Frequent Attenders: care and repetition in general practice

In the third post of our Waiting Times takeover series, Stephanie Davies and Martin Moore invite us to consider the figure of the ‘frequent attender’. In the face of repetition and chronicity, can care be an act of ‘staying with’? 

“A blizzard of problems” is how one General Practitioner describes his encounters with Carrie, one of several patients whose regular use of her local NHS general practice places her in that category reserved for ‘frequent attenders’. Contact with her is erratic. She tends to move between different doctors. Telephone conversations with her tend to be long and rambling. She always has a story about a crisis that has either already happened or is imminent. New problems arise as old ones grow in complexity. These are mostly problems with life in general, but they often skirt the edges of the pathological. I ask the GP if he can remember any of his actual words to Carrie during their last phone call: “What can I do in twenty minutes? I can give her my time, my absolute attention. She might say something. I listen to it. It goes inside, has meaning — it’s not just transactional”. He describes their encounters as “having the emotional temperature of somebody depleted in every way”.[1]

Green backdrop with a person resting on a table, a big clock on the wall.
Fig. 1. The Frequent Attender. Image generated by Open AI’s DALL·E

British general practice has been considerably transformed since the birth of the National Health Service in 1948 (NHS), organisationally, financially and culturally. Yet, throughout the past 75 years, one particular figure has haunted its psychological and social worlds: the frequent attender. Usually figured as a woman, she embodies a recurrent predicament for a publicly funded healthcare system with an ‘open door’ policy. On the one hand, her constant return appears proof of something working, of the NHS keeping its promise to be continuously ‘there’ for those who need it, with an open-ended offer of time in which to care. On the other hand, frequent attendance has been used as evidence of what is wrong with universal healthcare – that by being too available it becomes vulnerable to misuse or overuse, to the point where (according to critics) only disciplinary measures or charges can “protect” this time.

Looking for a different way of engaging the risks of open-ended offers of time in the NHS, this short essay combines historical enquiry and ethnographic observation to ‘examine situations from the point of view of their possibilities’ (Stengers, 2011, 12). From this perspective, we understand the frequent attender to be neither fundamentally good nor bad. Instead, we explore their figuration as intertwined with historic cultures of professionalism, and we reflect on how such patients can enable certain practices of continuing care. Through vignettes and observations, we invite you to think of her within the interruptible flow of everyday life, where the experience of waiting with what is painful, repetitive and sometimes unbearable has always been fundamental to caring for chronic things in NHS general practice.

‘Who is pressing on whom, and in what ways?’ (Callard, 2023).

Why, then, has the frequent attender historically been such a source of inconvenience for general practitioners? And what might it mean to place her ‘under the sign of care’? (Conley, 2016, 340).

For many doctors in the first two decades of the NHS, the answer to this first question was clear. Though some patients required frequent attention for intractable physical, psychological and social distress, a significant proportion of frequent attenders brought “trivial” complaints undeserving of medical attention – an elastic label that encompassed everything from small cuts, pimples and self-limiting colds, to somatic manifestations of neurosis (such as fainting, heart palpitations, or gastric distress). These patients simultaneously eroded GPs’ emotional and psychological resilience with ‘endless complaints’ (Taylor, 1955) and wasted time already severely pressured. Critics argued that such “trivia” produced a service ‘rushed to the point of indecency’ (Anthony, 1950), and prevented doctors ‘giv[ing] cases which really require attention the necessary time’ (Anon, 1950).

Complaints about wasted, pressured time have rarely just been about temporal economy, even when the temporal requirements of GPs were most intense. Rather, complaints about frequent attendance during the 1950s and 1960s were often loaded with political opposition to “free” universal healthcare, and structured by classed, racialized, and gendered anxieties over status lodged within a White liberal professionalism. This mixture was perhaps best captured in doctors’ laments at being ‘virtually unprotected against a small but obdurate minority of their patients who regarded the general practitioner as the nearest the Welfare State can get to a slave’ (Anon, 1956).

The White bourgeois masculinities and intersecting structures of Othering that framed general practice in the 1950s and 60s, underpinned the affective responses to patients. GPs’ hateful projections “stuck” (Ahmed, 2014) to subjects considered lacking in imperial and masculine self-control, or White bourgeois rationality and maternalism: the neurotic businessman, the ‘over-anxious mother’ (Anthony, 1950), the ‘hypochondriacal introverted specimen who shrieks for the doctor at for every imagined ailment’ (Edwards, 1961).

