Group consultations: better for patients, better for nurses?

With funding in general practice failing to keep pace with demand, practice nurses are feeling the pinch, and new ways of working may seem ever-more attractive. Could group consultations be one way of improving efficiency?

What are group consultations and how do they work?

Group consultations are an alternative to one-to-one consultations. They replace planned reviews and routine follow up. While common practice in the US where 10% of doctors work this way,1 they are a relatively new concept in the UK.

Group consultations are not peer support groups, group education nor expert patient training. They offer an alternative way to deliver planned clinical care.

Group consultations support 10-15 patients simultaneously. The session lasts approximately 90 minutes, with the clinician present for about half of the time.

For the first 30 minutes before the clinician arrives, a process facilitator works to identify patients’ questions. These are written up on a big board or flipchart, alongside key clinical indicators e.g. blood pressure; HbA1c.

The process facilitator groups the questions by theme to minimise repetition. When the clinician joins, there is a short break to review patients’ questions and clinical results.

Then, for the next 45 minutes or so, the nurse or doctor consults one-to-one with each patient in turn. Everyone listens and learns from others’ consultations. The clinician leaves.

In the final 15 minutes, patients reflect on what they have learned and commit to personal goals.

Why are we looking at group consultations now?

Primary care teams are on their knees. Burnout is rife amongst professionals.² Patients are dissatisfied with access in primary care. Demand keeps rising. No one is winning.

What’s the evidence to support this way of working?

There is a lot of evidence from the United States, Canada and Australia.

Studies demonstrate group consultations led by doctor and nurse practitioners improve clinical outcomes, reduce hospital admissions and A&E attendance and enhance patient experience and satisfaction.^3,4

A systematic review of shared medical appointments in patients with diabetes showed that group consultations were associated with lower HbA1c at 4 to 48 months’ follow up (mean difference=−0.55; 95% CI, −0.99 to −0.11) and consistent and statistically significant effects on systolic blood pressure compared to usual one-to-one care. Studies have reported large improvements in health-related quality of life and a greater impact using a disease-specific quality of life measures.⁴

The studies included in this review also showed significant impact on hospital admissions and emergency department visits amongst people with diabetes, with admission rates lower in the group consultation group compared to usual routine care and follow up.³ Studies have also found a reduction in hospital admission rates in older adults, with a tendency towards total healthcare costs lower for those participating in group consultations.

Evaluation also found that group consultations increase access and reduce clinic backlog without increasing clinic time,⁵ which supports stressed clinicians to cope. In addition, Noffsinger6 found that group consultations increase clinic productivity by 300% and calculated that applying group consultations reduced the need to hire additional clinical staff even when caseload increases.

GP practices in Smethwick, Birmingham introduced group consultations within an ethnically diverse community,⁷ for:

• Back pain
• Diabetes
• Hypertension
• Asthma
• Acute minor illness

The practice realised the following benefits:

• Improved access to GP and practice nurse care for people living with long term conditions
• More choice for patients
• Reassurance and increased personal confidence amongst patients and families
• Peer led learning, support and challenge to support behaviour change and self care
• Improved care experience
• Expanded capability and capacity; ability to do more with the same resources.

Independent evaluation also showed that group consultations contributed significantly to delivery of £2.5 million of quantifiable savings; freed practice capacity and created head space for quality improvement. At 12 months, 69% participants had improved their body mass index (average reduction from 35.4 to 34) and 84% had an improved blood pressure control compared to baseline. Participants fed-back that group consultations added value and reported improved confidence to self-care.⁷

Nesta⁸ funded a programme of work in 2012/13 that evaluated innovations in people powered health. Their programme supported pain specialists to run group consultations. Consultants saw 15 patients in the time they would normally see nine.

An audit of Croydon’s Service User Network (SUN), which applies group consultations with people with mental health issues found that hospital bed day use decreased after six months of participation in SUN with a total decrease from 330 days to 162 days in the group audited, a 30% reduction.

