TABLE OF CONTENTS


Introduction

Frequent attenders are common in general practice—patients who visit more often than average, often with a mix of physical, psychological, and social concerns. Some have ongoing health needs, while others may be influenced by factors like anxiety, isolation, or unmet support needs. Understanding this group is important for managing workload and providing more effective care. This support article identifies frequent attenders across your organisation and offer insights into why patients may be visiting frequently. 


Access the High Frequency Attenders Reports

Select the Services icon and click on Appointments.
 

 

To identify the cohort of patients, scroll down to the Overview section of the Past tab and focus on the High Frequency reports. 


Using the Reports 

The data is grouped into 3 categories as below:

 

 
You can perform a detailed analysis of each report, in particular where patients have attended 40+ times in the last 12 months by clicking on View.

 

 

To gain insights into the demographics of high-frequency attenders, click on the Demographics tab. This section offers detailed information on age ranges, whether patients reside in deprived areas, and any long-term conditions they may have.

 

 

Use the Staff tab to identify which staff members patients are consulting with, either by role or by individual staff member.

 

 
Remember: Not every frequent visitor is problematic—some patients genuinely require regular appointments, such as those needing complex wound care or ongoing clinical attention. The goal is not to reduce necessary appointments but to identify those whose frequent visits could be better managed through alternative methods. Often, these are patients whose needs are not being effectively met and who could benefit from different support or care pathways.

Identify who the patients are by clicking on the Patients tab. 

 

 

Use your patient list to review their records. This will help you understand the reasons for their visits and identify ways to provide better support, ultimately reducing the frequency of their attendances if required. 

 

View our support article for exporting patients lists to learn more on how to action your patient list. 


Next Steps

You now have lots of insights, what does it tell you and what can you do about it? As a starting point, look for the potential problem areas and think about potential opportunities, for example:
  • Does the patient have complex social, psychological or behavioural drivers? A structured review can help uncover issues like loneliness, health anxiety or poor health literacy. 
  • Will the patient benefit from multidisciplinary interventions, including Social prescribing link workers, Health and Wellbeing coaches and Care Co-ordinators. These roles can help patients access community resources as well as manage their conditions better, which may help to reduce the reliance on GP appointments.  
  • For patients with ongoing health needs, consider creating a personalised care and support plan. This may include regular check-ins, structured reviews or referrals to mental health or community services. 
  • Consider implementing care navigation tools to ensure patients are booked in with the most appropriate clinician or service. This can redirect non-clinical issues away from GPs and free up time for more complex cases.
  • Keep the list of frequent attenders under regular review. As patient's needs change or support is put in place, they may not longer require such frequent care. 


Additional Learning

Why not access  Ardens Academy and enrol on the Appointment Dashboard to enhance your knowledge of the range of resources available.
 

 

If you require any further assistance on the process above, please contact the Ardens Manager Support Team on: support-manager@ardens.org.uk