A general practice nurse (GPN) at Brigstock Medical Practice addressed unwarranted variation in the management of Type 2 diabetes through introducing a group consultation model at the surgery. This new approach has led to better outcomes for patients, better experiences for patients and staff, and better use of resources locally.
Where to look
Uncontrolled diabetes can lead to serious complications, but personalised care-planning enables people to manage their diabetes more effectively. The National Diabetes Audit (2016/17) showed marked geographical and service variations in the delivery of the eight of nine audited key care processes of diabetic care. They include measurements of blood pressure, HbA1c, cholesterol, urine albumin, serum creatinine, Body Mass Index (BMI), record of smoking status, foot examination and eye screening.
These are the basis of care planning to enable adults to take control and actively manage their condition NICE (2018). There is a strong evidence base for the efficacy of group consultations and diabetes management. Seven randomised controlled trials have demonstrated improvements in HBA1c compared to usual (1:1) care (Edelman et al, 2015)
A practice nurse and prescribing pharmacist team who manage chronic disease in an area of acute deprivation, with a diverse Black and Minority Ethnic (BME) and Eastern European community, identified that HBA1c targets for management of diabetes were not being met. This was unwarranted variation. This was compounded by feedback from patients which suggested they were finding it challenging to sustain change and take control of their condition.
What to change
The nursing and pharmacy teams recognised there was an opportunity to address this unwarranted variation and to offer new treatment options to these patients. This would reduce waiting times as there were more than 1000 patients with diabetes registered at Brigstock Medical Practice. Clinicians reflected that consultations on diabetes management were often repeated with different patients, offering comparable advice and resources, but self-management was not improving.
The nurse leads utilised previous evidence to explore whether group consultations could improve outcomes and access, whilst engaging patients in a different way that offered the potential to offer a more social and less medical model of planned care, integrate social prescribing, and improve staff experience.
How to change
Together, the practice nurse and prescribing pharmacists ran group consultations supported by non-clinical facilitators. They introduced 4 daytime group consultations a week for adults living with Type 2 Diabetes. The group consultations replaced annual reviews and follow-up appointments. All patients due for a diabetes Quality and Outcomes Framework (QOF) review were invited to attend a group consultation. Receptionists were given training to help them explain how group consultations work and why they were being introduced. Patients knew in advance that their biometric results would be shared with the group at the consultation.
The ‘clinical agenda’ for the group consultation was summarised on a Results Board. This summarised key biometrics and focused discussions on HbA1c, blood pressure, cholesterol, BMI, eye and foot checks and a medicines review. The facilitator worked with patients to identify questions they wanted to ask the clinician which supported the focus of the 45-60 minutes of group time. Where several people had the same question, the clinician would spend time discussing that question with the whole group. The clinical session ended with individual 1:1 discussions in the group setting where peoples’ individual concerns could be addressed, including for instance, changes in medication.
As people become more familiar with the process and understood what their results/numbers meant, the sessions moved on to address the underpinning psycho-social issues that support them to take control – and what may have been acting as a barrier previously. They feel more comfortable admitting their challenges in the group where they have support, and then can be asked if they need further support from the clinician. Onward referral to specialist support can be offered and arranged.
Better outcomes – Following the group consultations, 70% of patients had a reduction in HbA1c (average blood glucose levels) and 61% had improved blood pressure. Patients have also reported weight loss. Clinicians have observed group clinics are helping patients make lifestyle changes. Patients are also looking to attend social prescribing initiatives together, which they report they wouldn’t have done alone or before the group sessions. Some patients have been able to stop taking insulin and reversed their diabetes.
Better experience – Patients felt more connected and less isolated. They have reported learning more about their condition. Survey findings include:
- 90% of patients reported feeling more listened to;
- 80% had a better understanding of their condition;
- 85% reported experiencing improved access, with more time with clinicians;
- 85% would recommend to friends and family.
Patients also reported that they find the peer learning and support very powerful. Attendance at the groups is increasing and an increasing number of sessions (including in the evening) are now being introduced. Feedback includes:
- “We come together. We can relate to each other. We encourage one another to look after our health. This is important to us as diabetic people… I love it because I am learning a lot about how to manage my diabetes…I feel like crying because it changed my life.”
Better use of resources – Compared to delivering reviews as 1:1 care, the team have reported significant enhancements to time efficiency. Clinicians can now see three times more patients in the 45-60-minute group session in comparison to 1:1 reviews. Furthermore, there is now increased 1:1 clinic availability which is improving service provision for all patients.
Challenges and lessons learnt for implementation
It was important to fully explain and inform patients of the benefits of group consultations when they are used to 1:1 care. Reassuring patients and sharing evidence supported people to engage with the group consultations. Group clinics are now offered at a range of times to accommodate for all individuals.
The prospect of sharing confidential data through the ‘results board’ was daunting at first but this was overcome by using this to stimulate questions. It has provided a shift in emphasis and focus which has been welcomed.
For more information contact
Managing Partner, Independent Prescriber
Brigstock & South Norwood Partnership
The Experience Led Care Programme