Evaluation in Slough found group consultations:

• Save GP time and are productive, especially once GPs have gained experience of consulting this way, which happens after one or two sessions
• Are liked by patients. ‘By the third session, they want to take over’. They build community and more equal partnerships with clinicians, and may be activating patients; supporting them to gain confidence and take control, which are key steps in building self-management capability
• Lead to frequent attenders attending the practice less frequently. GPs and practice teams tell us that frequent attenders only come to the group consultation instead of consulting as much as two or three times a week. This is very promising because frequent attendance amongst a minority of patients is a significant strain on practices
• Are empowering, liberating and rewarding for clinicians. They enjoy consulting this way; have gained personal confidence and use the tools and techniques they have learned through training and coaching in other areas of their clinical practice
• Make time to discuss things that don’t come out in one-to-one appointments. This improves quality and means that patients feel more connected with their nurse or GP
• See peers educating peers and reinforcing clinicians’ advice. This changes beliefs and behaviours. GPs report that patients who may not accept their diagnosis; or those whom they have been persuading to start treatment e.g. attending pulmonary rehabilitation, have been reassured by group discussions and accepted their diagnosis or treatment; something that the GP had been failing to achieve alone
• Work best for complex, poorly controlled patients. Early feedback suggests that group consultations may be a most effective for this group and help them feel more in control of their health issues. As they are often the patients GPs find most difficult to support, this is a win-win.
• Improve patient compliance with reviews and monitoring. GPs report that patients who were not turning up for monitoring appointments attend when monitoring is part of a group consultation

As well as this emerging evidence base, the evidence for peer support suggests group consultations will have similar impact.⁹ It suggests that peer support helps people feel more knowledgeable about their condition; increases confidence and happiness and reduces feelings of isolation. There is also some evidence to suggest that peer support encourages people to take more care of their health, which may translate into improved health outcomes.

‘The open-group review of clinical measures like BP and HbA1c has had a significant impact on patients’ beliefs and attitudes. For instance, I had several patients who were in denial about diabetes. When they compared their numbers with their peers, they realised they needed to take action, which bodes well for their future outcomes.’ GP, Slough

What do patients think?

People and families – especially those living with long term health issues who visit their practice nurse a lot – consistently tell us that to self-manage their health issues, they want to:

• Have a closer relationship and spend longer with their GP or nurse; have more time to discuss issues playing on their mind. Having a close relationship gives people confidence to manage their condition and reassures them there is someone there if things change
• Be regularly followed up and reviewed. Proactive follow up reduces their anxiety. They worry less and feel safer and reassured. This is especially true of their medicines because people worry a lot about whether their medicines are working and about symptoms that could be side effects
• Talk to someone who understands their situation; someone who has been there and overcome the same difficulties they face. Talking to their peers gives people hope, inspiration and reassures them that their life can get better. Peer support also means people feel less alone and more supported. This is especially important when people have recently received life changing news like diagnosis of a new long term condition
• Set personal goals that help them to take control and cope – especially when their condition worsens. This is because people want to be as self-reliant as they can be. People want to avoid ending up in hospital if they possibly can. Setting shared goals also helps to build relationships and is experienced as empathy by patients.¹⁰

Group consultations can deliver all these things so it is no surprise that patients love them.

A further beneficial outcome is how they support practices to identify and nurture patient leaders. Dr Priya Kumar who is leading group consultation in Slough has seen many instances of this:

‘Over time, patients become experts as they live with these conditions and they have an innate understanding of the challenges and fears of their peers. 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!’

Slough is now pursuing a vision of group consultations seeding the establishment of peer led support groups for chronic conditions run by these emerging patient leaders. In time, the plan is for some patient leaders to go on and train as process facilitators, thus co-producing routine clinical care.

Confidentiality is a perceived barrier – mainly for clinicians. A signed confidentiality agreement secures it and in reality, very few patients express concerns about confidentiality. In fact, they find sharing their clinical data empowering. It remains the most common concern amongst health professionals even though in 18 years of consulting this way in the USA, there has not been a single case of a breach of confidentiality.

What are health professionals’ current experiences of delivering primary care?

Frontline UK health professionals tell us that:

• Repeating the same story to people day after day wears them down - especially when nothing seems to change. It is leading to burn out
• Working in isolation is difficult
• Ten minutes is not long enough. This leaves professionals feeling frustrated and powerless because they can’t deliver the kind of care they want to
• They would like closer relationships with people and families, but believe there is not enough time
• Confidentiality gets in the way of linking up those with the same condition in their practice.¹¹

In theory – and extrapolated from the US evidence – group consultations would reduce the repetition that is part and parcel of individual appointments and the pressure on practice appointment systems, and enhance working life by enabling clinicians to work with and learn from colleagues.

