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Thursday 24 January 2019
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Are group consultations the future of general practice?

Group consultations are said to save GP time and encourage patients to become more engaged with their practice. But how do shared appointments really work, and what are the pros and cons? Valeria Fiore reports

Group consultations are said to save GP time and encourage patients to become more engaged with their practice.
 
But how do shared appointments really work, and what are the pros and cons? Valeria Fiore reports. 
 
In the last few years, a new approach in general practice has made it possible for several patients with the same health condition to jointly see a GP, nurse or pharmacist.

These appointments, known as group consultations or shared medical appointments, on average last an hour, and have received a renewed interest after they were presented at the annual RCGP conference in Glasgow in October. There are some who worry that this new way of working could compromise the patient-doctor confidentiality. 
 
Quoted in The Independent in October, Joyce Robins, co-founder of Patient Concern, said that GP appointments should be private and that ‘if you are discussing things in front of a group of strangers, you might as well tell the local town crier so he can shout it from the rooftops.’
 
However, Louise Brady, lead nurse primary and community care at Greater Manchester Health and Social Care Partnership, told Management in Practice that group consultations will be included in the upcoming NHS plan, indicating that the approach is set to receive official endorsement.
 
If practice managers are considering introducing this initiative in their practices, there are a few aspects to keep in mind.
 
Early days
 
Group appointments were highlighted as a new consultation type in 2016 as part of NHS England’s flagship strategy the General Practice Forward View (GPFV). The consultations formed part of the 10 high-impact actions, ways of working introduced to help practices improve efficiency.
 
However, these types of consultations had been used by five practices in Slough from November 2015, initially as a pilot.
 
Today around 250 practices in the UK have been trained to implement group consultations by Georgina Craig, group consultations programme lead at The Experience- Led Care Programme, and Alison Manson, group consultations training lead at Group Consultation.
 
How do group consultations work?
 
Group appointments usually last between one and two hours, with 10-15 patients who all have the same symptoms. However, the number of patients who attend and the length of the appointments vary between practices and depending on the patients’ health conditions, says Ms Manson.
 
The clinician then decides who should attend the appointments, producing a list for the facilitator – who is usually a senior administrator at the practice but can also be the practice manager – who will ask patients to take part in the consultation.
 
Prior to attending the appointment, patients are asked to sign a confidentiality agreement form. The facilitator ensures that each group member is clear on their questions for the clinician, says Ms Manson.
 
‘It rarely happens that practice managers facilitate the discussion during group consultations. Having said that, the practice manager in my practice occasionally delivers group consultations because she enjoys it and finds it a way to keep in contact with her patients,’ says Dr Emily Symington, GP at Parchmore Medical Centre in Croydon and a governing body member for Croydon CCG.
 
Before the consultation, the facilitator puts together a summary of each patient’s key information. This is attached to the wall in the consultation room to allow the clinician to view the results, and the patients to compare their details with those of others living with the same condition.
 
The clinician only joins the group session for a limited amount of time, usually 30-60 minutes. This time includes the clinician answering questions in one-to-one consultations with each patient, with the other participants able to listen and learn from the answers. This prevents a situation where different patients ask the clinician the same question.
 
'Practices have to be brave’  
 
‘Introducing group consultations is a bit of a step into the unknown and practices have to be brave, and prepared to release some clinician and admin time to implement this new way of working,’ Dr Symington says.
 
However, according to Anthony Howarth, business manager at West Gorton Medical Centre in Manchester, practice managers are used to introducing new initiatives.

For instance, Mr Howarth says that practice managers initially faced challenges when they introduced PPGs, but after a while they ‘took on a life of their own’. He believes the same will one day happen with group consultations as patients become more used to working with the practice in this way.
 
Another stumbling block that could make practice managers hesitate about introducing group consultations is that some patients might not turn up. Whereas some patients have plenty of time to attend a session lasting up to two hours, others might find that to be too long.
 
‘Our biggest issue was patients not turning up and that was because appointments would take an hour of their time,’ says Kay Keane, business manager at the Alvanley Family Practice in Stockport.
 
However, this wasn’t a setback for her team as those who did attend told Ms Keane that they learned a lot more about their conditions. Mr Howarth says the response to group consultations at his practice has been overwhelmingly positive.
 
