Group Consultations: Overcoming Barriers

Patients are given consent and confidentiality forms before the group consultation. These
are a form of a behavioural contract with patients. Those who run group consultations widely
agree that clinicians tend to worry more about confidentiality than the patients do, and
patients understand that they are sharing information within a group. The clinic set up from
the outset is to explain our ground rules, helping each other by sharing our experiences,
agreeing to not letting anyone dominate the session, and what is said in the room stays in
the room, opportunity to discuss truly confidential issues 1:1 afterwards and, often
permission to laugh & joke Group rules are formed as a collaboration – patients can be given
the opportunity to contribute their own additional ground rules to those provided by the
healthcare professional. Consent is gained before proceeding. Patients are usually more than
happy to share their experiences with others, knowing that in turn, others will share their
experiences with them, to benefit the whole group

Practicing clinicians report that patient feedback is very positive – particularly if patients
understand what is involved and are well informed before they arrive. Evidence shows that
once patients have experienced a group consultation, the preference is for another group
consultation for follow up, compared to a 1:1 appointment.^{1, 2} Studies have shown
improvements in all aspects of self-management, including understanding of the condition and
medications, feeling in control of health, feeling that patients can be responsible for their own
health, and feeling that a patient’s health condition was not a barrier in life.^{2, 3}

Group consultations have proved popular when clinicians have knowledge and can consult in
another language. This is often an incredibly positive way of interacting with our patient
groups and forming networks of support and often result in patients feeling less isolated.
Translators have also been used effectively. When there is no “internal capability” many
clinicians have been known to deliver group consultations within a known cultural gathering
spot where many participants may draw on each other for support and assistance with
translation. It is also more cost effective to work with a translator in a group setting

When implementing new initiatives, it is often tempting to build confidence inviting patients
you know well and are motivated, aiming to keep it small to plan to build on your successes.
However, that often leads to failure, as small, selected groups become very small after
dropouts, which inhibits sharing of problems and pooling of solutions. So, it is much better to
go broader and bigger than your first intention. If you target high demand conditions or
service bottlenecks, then the benefits will be apparent to all early on, creating a virtuous cycle.
Once momentum builds, word will spread amongst your patient group, and you will be able
to reach your underserved populations. There are many BSLM Members doing great work in
accessing these harder to reach communities. The very first group consultations pioneered
by Joseph Pratt were directly to address inequality for poor TB patients in 1905, so these
models have always been good for that.

There is admin involved in booking patients into the clinics, organising consent and
confidentiality forms, evaluation and writing up notes. Additional time as a resource will be
the case for any new initiative, but there are many ways to ensure this is time well spent and
some lessons learnt from others who have streamlined these processes to optimise the time.
Some examples are; a dedicated email address, use of google forms and QR codes, system
flagging for booking patients directly into appointment books e.g. from phlebotomy
appointments, building in group clinics as part of routine QOF recall processes and by using
targeted searches to complete results boards. Some have found face to face group clinics use
less admin time than virtual but like any processes, the more you do, the easier and quicker
it becomes. Copying and pasting themes into the notes and then adding specifics is an
efficient way of writing up notes. Please do not forget that clinicians would need to write up
notes regardless of whether they see a patient in a 1:1 or in a group clinic. Those who
implement at scale and adapt existing systems (rather than sticking rigidly to how this is done
1:1) always save admin time per patient.

ARRS funding, in primary care, may be used to employ care co-ordinators to run the
administration and facilitation of group clinics. Let us also not forget that you would need
dedicated admin for routine recall for QOF so this resource could be re-deployed rather than
recruiting a new resource.

When implementing new initiatives, it is often tempting to build confidence inviting patients
you know well and are motivated, aiming to keep it small to plan to build on your successes.
However, that often leads to failure, as small, selected groups become very small after
dropouts, which inhibits sharing of problems and pooling of solutions. So, it is much better to
go broader and bigger than your first intention. If you target high demand conditions or
service bottlenecks, then the benefits will be apparent to all early on, creating a virtuous cycle.
Once momentum builds, word will spread amongst your patient group, and you will be able
to reach your underserved populations. There are many BSLM Members doing great work in
accessing these harder to reach communities. The very first group consultations pioneered
by Joseph Pratt were directly to address inequality for poor TB patients in 1905, so these
models have always been good for that.

BSLM want to help you get started and are producing some resources to help. There is also
dedicated training available, and we can put you in touch with other clinicians who are already
doing group consultations. We can also signpost you to websites and case studies through
BSLM and/or our Partners to help.

A group consultation or shared medical appointment lasts for 1.5 hours, with group rules,
consent and confidentiality and an ice breaker at the beginning set up by the facilitator. The
group then write down their broad questions for the clinician. The clinician then attends for
45-60 minutes, answers the themes of the questions, and then proceeds to do approx. 5
minute or short 1:1s with each of the patients in front of the others in the group, so that
everyone learns from each other. Some questions or themes may have already been touched
upon, so the timings are usually reduced as the session progresses. This is a fantastic way to
use a personalised care approach, ensure the group learn from each other, and also saves
time.