The supportive group setting is energising and provides a welcome change from traditional clinical practice.

Furthermore, when peer advice reinforces what the clinician is saying, and people take notice, change happens in the consulting room and the clinician sees it in real time, which is motivating and rewarding.

Clinicians rightly worry about record keeping. This is a challenge. Those pioneering the practice are starting to find ways to overcome it. Mobile technology is likely to be the most sustainable solution in the long run.

Group consultations are not for every nurse or doctor, but those who embrace it say it restores the joy to clinical practice.

Who is involved?

There are two roles in the room at a group consultation; the clinician who is the ‘expert’ contributor and who is consulting and a process facilitator who does not need to be clinically qualified to play their role. The facilitator manages the group dynamic, keeps the consultation to time, and makes sure everyone has their say.

Behind the scenes, the practice team also needs to work differently and support group consultation practice. There are changes to clinics administration. Patients may need to have had relevant clinical tests done in advance. This has the benefit of systematising follow up and review and ensures the clinician has all the information needed to make decisions, which is an improvement in its own right.

Plus, the consulting nurse or GP needs to invite people to attend the first session because studies show that if invited personally, the attendance rate is 90%.

How do we get started?

Decide the group of people to whom you want to offer group consultations. A good place to start is planned annual reviews. The strongest evidence is with diabetes and pain management. However, clinicians have applied group consultation practice to support people with a wide range of health issue from pre-natal reviews to management of complex health issues in older people - and everything in between.

Approach your practice team. Secure support from your practice manager, and at least one GP colleague. Think about who could be your process facilitator; a healthcare assistant or maybe even a really switched-on receptionist, a patient leader or a practice based care navigator or care coach could be ideal.

Then you need to read up on group consultations or look into training.

What support is available?

Group consultations are one of the 10 high impact actions in the GP Forward View.¹² You may be able to secure funding from local practice nurse development or education funds or from your local clinical commissioning group. (See Resources)

REFERENCES

1. Tozzi J. Your next doctor’s visit could get crowded. Bloomberg, 2015. http://www.bloomberg.com/news/articles/2015-01-29/health-why-group-medical-visits-are-catching-on

2. Jaques H. Study reports high levels of ‘burnout’ among GPs. BMJ Careers, February 2012. http://careers.bmj.com/careers/advice/view-article.html?id=20006523

3. Edelman D, McDuffie JR, Oddone E, et al. Shared Medical Appointments for Chronic Medical Conditions: A Systematic Review. VAESP Project #09-010; 2012. http://www.ncbi.nlm.nih.gov/books/NBK99785/

4. Egger, G. Dixon, J., Meldrum, H., Binns, A., Cole M., Ewald, D. Steven, J. (2015) Patients’ and Providers’ satisfaction with shared medical appointments. AFP 2015;44(9):674-679

5. Cabral J. A new paradigm: shared appointments in diabetes. Cleveland Clinic, cited in Clay H, Stern. Making time in general practice, October 2015.

6. Noffsinger, E. The ABC of group visits. Springer; USA: 2013 http://www.springer.com/gp/book/9781461435259

7. Pathfinder Healthcare Developments (Community interest company) Redesigning primary care: outcomes in Smethwick, 2011. https://www.gov.uk/government/case-studies/pathfinder-healthcare-developments

8. Nesta. Redefining consultations: changing relationships at the heart of healthcare, 2013 https://www.nesta.org.uk/sites/default/files/redefining_consultations.pdf

9. National Voices and Nesta. Peer support: what is it and does it work? 2015. http://www.nationalvoices.org.uk

10. The ELC Programme. Insights into people’s experiences of primary care, 2014. http://www.elcworks.co.uk

11. The ELC Programme. Primary care clinicians’ experiences of delivering care, 2015. http://www.elcworks.co.uk

12. NHS England. General Practice Forward View, 2016. https://www.england.nhs.uk/wp-content/uploads/2016/04/gpfv.pdf