Discussion
The purpose of this study was the one to define FA, or HU, in general
practice, establishing an absolute minimum number of consultations in a
given period of time.
Our results show that a threshold of 15 encounters per year can
represent a very useful value to that purpose.
In the past, several absolute thresholds have been suggested. In Italy,
for example, the criterion of absolute reference number has ranged from
2 to 24 contacts per year. The majority of the studies set the threshold
between 9 and 14 annual visits, the frequency of which GP in Italy would
be unanimous in defining FA.
In our study, it emerges how only 5% of the practice population has
seen their GP 15 times or more in 1 year.
In addition, the 15 GP encounters seem to match with a sudden and strong
increase of visit requests, so to be a good candidate to threshold
value.
Although the number of FAs accounts for only 5% of the GP practice
population, it does demand a very significant GP working time.
It is possible, but it was not the subject of study on this occasion,
that the encounters could last longer than average.
More specifically, the standard 10-minute encounter adopted by most GPs
in the United Kingdom may not suffice to deal with FA needs. Moreover,
we did not question whether and how often the FAs are clinically studied
with blood tests and imaging, or subject to referral to Secondary Care,
compared to their peers.
Our results, contrary to previous work on the subject, do not suggest
the need for greater specificity and sensitivity for the identification
of the FA using smaller groups, dividing all patients into age-by-sex
cohorts.
Unlike other studies, we have not excluded from the audit the subjects
over 75 years and paediatric patients.
Interestingly, the prevalence FAs seems to diminish rather than increase
in the very senior group compared to the group of 60-75 years throwing
doubts about the linear relationship between fragility and medical
complexity with the number of GP encounters, but also on the social
reasons unleashing frequent GP attendances.
It is unlikely that the financial impact of FAs on the budget of the NHS
is negligible.
Based on the cost ratio of sanitary and social units 2017 of the PSSRU
at the University of Kent, the cost of a Single Surgery Encounter with
the GP is estimated bee £38.00 (\euro 43.37; $53.55). The cost is
higher for the Home Visit and it increased further by the cost of
prescription, by the administrative costs, and the costs of the requests
for specialist visits.
Therefore, since the average number of encounters per year per patient
is 0.8, with some variability by age and gender range, and taking into
account the fact that about 1/5 of the population of practice does not
consult the GP during the entire 12-month period, the additional
financial burden arising from FAs will start from a minimum of
£555.00/year (\euro633.43; $782.18) per FA.
By extending this calculation to 5% of the UK population, the minimum
additional expenditure The British National Healthcare System that can
be attributed to FAs is £1.82 billion (\euro2.05 billion/$ 2.54
billion).
The magnitude of this figure, combined with the scarcity of human
resources and recruitment problems in General Practice in the UK, is
such that it would seem to urge to manage more effectively FAs. Their
timely identification would therefore be an important starting point.