For example, if there are 10-15 patients in the clinic, the clinician has consulted with 10
patients within 45-60 minutes but for the patients, they have felt dedicated time with their
clinician. Patients are also able to answer each other’s questions which givesthem confidence
that they, in turn, can manage their own conditions. Often, patients will stay connected with
each other and exchange numbers and some are known to go for walks or swims together
locally and form networks of support to self-care.

This is often thought to be the hardest problem. We are often consulting in silos, and it can
be lonely. Group clinics provide an opportunity for a multidisciplinary team-based approach.
Clinicians learn from each other as well as from their patients. Running group clinics has also
been shown to improve staff retention, improve job satisfaction, staff wellbeing and
teamwork. Importantly, for healthcare workers, patient groups offer increased satisfaction,
improve teamwork and increased clinician education.⁴ Have a chat to your teams, you may
find a facilitator amongst your admin or reception teams! If any of your clinicians have a
specialist area, this may be their opportunity to harnesstheir knowledge. You could also invite
partnersfrom the voluntary sector, council, community, or acute/ mental health trust to work
with you in your group clinics as an example of integrated neighbourhood working around
the needs of the patient. This may be a tool to use in elective recovery, or during public health
campaigns. With any change, there will always be some who will be last to come on board or
that you’ll never convince. Keep going!

One of the key aims of group consultations is to deliver all aspects of care ratherthan doubling
up on another appointment. There are very rare instances where a follow up appointment
may need to be organised, e.g. if a patient needs an intimate physical examination, but if lots
of appointments are being delivered in groups, that creates more capacity for 1:1
appointments and improves access for all.

Ask your team! There is always somebody interested! Ask your staff who specialise in clinical
areas, doctors, nursing team, ARRS staff e.g. pharmacy team. If you have a health and wellbeing coach or social prescribing link worker, this is ideal for their skill set and mental health practitioners.

Doing group consultations actually saves you time! A clinic of 12-15 patients can replace a
morning or afternoon clinic. If a clinician is only needed for half the time, the clinician can go
back to their admin or seeing patients and often just not repeating yourself throughout the
day can feel like it was so much shorter

This can give patients and clinicians better continuity of care!

You can decide which patients you would like to see in groups. This is an excellent way to
engage your multidisciplinary team and will give your patients different tools and techniques
to give them confidence to manage their conditions. They will develop insights into what
mattersto them, using a lifestyle medicine approach and usually leadsto deprescribing, which
is one of the reasons why pharmacists, nurses and other allied health professionals value this
so much. Group clinics are a way of increasing access, and thus continuity of care. Consider
which team members and facilitators will be used, as Group Consultations can be a way to
improve continuity of care eg if patients will interact with the same facilitator and MDT
members each week, or if they would know team members from other day-to-day
practice/healthcare settings.

Group care allow you the opportunity to still see the same numbers of patients but in a more
efficient and holistic way without also having to repeat yourself multiple times e.g. a diabetes
or asthma clinic. If utilising additional resource, such as ARRS roles, this will not impact on
existing capacity.

We know that demands are rising and some of our patients attend frequently, and we do not
seem to find the underlying cause of what they need. Perhaps, the approach we are taking
needs a rethink. Any change needs a vision and a shared purpose. Group Consultations allow
a personalised care, holistic, person centred and multidisciplinary team approach which are
valued by patients and those working in this sphere. There is much evidence that shows
impact from group consultations showing better outcomes for patients. Staff also value the
team approach which group care provides and have cited this model as a key driver for joy
in the workplace!

Many are using funding from extended hours, ARRS and QOF/IIF monies. There are also
pockets of funding which may be utilised such as women’s health strategy funding or diabetes
pharmaceutical budget.

There is much evidence to show that group consultations CAN improve outcomes, but even
if they deliver the same outcomes, there are huge potential system benefits. The best way to
think about this is against healthcare’s quintuple aim: they can deliver better outcomes,
patient & clinician satisfaction, efficiency and great education. The strongest evidence lies
with type 2 diabetes⁵ and women’s health, but these have been used successfully for almost
every condition and setting. To demonstrate impact on health outcomes, we suggest Patient
Reported Health Outcomes are easier and be realistic about what you are going to measure.
Don’t expect BMI to radically drop after one group clinic etc. Look for confidence, motivation,
self-care markers etc. A ‘pilot’ Group Consultation can be a good way to get started and can
be used to collect your own before and after outcome measures which can be used to
evaluate your group intervention. Consider including both qualitative data (eg patient
satisfaction, patient confidence levels) as well as quantitative data. This can be a good
opportunity to get feedback from patients on different aspects of the groups, eg the
structure, content and timings of your groups; also patient experience and satisfaction with
the group format. .

There is an opportunity to use meeting rooms, waiting areas out of hours and to collaborate
with communities and use assets to collaborate and integrate with neighbourhoods. Virtual
group consultations also provide a valuable resource without the need for estates. your GP
Practice or NHS Trust will direct you to their preferred provider. Consider the most convenient
times to hold the groups which may vary depending on the topic/condition and target
population.

If you set your clinics up as part of business as usual, patients may be diverted away from
usual care into group clinics, thereby creating more capacity. Examples of this e.g. qof reviews
for long term conditions and menopause group clinics.

Core NHS primary medical services provided under a primary medical services contract (GMS,
PMS, APMS) delivered through a digital platform (as opposed to face to face group
consultations) are in scope of CNSGP. See CNSGP for more details.