‘A lot of the patients said they feel rushed during the usual 10-minute consultation, whereas during the group consultation, which is between 60-90 minutes, they felt they had more time to ask questions and really understand the results they had been presented with,’ he says.
 
‘Community involvement’

Mr Howarth believes group consultations suit the needs of his practice’s demographic. ‘We work in a quite deprived area but we’ve got a strong community. They like the idea of being involved with their care, the practice and talking with other people.’
 
However, there are several reasons why practices might prefer not to launch group consultations. According to Ms Craig, it’s often because practices don’t have ‘enough headspace to plan the change’.
 
‘When you talk to GPs, they are often keen to get on board but might later change their minds. This might be due to the fact that their practice manager or nurse recently left, for instance,’ she says.

Ms Craig – who is running a learning programme evaluation for Camden, Islington and Haringey Community Education Provider Networks interviewing practices on the reasons they exclude or suspend group consultations – found that sometimes group consultations do not meet their expectations.
 
This can, for instance, be the case if they thought patients would take part in group education sessions instead. One anonymous respondent to the evaluation said: ‘We aren’t in a position to release a clinician for a whole day of training or a practice manager for a half day.’

Other practices told Ms Craig they had bigger priorities, whereas some thought it wasn’t the right move for them as they had recently lost key members of their team. Lack of onsite training was another point some practices raised. They told Ms Craig they could not release staff to attend offsite training and would have preferred onsite support.
 
Practice staff are not required to have training but it definitely helps the practice get started and make faster progress, Ms Craig says. Ms Manson says that clinicians need some orientation in this new model of care and support with designing a group consultation that will work for everybody. 
 
Meanwhile, practice managers might need guidance on implementing group consultations without creating extra work, she adds.
 
Improved access and efficiency
 
Accommodating as many as 15 patients in one room means practices will need to plug some financial resources into the project. But the potential for releasing efficiency is just round the corner.
 
‘If you look at it from a strategic perspective, you have efficiency savings and better access. We know it supports patient outcomes and leadership with the whole practice team because it is about embedding a new model of care, a different consultation style within practices,’ Louise Brady says.

After reviewing the impact of group consultations across more than 50 practices in the Greater Manchester area, Ms Brady found that of patients with long-term conditions who took part in group consultations, 95% preferred them to one-to-one appointments, as she reported in a research piece for Health Education England.

‘Group consultations are certainly the thing that saved us the most time. We tried to introduce virtual appointments such as Skype consultations and that didn’t work for us,’ Ms Keane says.
 
‘But with group consultations, we can see around 12 patients in one hour. That is just brilliant for us as it saves our practice nurse time. It is great for the patients who can build their own peer group of people with the same conditions,’ she adds.
 
Through group consultations patients who have the same health conditions are given the physical space to meet and share learning. Ms Keane, who organised an ‘asthma party’ for children with the condition, made sure the experience was an occasion for the family of the child to come together and meet other patients.
 
‘Having the whole family together can turn the experience into fun. The nurses had some puppets and the children had to put the spacer device [a tube-like device that makes it easier to use the inhaler] on the puppet, to learn how to do it on themselves,’ she says. But the benefits don’t end there.
 
‘What group consultation does is help some of the most deprived [patients] in the most deprived areas. What we found is that patients who normally don’t engage even in a one to one with a clinician – we have been able to support them far better in a group.
 
'So if you look at it from the point of view of reducing health inequalities, this is quite transformational work,’ Ms Brady says. Beyond the benefits to patients, Mr Howarth says group consultations have also helped him empower his practice staff.
 
‘We want to be more crossorganisational, to get some of the admin team within group consultations. They know the patients and have good relationships with them,’ he says.
 
Practice nurses also lead group consultations and, in their case, funding for training might come from the General Practice Nursing 10-point plan, introduced in 2017 and backed by a £15m investment.
 
For other members of staff it could come from the GPFV or the practice manager development programme, but how this money is spent depends on each local health body’s priorities, Ms Brady says.
 
With the promise of group consultations acquiring greater relevance as part of the NHS long-term plan, the health service and the Government also need to ensure practice managers and their staff are given the right training and support to introduce this alternative way of working.