Structures of discrimination shaped the division of frequent attenders between the “legitimate” chronically ill, and the “illegitimate” neurotic or sickness prone ‘weaker brethren’ (Taylor, 1955) – a distinction framed by older, racialised logics of the deserving and undeserving subject in British Liberalism (Shilliam, 2018). GPs might still experience frustration with patients whose chronic but ‘legitimate’ ailments refused trajectories of cure and resolution. But their responses were overlaid with “care-as-concern” and a willingness to endure as a “good doctor”, ways that were not extended to the supposedly “undeserving”. As one GP recalled in regards to his mid-century practice: ‘there were those who had to come regularly’, perhaps monthly, ‘because they had some chronic condition which you needed to look at and assess, and advise them on… even just hold their hand …. I mean, that was essential’. But then there were ‘the inadequate, really… they couldn’t cope with life as they found it’. These were patients who ‘you’d explain, who still couldn’t see what you were getting at’, but who would return. And ‘that was the one thing, because you knew they’d come back again, and you were beating your head against a brick wall. This is why so many of them eventually got things like Valium and so on because you’d got to give them something, some good medicine. You’d got to get them off your back somehow. They were very time-consuming, you see’ (Wellcome Library Archive, 1993).

‘ –– to risk taking the present moment, taking the encounter, on its own terms’ (Meyers, 2023).

Durational time in contemporary general practice tends to be grasped through the organisational structures used to ‘manage’ it. Clinical pathways are linear – they move the patient from A to B, which means that providing healthcare is difficult to separate out from the activity of managing or acting on time, moving it along, starting and stopping, making things happen from a distance.  Chronic states on the other hand, where ‘symptoms appear, disappear and reappear, return, arrest time, and efface it’ (Meyers 2016, 361), are characterised more by experiences of backsliding and repetition than they are by those of progression and moving on. Across the NHS’s history, then, part of the problem seems to be that, through no fault of her own, the frequent attender fails to show proper respect for the temporal borders needed to realise projects of ‘good’ efficacious medicine. Instead, she represents for GPs what Lisa Baraitser (2017) describes as time ‘without project’ – ‘a form of time that does not define itself in relation to a projection into an open libidinal future – a way of being in time that is not about going anywhere, and is not about going nowhere, but is perpetually concerned with what is produced…’ (p. 61).

Observations of present-day encounters between GPs and frequent attenders – patients returning with unresolvable pain, psychological distress, or social hardship – are described as coming close to ‘the everyday life hell’, as one GP put it, of being stuck in an endless cycle of repetition. Yet, if to be ‘without project’ could be an everyday hell that some GPs seek to escape, it could also be an everyday hell in which a commitment to staying with the other was continuously renewed. The GP’s time, in other words her ‘self’, was sometimes the only thing left to offer, as a kind of substitution, in the moment, for anything more tangible or enduring. In this way, the effort of staying with the stalled or repetitive time of care, sometimes had the effect of stretching the limits of what could count as worthy of collective concern and ongoing attention.

Historically, such “staying with” could be seen in practices of ‘chronic visiting’ to “incurable” house-bound patients (Wellcome Library Archive, 1993), in early forms of GP psychotherapy (Balint, 1957), and in more traditional offers of “sympathy”. Describing patients who had attending the surgery simply to be heard, one GP mused how ‘unwittingly, he has called for sympathy and understanding and it is my solemn duty to supply it – judiciously. These are time-takers, yes, but not time wasters’ (Kirkness, 1956). Current temporal economies – structured by appointments, targets, and deputation – often appear to limit the elongated practices of care romantically associated with the “family doctor”. Yet, open offers of care do persist (Davies, 2022). Continuity, however tenuously grasped or uncertainly offered, survives in the ‘seams’ (Anucha, 2023) of productivity.

One way of describing what the frequent attender does (or could do), therefore, is to insist on staying with a non-progressive temporality of care, through which GPs might experience a shared vulnerability to aspects of living with pain or other intolerable states that cannot be transcended. Adopting a mode of attention similar to Schrader’s ‘abyssal intimacy’, where to share in an experience of non-power enables a passive notion of care, GPs can be caught in activity that requires their selves to be put on hold whilst they register realities that are as unassailable for them as for the patient. They can find themselves ‘suspended in a zone of indeterminacy, hesitating, slowing down, not exactly knowing what to do, confused, listening intently to what might still be hidden…but also desiring (sometimes) to act with passion’ (Schrader, 2015, 683).

