How to cope with heartsink patients
What should you do when a patient's demands seem unwarranted or unreasonable? And what impact do such patients have on primary care workload?
In any given working day about a million patients attend their local GP surgery - it is remarkable that primary care in the NHS works at all. However, it is also clear that in most cases where people get symptoms, they do not consult a healthcare professional at all. Even when a symptom is severe or debilitating, or is thought (by a patient) to represent serious illness, there is still only a 50% chance that it will be brought to the attention of a healthcare professional.1 If at present one in ten symptoms is presented to a healthcare professional, this means that nine out of ten symptoms are not presented. If this ratio changed only slightly, with only eight out of ten symptoms being self-treated, then the workload of primary care would double.
The number of people seen in primary care continues to rise. Government statistics looking at the period from 1995 to 2008 show that in the UK in 1995 each patient consulted with a healthcare professional in primary care 3.9 times; by 2008 this was 5.5 times. So the total number of patients seen in 1995 was about 217 million, rising to 300 million by 2008. Putting this in practice terms, in 1995 the average practice saw 21,100 patients, rising by 2008 to 34,200.2 So if you were wondering why the job seems to be getting busier, one of the reasons is increasing patient demand.
But why, in a population that is healthier and living longer, are the demands on primary care increasing inexorably? The answer is not clear, but that does not stop speculation.
MORE TREATMENTS ARE AVAILABLE
Until relatively recently there was no treatment for shingles, and it was not considered necessary for GPs to prescribe a cocktail of 'preventive' drugs - each with its own side effects and monitoring requirements - on patients who had survived a heart attack.
LIFE EXPECTANCY IS INCREASING
People are being kept alive who would in previous generations have died. Although living and working conditions and lifestyle choices are major determinants of how long a person lives, it would be wrong (if indeed somewhat embarrassing) to infer that improvements in healthcare have made no contribution at all to life expectancy.
Our hospital colleagues are getting cleverer at getting people better. At present there are 24,500 published journals on health-related topics, a number rising at the rate of 3.5% a year.3 The pace of medical progress is accelerating. Although it is clear that no one person can know everything, information technology means that far greater information is accessible to healthcare professionals than at any time in history.
Our primary care colleagues are getting cleverer at getting people better. Colleagues are getting trained better. Nursing is now a graduate profession. GPs are no longer allowed to be GPs without having attained a postgraduate qualification and having undergone specific training for the task.
PATIENTS ARE LESS STOICAL
This may be true but is hard to assess. People may be less willing to tolerate minor symptoms, but a problem that a healthcare professional may regard as trivial may not be regarded the same way by the sufferer. For years primary care workers have complained that patients need to get tougher and sort themselves out without bothering a professional, but for years the media have been telling patients of more and more things to be worried about. Can there be a primary care professional who has not been confronted with an anxious patient bearing a newspaper clipping?
CONSUMERISATION OF HEALTHCARE
All the political parties have signed up to the idea of 'patient choice'. Of course healthcare professionals should be accountable for their actions and omissions, but the main reason that people consult a healthcare professional is because in some important respects the professional knows more than the patient. There is a genuine difference between wants and needs. The difference between delivering healthcare and selling a washing machine seems to have been lost on some people.
PSYCHOLOGICAL DISORDERS MORE COMMON
Despite the improvements in material conditions, the total stock of psychological disorders is increasing.4 It is probable that 'happiness' is not the inevitable consequence of more healthcare anymore than it is a consequence of greater material wealth.
Perhaps overall illness is getting more common, or perhaps it is just that people who live longer have time to accumulate more diagnoses.
IMPROVED ACCESS TO SERVICES
A wider range of easily accessible services is available, such as same-day consultations, and telephone or internet access to healthcare professionals. Professional time and attention is not as 'expensive' (in the sense of 'hard to get') as it used to be a generation ago. So consultations may be booked on a 'just in case' basis.
