On Wednesday 29th March 2023, we held an event at Newcastle University where members of the public, general practitioners, primary healthcare professionals and researchers from four different universities came together to discuss the potential of shared medical appointments (SMAs), also known as group consultations, to improve patient experience while also tackling the significant demand in the NHS for appointments for people with long term conditions.
What are shared medical appointments/group consultations and how could they help?
SMAs are longer appointments whereby patients with the same condition share their appointment. SMAs are typically facilitated by a member of staff in the practice with a healthcare professional, typically nurse, pharmacist, and/or physiotherapists joining part of the appointment to conduct a clinical consultation with each person in the group.
In contrast to group education programmes, SMAs replace or are offered as an alternative to a 1:1 appointment and may include physical examinations, medication adjustments or other clinical interventions. SMAs provide participants an opportunity to ask questions of clinicians and other patient and receive formal education and counselling during the appointment.
Watch our short animation about an upcoming study of shared medical appointments for people with COPD:
What we discussed
The event was a fantastic opportunity to discuss the latest evidence to inform the use of SMAs in NHS primary care. We had a great mix of discussions and reflections about this care delivery model from those with and without SMA experience. The event has highlighted the enthusiasm for this new care delivery model and a need for future collaborative efforts to strengthen the evidence base and identify the best way to use them.
In the morning session we heard those with experience of delivering SMAs and those researching in this area. This provided an excellent basis for discussions and reflections about this care delivery model in the afternoon workshops where we were able to dive a little deeper into the issues.
Take away messages from the day
What works well?
- Most attendees enjoy receiving care in this way, they feel reassured that they ‘aren’t the only one with the condition’ and find listening to the conversations between health professionals and other patients helpful. They also like being able to listen to and share their lived experiences with others. Some even keep in touch with each other outside of the practice to provide further support.
- Despite having some initial reservations about the process, practice staff enjoy delivering care via SMAs reporting them to be less repetitive than lots of 1:1 appointments.
- Involvement of social prescribing link workers as part of the delivery teams helps to connect patients with community services that can help them look after themselves.
How can they be improved?
- Effective communication to patients and staff about SMA, the benefits of SMAs and what to expect. Communications should be developed with patients and practice staff. These communications should address privacy, confidentiality, and liability concerns that people have reported, especially shared appointments delivered by video. Communications should be via various channels, including from and within practices themselves.
- Readily accessible training resources and opportunities for sharing best practice, observing SMAs are important ways to help build confidence amongst staff and overcome scepticism and ultimately facilitate the wider roll-out of these care delivery models.
- Efforts to accommodate patient practical barriers to attendance such a childcare, work commitment, transport are welcomed- but a broader cultural shift to enable people to feel empowered to prioritise their health and attend longer healthcare appointments would be most beneficial.
What more do we need to find out?
- How best to deliver SMA to achieve the best results, at what stage of the patients care pathway they most effective, which appointment types should they replace/be offered as an alternative.
- SMAs involve lots of different people (teams of practices staff and patients) doing lots of different things (prompts/cues, action-planning, social support) to achieve several goals. We need to figure out exactly what people need to do during the SMA to best support patient self-care.
- SMAs might be a good way of helping people with co-occurring physical and mental ill health. However, whether people will feel comfortable sharing their emotional needs during an SMA is unclear due to mental ill health stigma. There are lessons to be learned from mental health group therapy sessions.
What happened on the day
The morning session was chaired by Dr Shona Haining, Head of Research and Evidence at NECS, with both in-person and remote presentations – see below for a list of the talks and presenters.
PhD student Ellie Scott (Keele University): The use and uptake of video group consultations by healthcare professionals in primary care general practice: a cross-sectional survey
We organised workshops around the Normalization Process Theory (NPT).
Workshop 1 – Coherence
Stuart Edwards a public member of the NIHR Policy Research Unit Behavioural Science (PRU BehSci) Patient Public Involvement and Engagement (PPIE) strategy group facilitated workshop 1. This centred around the NPT domain: ‘coherence’ – making sense of SMAs. Attendees were asked: What are SMAs? How should SMAs be used in primary care? For what purpose? How frequently should patients attend? Which patient groups benefit most?
