Sweet FAs. Not! (or How to Respond to “Frequent Attenders”)

Frequent attenders, to use the stock institutional phrase, have not only defeated exasperated and puzzled managers in mental health services and A+E – they have also driven the cream of researchers to a kind of limp resignation. This leads to an unusual waffly helplessness - for example, “specific treatment and management protocols need to be developed for this group of patients” – or, on occasions, frank defeat. Thus, a “systematic literature search” in 2008 found nothing to indicate “that any intervention improved quality of life or morbidity” for frequent attenders and concluded as follows: “no evidence was found that it is possible to influence healthcare utilisation of frequents attenders” or FAs as they are known, usually off the record.

“Resistant attenders” may be a more productive way of characterising this band of determined and promiscuous help-seekers. And the first law of disarming resistance is to watch your language and the thinking which it structures. This means looking away from mechanical, linear approaches (though there is a place for them later) and indulging in a spot of lateral or divergent speculation – difficult in the NHS where there is a hidden embargo on thinking and an obsessive-compulsive fascination with doing.

There aren’t any truths but there may be some near-truths which might contribute, not so much to solutions, as to a slightly different mentality which, if systemically applied, might lead to some dividends. Here are a few:

i) Where there is no brake on demand, supply will be overwhelmed

The swamping of A+E, whether it is for physical or mental health problems, is a function of supply lagging behind untrammelled demand. The usual brake on demand is, of course, price. In the NHS there is cost but it is so distant that it doesn’t impinge on everyday consumption or activity. There are other potential brakes on behaviour in this sphere – stigma, shame, a wish to be independent or self-sufficient, rival, informal sources of diagnosis (traditionally, the benign or wise grandmother), treatment and reassurance – and so on. But, for a dense variety of reasons, these restrain demand much less than they used to do – and whether or not this is a good thing is down to the colour of your politics or, in a sense, the depth of your pocket.

ii) Where there are no incentives, there will be no change.

Where there are no immediate incentives to do things differently, staff will tend to do what is familiar and congenial. Reducing the number of frequent attenders requires different practice from staff working in the community outside hospital, which is where it is thought treatment should generally be provided. Financial incentives don’t work because their benefits are too far removed from activity. That is to say, they are generally the concern of senior managers who are distant from where day-to-day clinical activity takes place. Pushing actual budgets right down the hierarchy would bring financial incentive closer to activity but this is perceived as ceding control to those who can’t be trusted with it, a widespread and intractable folly which impedes adaptive and progressive change.

An endemic NHS habit is to react to problems by increasing control and creating a taller, steeper hierarchy. An excellent example of this is the way in which acute psychiatric hospital beds are organised and their use managed. Not that long ago, a consultant would be based in the community but also have a fixed, if slightly nominal, number of beds in the local hospital and he or she would have clinical responsibility for patients wherever they happened to be looked after. They would get to know their patients, their histories both inside and outside the institution, and their networks. They would also be likely to discharge patients from hospital earlier, partly because of this extensive knowledge and understanding, but also because they would be looking after them immediately after discharge as well and more likely to take appropriate risks. But, more important, the consultant and his or her multi-disciplinary team would have a direct incentive to move patients out of hospital promptly so that they could move more acutely unwell patients into their vacated beds.

As so-called “pressure on beds” has increased, there is now a kind of joint account of beds on which a number of different teams can draw. This arose partly out of an uneven use of beds which meant that some teams always exceeded their quota; but also because, in the redundant (in the original sense of flowing back and forth without any progress or benefit) cycle of change in the NHS, those who favoured the new arrangement weren’t around to experience the drawbacks which led to it being replaced twenty years before. With the possible advantage of being able to use beds in other parts of the service, more protocols and layers of control were levered in which took out low-level, creative management of beds and pushed the threshold of admission much higher. This not only meant that acute wards became chaotic, lawless places looking after floridly ill patients but crisis became the key to admission, often out of hours when barriers are a bit more permeable. And the halcyon days when risky patients could be educated to check themselves into their local ward, where staff knew them well, before their illness kicked off were lost to the organisational memory.

A service is efficient when: responsibility is ultimately vested in one person; clinical activity is shaped by clear, meaningful incentives; and all the components of a clearly defined clinical cell work to the same, organisational priorities.

The linear, convergent approach to a perceived problem is to diffuse responsibility and to lever in these extra filters or barriers, for example by having home treatment teams and on-call senior managers screen all admissions. This marginalises staff in the community (where both in physical and mental health most clinical activity takes place), deskilling and demoralising them, and, most important, turning their focus away from the central, global task of effectively managing very expensive hospital beds.

iii) Beware perverse incentives

Liaison psychiatry (this is the service which assesses frequent attenders at A+E who appear to have mental health problems), and triage generally in mental health, tend to be staffed by energetic, diligent and thorough nurses who have an aptitude or liking for the work. They are also backed up by security staff and have the benefits of easy access to medication and relatively easy access to in-patient wards and more senior staff. This is in marked contrast to community staff who work in a more exposed or vulnerable way, with little or no back-up when patients are disturbed or threatening.