Those practice nurses among you who do telephone triage will be familiar with the rush of demand that builds up as soon as a new service is offered, particularly if it can be accessed with a minimum of inconvenience and cost. A cost is incurred, but not by the patients. In my practice the practice nurses offer a 'phone-back' telephone triage and consultation service, and it is amazing how many patients have abandoned their landlines and can now only be contacted on their (more expensive) mobile phone network. After the triage, it is estimated that a GP consultation now costs the NHS an average of £28.35.5
CASE HISTORY
Jackie is 38 years old and has no known chronic illness except health anxiety. At her age and gender the statistics suggest we should be seeing her about six times a year (consultation rates vary significantly with gender and age).2 However, in the last 12 months she has received 43 phone calls from the triage nurses, and been seen at the surgery on 40 occasions.
So what should we do? All the strategies detailed below have been tried but to no avail. However, the practice team felt that they were all worth a try.
Hidden agenda
As one of our practice nurses put it to me, 'we are clearly not giving this lady what she wants.' This falls into the consulting area called Ideas, Concerns and Expectation (ICE). If Jackie has a particular concern or a set of concerns about her health, which has not yet been discovered and responded to, then it is perfectly logical for her to keep seeking attention. Indeed, it may be a token of her remarkable faith in the healthcare professions that she keeps consulting, despite the evidence that so far we have not done her much good. Ways of trying to determine your patient's health beliefs have been discussed in a previous article in this journal.6
Psychological approach
It is tempting to conclude that any patient who makes our working life awkward must be 'nuts'. Such a reaction is clearly unprofessional. However, rates of anxiety and depression in the UK population are high - Anxiety UK reports that 1 in 6 of the UK population have an anxiety disorder at any given time.7 If Jackie's use of the triage service is the result of an underlying disorder, then this possibility needs to be explored and dealt with. Treating any anxiety will probably not immediately result in a reduction of her service use, but at least if the diagnosis is correct there is a better chance of the correct treatment being implemented.
Threshold for being seen
Nearly all Jackie's contacts with the triage service have led to an urgent GP consultation. The situation could be managed by bypassing the triage service all together and just booking the consultation. However, this is giving Jackie access to services in a way that is not given to other practice patients - she has become a special case - and yet there is no reason other than her demands to take this course of action. Of course all health-care takes account of individual patient factors when allocating services, for instance related to the clinical urgency of the situation, but this proposal cannot be implemented for all patients and might be interpreted as an unfair use of resources.
Routine appointments
As she is being seen by a clinician at the practice roughly once a week anyway, would it not be sensible just to book her a weekly appointment when she can unload her neurosis de jour so that she did not have to use the services in such a kneejerk manner, accessing emergency care when she feels the next twinge? Worth a try, but anxiety is typified by sudden urges and fears that have, by their nature, to be dealt with immediately.
Disciplinary measures
Jackie is using more primary care resources than can be justified by her stock of morbidity. A discussion comparing her consulting behaviour with that of similar women of her age and health might at least suggest to her that her behaviour is unsustainable and that another approach to her problems is required. More overtly, the practice might discuss with her the changes in her behaviour it requires to reach a sustainable compromise, with a plan to review the situation to assess progress. It might even be necessary to consider the ultimate sanction - removal from the list so that she will need to register with another practice. Such a process would involve a formal warning letter before implementation, and the gap in time between warning and implementation could well be characterised by a deterioration in the patient/professional relationship.
CONCLUSION
Every general practice has one or more 'Jackies'. Their appearance on the telephone list will elicit inevitable groans. However, Jackie's problems are real to her, and according to her understanding she is taking appropriate action. The provision of healthcare is a two-way relationship between professional and patient. While it is always tempting for one party to blame the other for any problems in the relationship, as any relationship counsellor will tell you problems in a relationship involve both parties and can only be solved by both parties. It takes two to tango.
REFERENCES
1. Hannay D R. The 'iceberg' of illness and 'trivial' consultations. JRCGP 1980;30:551-554
2. Final Report to the NHS Information Centre and Department of Health. Trends in Consultation Rates in General Practice 1995 to 2008
3. Fraser AG and Dunstan F D. On the impossibility of being an expert. BMJ 2010;341:1314-5.
4. Wilkinson R and Pickett K. The Spirit Level. Why Equality is Better for Everyone. London:Penguin,2010
5. RCGP Scotland. Manifesto. March 2011
6. Warren E. The consultation: how to do it - part 3. Practice Nurse 2010;40(9):12-14.
7. Anxiety UK. Frequently Asked Questions. http://www.anxietyuk.org.uk/about-anxiety/frequently-asked-questions/
