Context
Primary care capacity is usually discussed as a problem of supply: too few appointments, too few clinicians, too little time. Less often examined is how demand is distributed across the registered list, and what that distribution implies for how services are organised.
The challenge
Every practice recognises the pattern. A small group of patients returns repeatedly, often with problems that span physical health, mental health and social circumstances. Because each contact is handled as a separate episode, the underlying pattern stays invisible in the appointment system, and the response defaults to offering another appointment.
Approach
Work focused on four connected activities: developing and testing consistent identification searches so that different practices could identify comparable cohorts; analysis across four pilot practices; clinical interpretation of that data with practice teams, looking at individual circumstances rather than appointment counts alone; and developing practical resources that practice teams could use without additional staffing.
What the analysis showed
Across the four pilot practices, an average of 3.9% of registered patients accounted for 26% of GP appointments. This is a baseline finding about how workload is distributed. It is not evidence that any intervention reduced appointments or released capacity.
What was considered in response
- Continuity of care, so that a patient is seen by a clinician who knows them.
- Structured appointments with a defined purpose, rather than additional open-ended slots.
- Multidisciplinary support, including colleagues from outside general practice.
- Social prescribing where the underlying need was not primarily clinical.
- Practical resources, including the 7H+T assessment framework, to structure conversations about the factors driving repeated attendance.
The 7H+T assessment framework
The 7H+T framework was developed during this work as a practical assessment framework: a way of structuring a conversation about the factors sitting behind repeated attendance, so that a clinician can organise what they are hearing and agree a plan. It is not a validated scoring instrument, it is not a diagnostic tool, and it does not produce a risk score. It organises thinking across seven dimensions:
- Biological
- Psychological
- Social
- Family
- Cultural
- Administrative and organisational
- Doctor–patient relationship
The value of the framework is that it makes the non-clinical drivers visible in a consultation that is otherwise recorded only as a clinical contact.
Outcomes and what is not claimed
This work did not include the controlled measurement needed to demonstrate reduced appointment numbers, released capacity or improved clinical outcomes, and no such claim is made here. What can be stated is narrower and still useful: the cohort can be identified consistently across practices, and the concentration of workload is large enough to justify attention.
Lessons
- Data identifies the cohort. Clinicians explain it.
- Repeated attendance is more often a signal of unmet need than of inappropriate demand.
- Interventions that add work without removing any rarely survive contact with a busy practice.
- The label itself carries risk. Naming people as frequent attenders can become a justification for withdrawing care rather than reorganising it.
My contribution
The wider programme was a system-level initiative involving multiple practices and partner organisations. My contribution was specific to it: primary care clinical leadership, shaping and testing the consistent identification searches, clinical interpretation of the utilisation data with practice teams, design of the interventions considered at practice level, and contribution to the practical resources including the 7H+T framework. I did not lead the wider system programme, and this case study does not claim that I did.