A three-year historic cohort study from primary care in the Netherlands has found that one out of every seven frequent attenders continued to  attend frequently in each of the following two years. These persistent frequent attenders comprised only 1.6% of the practice population but were responsible for 8% of all face-to-face consultations.

Data were obtained from the records of all adult patients from five primary healthcare centres (28,860 patients). Frequent attenders were defined as those with an annual attendance rate within the top 10% of their sex and age group. Of the 3,045 patients who were frequent attenders in 2003, 470 (15.4%) continued to be frequent attenders in both 2004 and 2005.

The mean annual consultation rate for persistent frequent attenders was 10.2 compared with 1.4 for non-frequent attenders.

Problem-orientated records were kept, with a list of current medical problems. The prevalence was calculated for nine medical problems which had been previously linked to frequent attendance. Compared with the non-frequent attenders, persistent frequent attenders had a high prevalence of chronic physical disease, particularly diabetes (relative difference 421%), social problems (607%), psychiatric problems (402%) and medically unexplained symptoms (370%). They received more prescriptions for psychotropic medication and analgesics.

It is unclear, however, whether these relative differences indicate a true increase in prevalence or simply reflect the fact that frequent attenders have more opportunity to report symptoms and problems to their doctor.

A previous study found that depressive symptoms were the major predictor of frequent attendance and recommended that GPs should consider depression as a likely diagnosis for frequently attending patients.¹ However, the results from studies which screened for, and treated, major depression were disappointing: for every structured clinical interview for DSM-IV only 2.6 depression-free days were achieved and the frequency of attendance was increased.²

A family systems approach may be more fruitful.³ Family trees may enable us to connect frequent attendance with childhood experiences: there is a strong association with both childhood illness (affecting the child, siblings or parents) and adversity.⁴ They may also help us to connect family members and identify family patterns of illness behaviour. The first study to achieve a significant reduction in consultation rates incorporated a systemic approach, linking frequent attendance to biopsychosocial, family, cultural, administrative and doctor-patient factors.⁵

An analysis of frequent attenders in our practice found that 16 patients appeared among the top 50 most frequent attenders for two years running (32%). Over the two-year period these 16 patients took up  727 face-to-face appointments. In my experience, family tree work enhances mutual understanding of the patient’s problems, facilitates brief interventions and improves the therapeutic relationship. However, for the hard core of persistent frequent attenders, while it can make consultations more worthwhile and interesting, I am not yet convinced that it can reduce the number of them.