11 May Creating time to care: are group consultations the solution?
Primary care is at breaking point. GPs report high levels of stress and burnout, with the relentless demand for 10 minute appointments and reviews, leaving both doctors and patients feeling dissatisfied. We have worked this way for so long, it is hard to imagine an alternative way to consult.
Yet, there is one. And it is causing a quiet revolution across the country.
Called ‘group consultations’ or ‘shared medical appointments’, this new way of practicing medicine is especially impactful when delivering planned care and annual reviews for those with long term health issues – and it could make the experience of care better for both primary care teams and patients – and create time to care.
In this GP View feature, we explore what group consultations are; the evidence base that supports working this way and what those who are pioneering the approach are saying about why they offer a win-win for professionals and patients alike.
What are group consultations?
Group consultations are clinical consultations delivered in a supportive group setting. The GP consults one to one with 10-15 patients in turn, with everyone else listening in. Each consultation lasts approximately 90 minutes. For the first 15-20 minutes, a facilitator works with participants to identify their questions for the doctor. Their ‘numbers’ (clinical test results) are written up on a ‘results board’ for everyone to see. The facilitator themes and groups the questions. Then the clinician joins and there is a quick break whilst the facilitator briefs the clinician. For the next 45-60 minutes, the clinician works with the group, consulting with each individual in turn, with the rest of the group listening in and learning from being a ‘fly on the wall’ during other peoples’ consultations. Then the clinician leaves. In the last 15-20 minutes, the facilitator works with participants to reflect and review their learnings and encourages each individual to set personal improvement goals.
This unique way of consulting is very different, and not to be confused with peer support groups, group education sessions nor expert patient programmes, which are often an adjunct to planned care.
Group consultations replace one to one consultations and reviews, and in this way offer up to 300% clinic efficiency gains.
The evidence base
There is a strong international evidence base that supports group consultations and recently, there has been a UK evaluation across six practices who have introduced group consultations in Croydon. It found improvements compared to usual care across all domains measured:
Improved patient reported outcomes
The majority of patients awarded group consultations top marks and would recommend to a friend. Patients scored all aspects of group consultations higher than ‘usual care’; found them more relaxed; enjoyed their health issues and medicines being regularly reviewed and being able to raise questions that mattered to them, and having more time with the doctor. More than half of diabetic patients said they would prefer group consultations to usual care. Patients also liked meeting people with the same condition, learning from others’ experience and knowledge, sharing experiences, and feeling connected with people they had something in common with. Half of patients said they intended to keep in touch with at least one person from the group.
More confidence to self-manage
Large improvements were measured compared to from baseline scores in all aspects of self-management, including: patients feeling supported by others with similar health issues, understanding their condition and their medications; feeling in control of their health, that health was their responsibility, and that their health condition did not get in the way of their life.
Improved control in type 2 diabetic patients
The average reduction in HbA1c for diabetic patients was 7.1 mmol/mol. Poorly controlled patients achieved twice this reduction at 13.2 mmol/mol, leading evaluators to conclude that group consultations may be particularly effective for diabetics with poor control.
Positive staff reported outcomes were positive; particularly amongst GPs
Almost every member of staff completing a follow up survey admitted to having reservations about the process at the start, and subsequently found it to be better than expected, expressing surprise that patients opened up and interacted well. There was some concern at the amount of administrative and preparatory time taken, but more than half felt the positives outweighed the negatives and most would recommend group consultations to colleagues.
What GPs say
Dr Priya Kumar is a GP in Slough and Primary Care Strategy Lead for Slough CCG. She was one of the first GPs to give group consultations a go as part of a PMCF funded pilot in 2014/15:
“I have been practicing group consultations for over a year now. At first, I have to admit that I was sceptical. We had been running group sessions with our patients to support weight management, so I had already witnessed the benefits of peer support. But I found it hard to imagine that patients would be happy to share their clinical results with peers nor that group consultations would actually reduce demand for one to ones – especially amongst the South East Asian community whom we support in our practice. However, from the first session I could see that the new model worked really well for people – and by the third group consultation, patients wanted to take over!
As you can imagine, there is significant duplication in the questions patients want to ask. For me, group consultations provide the added bonus of minimising repetition, which can really grind you down over the course of a clinic of 10-minute appointments.
The open-group review of clinical measures like BP and HbA1c is also very powerful and has a significant impact on patients’ beliefs and attitude. For instance, I had several patients who were in denial about diabetes. When they were able to compare their numbers with their peers, they realised they needed to take action, which bodes well for their future outcomes. Some patients emerge as natural leaders. In an asthma group, one mum who has four children with the condition shared her tips and knowledge. I found I learnt a lot. She knew far more about managing childhood asthma than I do!
There are still some challenges we need to overcome; finding an efficient way to take notes for the care record is a big one, but from my perspective, group consultations are here to stay – and must become a routine way of working for both GPs and practice nurses. “
What practice nurses say
Chris Ballinger is a practice nurse in Croydon, and supported GP colleagues as a group facilitator:
“As I was already involved in successful group education for people living with Type 2 Diabetes, group consultations a natural progression. I act as the process facilitator; although I do believe that trained nurses could definitely play the clinical expert role.
Group consultations are very different from group education. For a start, participating patients set the agenda; mainly their concerns, anxieties, and questions about the management of their condition. Tapping into the knowledge of both the group and the clinician, everyone gains knowledge and confidence to manage their condition. Like any consultation, there is an element of education.
The difference is that group consultations shift the balance of power and expertise. Peer support and advice is more important, and the focus is on patients taking control of the management of their condition.
As patients feel more confident and able to manage themselves, over time clinicians who adopt group consultations are likely to see a reduction in demand for individual appointments; especially for chronic disease management. Group consultations have also been proven to reduce unplanned admissions to hospital and A&E visits in the USA.”
Finding new ways to create time to care requires radically new thinking. As Einstein wisely said, we cannot solve todays problem with the same thinking we used when we created them.
Group consultations are radically different yet easily way to create time to care. Is it time you gave them a go?
Georgina has over 28 years-experience in health service design. Most of her career has focused on prototyping and spreading innovations in service and system management design in both for prfit and not for profit organisations. She is a social entrepreneur and through The ELC Programme has invested in designing and spreading new approaches to person centred whole system management and innovations in clinical practice like group consultations. She also works nationally and is on the Executive Board of The NHS Alliance where she is supports health creation with a particular focus on designing health creating outcomes measurement tools and systems and creating health through work.