eating contact with CMHT, 1 severe eating disorder, 1 complex social problemdisorder, 1 complex social problem

• 10 depression anxiety – 8 on waiting 10 depression anxiety – 8 on waiting list for PCMHTlist for PCMHT

• 2 severe illness - both died2 severe illness - both died• 7 straightforward physical illness7 straightforward physical illness• 26 multiple symptoms26 multiple symptoms

Sheffield studySheffield study

• Waller and Hodgkin 2000Waller and Hodgkin 2000• 9 practices9 practices• 1.3% of list 8.3% consultations (20 pa)1.3% of list 8.3% consultations (20 pa)• 3.6% generated 17.6% consultations 3.6% generated 17.6% consultations

(15pa)(15pa)• 42% on ADT 42% on ADT • 1/3 repeated the behaviour the next 1/3 repeated the behaviour the next

yearyear

How was this managed?How was this managed?

• Discussed with GPsDiscussed with GPs• !0 patients in referral process with PCMHT!0 patients in referral process with PCMHT• CMHT contacted re top 3CMHT contacted re top 3• ED admittedED admitted• Social problem family – regular apptsSocial problem family – regular appts• Remaining ones noted and VY worked with Remaining ones noted and VY worked with

15: genogram, ICE, stress cycle, 15: genogram, ICE, stress cycle, hyperventilation, HADS and ADT where hyperventilation, HADS and ADT where appropriateappropriate

• 3 patients offered regular routine FU3 patients offered regular routine FU

continuedcontinued

• Training all staff on Stress management and Training all staff on Stress management and Health Related AnxietyHealth Related Anxiety

• 2 GPs, HCA and pharmacist on Positive 2 GPs, HCA and pharmacist on Positive Mental TrainingMental Training

• Regular meetings with HV and school nurseRegular meetings with HV and school nurse• Better focus with PCMH teamBetter focus with PCMH team• Change to green slip for appointmentsChange to green slip for appointments• Cultural shift to active managementCultural shift to active management• Less use of locums Less use of locums

One year onOne year on

• 44 patients44 patients• One consulted 10 times – SMI plus One consulted 10 times – SMI plus

new diagnosis of pulmonary fibrosisnew diagnosis of pulmonary fibrosis• Less than 1% listLess than 1% list• Even age distribution except 20-40Even age distribution except 20-40• More femaleMore female• Saving 200 appts over 3 monthsSaving 200 appts over 3 months

Some casesSome cases• Margaret 60 divorcedMargaret 60 divorced• Headache, dyspepsia, migraine hypertension Headache, dyspepsia, migraine hypertension

obesity, neck ache, back acheobesity, neck ache, back ache

• GenogramGenogram• Women who love too muchWomen who love too much• Self-help leafletsSelf-help leaflets• Breathing and relaxation techniquesBreathing and relaxation techniques• Solution focussed questioningSolution focussed questioning• 90 minutes over 6 appts90 minutes over 6 appts• 2012 – has not been a frequent attender since 2012 – has not been a frequent attender since

despite hip surgery, DVTdespite hip surgery, DVT

Patient commentsPatient comments

• Rachel – pleased to have diagnosis of Rachel – pleased to have diagnosis of ME and not to have to pester the ME and not to have to pester the doctors any moredoctors any more

• Jo 68 – phoning Drs sign of being Jo 68 – phoning Drs sign of being unwell and needed CMHTunwell and needed CMHT

• Liz 32 – finally agreed for referral Liz 32 – finally agreed for referral for psychotherapyfor psychotherapy

What are the patients What are the patients needs?needs?

• Have the workings of their bodies explained to Have the workings of their bodies explained to them.them.

• Distress – relationships, work, school money Distress – relationships, work, school money housinghousing

• Depression – referral and AdtDepression – referral and Adt• Anxiety disorders especially HRA need Anxiety disorders especially HRA need

recognitionrecognition• Major MI treated and managed better between Major MI treated and managed better between

team and surgeryteam and surgery• Good quality self-help literature including booksGood quality self-help literature including books• Good quality referralsGood quality referrals

Skill implications for Skill implications for whole teamwhole team

• Active management not reactiveActive management not reactive• Good assessmentGood assessment• Eliciting patient’s backgroundsEliciting patient’s backgrounds• Explaining stress and its effect on bodyExplaining stress and its effect on body• HyperventilationHyperventilation• Managing affect in consultation and on the Managing affect in consultation and on the

phonephone• Therapeutic skills for watchful waitingTherapeutic skills for watchful waiting• Finding the Frequent attenderFinding the Frequent attender• Noticing the medication abuserNoticing the medication abuser• Using self help materials to empower the Using self help materials to empower the

patientpatient

More advanced More advanced consultation skillsconsultation skills

• BATHEBATHE• SFBTSFBT• CBTCBT• HypnotherapyHypnotherapy• NLPNLP• EFTEFT• Human Givens – enhanced CBTHuman Givens – enhanced CBT• Systemic (Family Therapy)Systemic (Family Therapy)

Primary care team and the Primary care team and the wider communitywider community

• Community resources: where there Community resources: where there are gaps patients will present in the are gaps patients will present in the surgery: young Mums, middle aged surgery: young Mums, middle aged women, elderlywomen, elderly

• Mental health organisations Mental health organisations • Social Care organisationsSocial Care organisations• Third sectorThird sector

Further updateFurther update• Two practices have merged with different FA problemsTwo practices have merged with different FA problems• GP trainees and medical students given data to auditGP trainees and medical students given data to audit• Monthly PCMH meeting: school nurse, HV And CMHT – Monthly PCMH meeting: school nurse, HV And CMHT –

safeguardingsafeguarding• MIND and PCMHT doing condition management MIND and PCMHT doing condition management

programmeprogramme• Menopause eveningMenopause evening• COPD afternoonCOPD afternoon• Training for all staff on personality disorder, recognising Training for all staff on personality disorder, recognising

abuse and domestic violenceabuse and domestic violence• GP and nurse practitioner consultation skills trainingGP and nurse practitioner consultation skills training• Locality practices all doing FA audit and being surprised!Locality practices all doing FA audit and being surprised!• Ideas in pipeline are a group for women 45-65 who are Ideas in pipeline are a group for women 45-65 who are

FAs, pain management group and mindfulness groupFAs, pain management group and mindfulness group• Consideration of employing MH practitioner rather than Consideration of employing MH practitioner rather than

GP – a missing tier in service deliveryGP – a missing tier in service delivery

ReferencesReferences

• Waller and Hodgkin: General practice -Waller and Hodgkin: General practice -demanding work 2002 Radcliffedemanding work 2002 Radcliffe

• Asen Tomson and Young: ‘10 minutes for the Asen Tomson and Young: ‘10 minutes for the family’ 2004 Routledgefamily’ 2004 Routledge

• Larivara 1996 ‘Developing a Family Systems Larivara 1996 ‘Developing a Family Systems approach to rural healthcare: dealing with the approach to rural healthcare: dealing with the heavy user problem’ Families, Systems and heavy user problem’ Families, Systems and Health 1996 14:291-302Health 1996 14:291-302

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

• McDaniel et al 2004 Family Oriented Primary McDaniel et al 2004 Family Oriented Primary care. Springer Verlagcare. Springer Verlag