Primary care providers are under sustained pressure to provide an increasing range and volume of services to facilitate reduction in costly secondary care and shifts to better coordinated community provision.1 Demand for primary care and GP consultation rates have increased by >20% in the past two decades.2 Innovation is required to provide appropriate care that also enables greater capacity in primary care.3 A small group of patients are consistently in the top decile of frequent GP consulters over at least a 3 year period.4 Such patients have a median of three long-term conditions, two psychiatric conditions, and high health anxiety, often fuelling medical reassurance.5,6 Even small reductions in care use, while providing appropriate care, could provide significant gains in capacity.
Interventions for frequent attendance usually assume that primary care attendance will decrease when health improves. The evidence for this assumption is mixed with some studies supporting it7 and others contradicting it.8 Close medication management, GP training, care coordination and psychological interventions such as cognitive behaviour therapy (CBT) have been effective in either improving mental health or reducing service use,9,10 but improvements waned over time in some cases.11 However, the definitions used in almost all intervention studies either set the threshold for attendance too low or over too short a time frame, typically 1 year to differentiate them from the regular general practice population long term. Defined in this way, most frequent attenders return to normal consultation rates within 12 months.12 Those who continue to frequently attend for a second year are likely to continue attending at a high rate.4
A number of studies have demonstrated that service utilisation is reduced after CBT, particularly when treating disorders associated with high service use,13 including reduced hospital use when offering mindfulness-based cognitive therapy for medically unexplained symptoms (MUS),14 and reduced overall service use when offering individual CBT for somatisation disorder.15 Only two studies have explicitly considered repeated service use in MUS, however, and only one identified those frequently attending for 2 years.16,17 Even then the threshold was not high enough to apply the clinical differentiation suggested,12 and did not report change in service use. Perhaps the closest to a study exclusively focused on CBT for frequent attendance is a recent pilot study of CBT in emergency care frequent attenders, which showed a reduction for all participants who had taken part.18 Nonetheless, service use is still determined over a short time frame and emergency care priorities and arrangements are different to primary care. In sum, the existing research suggests that CBT can help reduce service use, but little has been done to investigate this specifically and nothing has been done to explore this application in long-term frequent attenders in primary care. Long-term frequent attenders may not find CBT acceptable. Therefore, a feasibility and acceptability study was conducted.
How this fits in
A range of interventions have been trialled to reduce high service use with mixed results. Most studies have focused on those who frequently attend in the short term. This study addresses those who are likely to continue frequent attendance for several years by offering cognitive behaviour therapy (CBT) to long-term frequent attenders. This feasibility study suggests that long-term frequent attendance can be reduced and general mental health improved by offering CBT.
This study aimed at identifying a sample of patients willing to participate in individual CBT delivered in the practice, by screening patient electronic records of practices for long-term frequent attendance (feasibility); determining whether the intervention was acceptable to these patients in terms of attendance at treatment sessions and questionnaire responses (acceptability); and whether the intervention was associated with reductions in primary care use and improvement in physical and mental health.