Figure 1 Keywords used to describe SMAs
Workshop 2 – Cognitive participation and reflective monitoring
Jan Lecouturier, Senior Research Associate in the PRU BehSci, facilitated workshop 2 that focused on the NPT domains: ‘Cognitive participation’ and ‘Reflective monitoring’. Attendees were asked to reflect upon how to encourage patients and practice staff to attend/deliver SMAs in practice. Attendees were also asked to consider how best to keep patients and staff engaged over time and practice reflective monitoring.
Summary of reflections about SMA uptake by patients and staff
Engaging patients to attend SMAs
- Clear communication- provide patients with information about SMAs. For example, what they are, what and who they involve and what to expect. Be clear which healthcare professional is going to be present at the SMA.
- Advertise- share information via GP newsletters, posters, flyers, leaflets, video screens (patient vlogs) in the surgery, GP websites, social media, text messages from practice. Encourage peer promotion- share personal perspectives and experiences. (Develop information materials with patients/public).
- Make SMAs the default appointment type, with an opt out clause, to encourage patients to try them.
- Offer the SMA sooner than 1:1 appointment- (ethical?).
- Raise awareness of SMAs during other activities, such as social gatherings or health fairs.
Engaging staff to deliver SMAs
- Training- involve role play (peer teaching) to improve confidence and skills, provide more information than ‘how to’, make training fun and engaging, include team work- share positive experiences of SMAs.
- Provide protected time to attend training, provide professional development accreditation
- Outline potential benefits to individuals and colleagues with examples/ case studies. Link to practice strategy.
- Raise awareness of potential benefits to staff
- Admin – could reduce number of patient queries, and complaints
- Health professionals: reduce costs, efficient use of time, improve patient outcomes, meets Quality and Outcomes Framework (QOF) data and therefore increase income.
- Incentives- pay staff extra money to deliver SMAs
Reflections about engagement during group and reflective monitoring
How to keep patients engaged during an SMA?
- Manageable group size (try different group sizes with volunteers first)
- Effective facilitator should provide:
– Reassurance around confidentiality
– Encourage individual to speaks
– Manage time carefully, ensure questions are answered
How to practice reflective monitoring
- Listen to patient need, collect anonymous feedback, use PPIE to ensure the session meets patient needs.
- Collect feedback from staff around what is working well and what is not working well.
Workshop 3 – Collective Action
Fiona Graham, Research Associate in the PRU BehSci, facilitated workshop 3 that focused on NPT domain: ‘Collective action’. In this workshop delegates reflected on the work required to make SMAs successful and the key challenges to practices staff and patients.
Figure 2 Top challenges for practice staff
Figure 3 Top challenges for patients to attend
Want to find out more?
Research discussed on the day
Read our policy briefs: https://behscipru.nihr.ac.uk/outputs/policy-briefings/
Can shared medical appointments in general practice support people living with chronic obstructive pulmonary disease in the North East and North Cumbria region of England? https://doi.org/10.1186/ISRCTN88389291
Graham F., Martin, H (June 2022) Survey of group consultation activity in general practice in the North East and North Cumbria Integrated Care System. https://www.necsu.nhs.uk/wp-content/uploads/2022/06/Survey-of-Group-Consultation-Activity-in-General-Practice.pdf
Tang MY, Graham F, O’Donnell A, Beyer F, Richmond C, Sniehotta F F, Kaner, E. Effectiveness of shared medical appointments delivered in primary care for improving health outcomes in patients with long-term conditions: a systematic review of randomised controlled trials. medRxiv 2022.03.24.22272866; doi: https://doi.org/10.1101/2022.03.24.22272866
Graham F, Tang MY, Jackson K, et al Barriers and facilitators to implementation of shared medical appointments in primary care for the management of long-term conditions: a systematic review and synthesis of qualitative studies BMJ Open 2021;11:e046842. doi: 10.1136/bmjopen-2020-046842
Graham, F., Martin, H., Lecouturier, J. et al. Shared medical appointments in English primary care for long-term conditions: a qualitative study of the views and experiences of patients, primary care staff and other stakeholders. BMC Prim. Care 23, 180 (2022). https://doi.org/10.1186/s12875-022-01790-z
TOGETHER 2 study: Evaluating video and hybrid group consultations in general practice: mixed-methods, participatory study https://www.phc.ox.ac.uk/research/interdisciplinary-research-in-health-sciences/together-2