The inevitable, if unintended, consequence of this is that career or experienced patients, or those who like to manipulate or by-pass services, have an incentive to go to A+E where they will be seen relatively quickly (especially if they are acting out) rather than to community services where they will be expected to observe bureaucratic and therapeutic boundaries.

iv) Anxious defensiveness has turned failure into success: a default disposal has become the norm.

Not that long ago, it was a source of shame for staff in the community if a known patient turned up at A+E because it was felt to demonstrate a failure of treatment or approach. Now, because clear advice to patients about what they should do in a crisis (NB real mental health crises are in fact few and far between) has become an integral part of the plan of care, it is viewed as a sign of success if a known community patient gets to A+E out of normal working hours. In fact, giving written advice to patients about going to A+E in a crisis has become a clinical target, backed up by cash.

v) The police have come to be seen as an integral part of the mental health service and more competent and responsive than community staff

This is partly because mental health services have become crisis-driven, meaning that the trigger or threshold for admission is much higher than it used to be. As a result, there is a cohort of patients in the community who are more disturbed or resistant to being treated and therefore more likely to come to the attention of police, who may repeatedly take them to A+E or under the Mental Health Act to hospital. Again, use of the police has become an established, de facto part of the care-plan rather than a clear warning sign that the service isn’t working.

vi) Uncertainty about capacity is institutionalised

Where once there was a presumption that patients, even if suffering from a serious mental disorder, had capacity and therefore were responsible for any self-injurious acts and for protecting themselves from them (for example, by not drinking excessively or taking those street drugs which increase instability and impulsiveness), there is a developing sense that people with unstable, explosive or self-destructive aspects of their personality, almost by definition, have significantly impaired capacity.

In wider society, the so-called culture of blame is the result of a covert, unacknowledged shift of responsibility (and therefore culpability) away from the individual to the state or state officials. This has led to an ingrained defensiveness in clinical mental health services which has made it nearly impossible for staff to say to patients, in the absence of hallucinations or delusions which may erode capacity: “if you take a life-threatening overdose while drunk, that is your decision and we will not protect you from yourself by admitting you”. Staff on the ground will almost always err on the side of caution by admitting a patient or encouraging him or her to go to A+E because this is seen as their only insurance against criticism or even disciplinary action should the patient go on to commit suicide or harm others.

vii) Frequent, brief admissions may be a good thing rather than something to be reduced or eliminated

Frequent attenders ruffle the implicit schemas which senior managers carry around in their heads. They are felt to be getting away with something or, through manipulation or sabotage, subverting the smooth excellence of the service. A main tenet of a systemic approach to what is perceived as a problem is, first, to unpick what a problem actually is, namely a fact plus a judgement. This helps to switch the focus from the former to the latter. Secondly, it advocates that pejorative words are rinsed out of thinking so that interventions come from a position of near-neutrality. Thirdly, it works from the premise that when the behaviour, of both systems and individuals, becomes stuck or redundant (see above), they are doing “the wrong thing for the right reason”. That is, impulse or motivation are sound and positive but the activity which they lead to is disabling or counter-productive.

These hypotheses can help loosen the rigid organisational thinking which leads to the rigid patterns of behaviour which in turn convince rigid thinkers that what is needed is just more of the same. A more divergent, but steadfastly neutral, approach has a better chance of defusing resistance, resulting in more adaptive or progressive behaviour. Here are a few examples of the slightly but significantly different thinking that this approach may throw up:

• for a small subgroup of frequent attenders frequent attendance may be the safest and most clinically effective way that their disorder or problem can be managed (but they need very careful identification): this group could be taken off the caseload of community services where they tend to take up a lot of clinical time with minimal or no benefit
• some frequent attenders should be given a fixed number of attendances per year (again, careful identification is important)
• treatment shifts from their underlying disorder to the disorder of their frequent attendance (ditto) – sometimes called “reframing”
• assume that there is a “right reason” which wrongly takes the patient to A+E, and identify and treat it

So: defensive practice + lack of organisational clarity about capacity and risk-taking + accessibility + hospital services which are more responsive and better supported than community services + linear approaches to symptomatic behaviour + moving responsibility and control up the hierarchy + having no brakes on demand + a state-fostered culture of expectation of and entitlement to health services round the clock = frequent attendance