When examined from the point of view of her possibilities, therefore, the frequent attender can be a productive figure with whom to think through the problem of time in general practice. As the one who keeps making the time needed, if not for care as an act or event, then as something ongoing, repetitive, and waited for, she embodies what is most inconvenient for masculinised medicine and neoliberal ways of organising welfare – the demand to stay in relation to the stalled, negative or repetitive time of caring for what is not getting any better. With the rise in health-related anxiety, complex conditions and multi-morbidity, and in an atmosphere of ongoing crisis over the NHS’s future, the question of what it means to offer time to situations beyond reparation, is far from a theoretical question. Rather than seeing the frequent attender as somebody who is guilty of ruining the NHS for everybody else, this means seeing her as somebody who enables questions about how to ‘hold’ rather than migrate the temporalities of endurance (Berlant and Povinelli, 2014), that are needed to ‘hold up’ any system of universal healthcare.

[1] This description is based on material collected as part of an ethnographic study of general practice. Davies, Stephanie. 2022. ‘Waiting, Staying and Enduring in General Practice’. PhD Thesis. Birkbeck, University of London.

References

Ahmed, Sara. 2014. The Cultural Politics of Emotion. 2nd Edition. Edinburgh: Edinburgh University Press.

Anon. 1950. ‘The GP at the Crossroads’. British Medical Journal 1(4666): 1375.

Anon. 1956. ‘Doctors Examine Annoying Patients’. The Manchester Guardian 10 July: 4.

Anucha, Kelechi. 2023. “Fugitive Care.” (Paper presented at The Time of Care, A Waiting Times Conference, Birkbeck College / University of Exeter, London, 29th March 2023).

Anthony, E. 1950 ‘The GP at the Crossroads’. British Medical Journal 1(4661): 1077-9.

Balint, Michael. 1957. The Doctor, His Patient and The Illness. London: Pitman Medical.

Baraitser, Lisa. 2017. Enduring Time. London: Bloomsbury Publishing.

Berlant, Lauren, and Elizabeth A. Povinelli. 2014. Holding Up the World, Part III: In the Event of Precarity … A Conversation. E-flux electronic journal. https://www.e-flux.com/journal/58/61149/holding-up-the-world-part-iii-in-the-event-of-precarity-a-conversation/.

Callard, Felicity. The Time of Care, A Waiting Times Conference. Verbal response to papers. Conference, Birkbeck College / University of Exeter, 28th March 2023.

Conley, Verena Andermatt. 2016. ‘The Care of the Possible’. Cultural Politics 12 (3): 339–54.

Davies, Stephanie. 2022. ‘Waiting, Staying and Enduring in General Practice’. PhD Thesis. Birkbeck, University of London.

Edwards, W. 1961. ‘Out of practice’. Family Doctor 11(4): 254-5.

Kirkness, James. 1956. ‘Evening Surgery’. Family Doctor 6(9): 765.

Meyers, Todd. 2016. ‘The Poisonous Ingenuity of Time’. South Atlantic Quarterly 115 (2): 351–65.

Meyers, Todd. The Time of Care, A Waiting Times Conference. A written response to papers presented at the conference, Birkbeck College / University of Exeter, 28th March, 2023.

Schrader, Astrid. 2015. ‘Abyssal Intimacies and Temporalities of Care: How (Not) to Care about Deformed Leaf Bugs in the Aftermath of Chernobyl’. Social Studies of Science 45 (5): 665–90.

Shilliam, Robbie. 2018. Race and the Undeserving Poor: From Abolition to Brexit. Newcastle-upon-Tyne: Agenda.

Stengers, Isabelle, and Erik Bordeleau. 2011. ‘Interview with Isabelle Stengers: The Care of the Possible’. Translated by Kelly Ladd. Scapegoat: Architecture | Landscape | Political Economy, Service, no. 1 (Autumn): 12–27.

Taylor, Stephen. 1955. Good General Practice: A Report of a Survey. Oxford: Oxford University Press.

Wellcome Library Archive. 1993. GP/29/40, Michael Bevan Interviewing Dr Malcolm House.

About the authors

Stephanie Davies is a postdoctoral researcher based at the Department of Social, Therapeutic and Community Studies, Goldsmiths. She researches the temporalities of caring for chronic things and has recently completed a PhD about waiting, staying and enduring in NHS general practice.

Martin Moore is a Lecturer in Medical History at the University of Exeter, based in the Wellcome Centre for Cultures and Environments of Health. His work focuses on historical cultures of professionalism and care within post-war British health services, and as part of the Waiting Times project is currently writing a history of waiting, time, and care within NHS general practice.

This research was funded in whole, or in part, by the Wellcome Trust [Grant number 205400/A/16/Z], and the ideas in this paper have been developed in discussion with colleagues working on the research project, Waiting Times.

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