Leading change

General practice nurses (GPN) in the Premiere Health Team, Leigh (Wigan CCG) and West Gorton (Manchester CCG) medical practices introduced group consultations for adults with Type 2 Diabetes. This new approach has led to better outcomes, experiences and 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. These are the basis of care planning to enable adults to take control and actively manage their condition NICE (2018). 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.

What to change

There were many patients with Type 2 diabetes registered with GP practices. The GPNs knew they spent significant time in consultations with patients about managing their diabetes and were aware that their repetition of information and advice was not impacting on health outcomes. It was identified that group consultations could be an opportunity to improve outcomes and access, whilst engaging patients in a different way that offered the potential to provide a more social and less medical model of planned care. Experience in other parts of England suggested that it could also improve staff experience by reducing repetition and creating more time to care and support patients.

Group consultations have a strong evidence base of impact in diabetes, with seven randomised controlled trials showing improvements in HbA1c compared to usual (1:1) care (Edelman et al, 2015).

The practice nurses took part in the North West General Practice Nurse Group Consultations Practice Development Programme in 2017. The programme was set up to reflect the drive in primary care to support patients through new consultation approaches. The aim being to improve continuity and convenience for the patient, and connect them directly with the most appropriate professional through new ways of working. This enables staff to work smarter and can lead to reduced demand on GP time, in line with the ambitions of The GP Five Year Forward View (2016).

How to change

At West Gorton practice, GPNs introduced a programme of two group consultations, four months’ apart. Patients with Type 2 Diabetes were identified based on who was due their diabetes review using recall software. The nurses ran the groups together; one nurse acting as a group facilitator. The first session focused on HbA1c, blood pressure, cholesterol, Body Mass Index (BMI), eye and foot checks and medicines. The second session centred around issues that patients wanted to explore further, which they identified at the first session.

At Premiere Health practice in Leigh, a GPN, supported by a non-clinician facilitator and a student nurse adopted a group consultation approach, offering three monthly sessions to Type 2 diabetes patients. At the first session, weight and blood pressure measurements were taken and it became clear that weight control was the group’s biggest issue. In response to this, at follow-up consultations, the team prepared healthy recipes to encourage more home cooking and ran a food quiz to identify hidden sugars in common shopping basket foods. Alongside this, clinical aspects of diabetes such as impact on the kidneys and blood pressure were discussed. The food quiz had a huge impact and the hidden sugar in foods shocked everyone involved.

The ‘clinical agenda’ for all the group consultations at both practices was summarised on a Results Board of key biometrics. This focused discussions on HbA1c, blood pressure, cholesterol, BMI and whether patients had had their foot examination, medicines review and diabetic eye screening. In both practices, patients knew in advance that their biometric results would be shared with the group at the consultation. Before the clinician joined the group, the facilitator worked with patients to identify questions they wanted to ask the clinician. Once the clinician joined, she and the facilitator decided how best to use the 45-60 minutes of group time. Where several people had the same question, the clinician spent some time discussing that question with the whole group. The clinical session ended with individual 1:1 discussions in the group setting where peoples’ outstanding individual concerns could be addressed, including, for instance, changes in medication.

Adding value

Better outcomes – Across the two practices, 31 patients that were followed up at 3 months achieved an average 10% reduction in HBA1c, indicating an improvement in blood glucose management. Six patients at the Premiere Health practice achieved reductions in blood pressure (average reduction of systolic 12.5% and diastolic 5%) and an average weight reduction of 3.9%.

Better experience – Patients reported high satisfaction rates and that they learnt more in the group compared to 1:1 consultations, even if their diabetes was already well controlled. Some individuals found group review less intimidating than 1:1s and enjoyed attending, with new friendships and support developing. GPNs observed that using the group consultation approach shifted the balance of power and strengthened a more person-centred approach. The consultations were life changing for some. For example, a very nervous patient overcame her fears and reported being ‘more readily accepting and more able to listen without my previous anxiety getting in the way’.

Another Patient’s feedback said: “you’ve listened to these people talking and you go away thinking I’m not the only diabetic in the world. Even though we are all different, we are in the same group…it’s brilliant. I don’t know where I would be without it.”

The GPNs enjoyed delivering the group consultations as there was less repetition. Overall, 93% of GPNs in the North West GPN Group Consultations Practice Development Programme reported that they found the group consultations fulfilling. None reported that they felt stressed by using this approach and 57% reported that the sessions energised them. This was a big improvement to baseline data where only 19% had described 1:1s as energising. Being involved in and facilitating group consultations also accelerated Health Care Assistant and student nurse skills development.

Better use of resources – West Gorton practice calculated significant efficiency gains in clinician time. The nurse consulting saw 8-9 patients in 60 minutes; the same time it would have taken to see 4 patients in a 1:1 clinic.

Challenges and lessons learnt for implementation

It was time consuming to introduce group consultations initially. The timing of the phone call with patients to invite them to the first consultation is everything and it was found that a good time to ring is early evening. Check with patients at the beginning of the call that they have a few minutes free to talk.

A consulting GPN was surprised that some patients did not understand what specific clinical biometrics meant e.g. HbA1c and estimated Glomerular Filtration Rate (eGFr) after years of her talking about them.

A consulting GPN felt that patients didn’t need the GPN as much as had been expected in the group consultation. GPNs learnt to let patients lead and support them with their agenda.

The room in which group consultations is carried out is important to support creating a relaxed atmosphere. Invite extra patients to group sessions in case individuals do not attend. New patients can also be added to second sessions of a group to increase numbers.

For more information contact

Delia Clarke
General Practice Nurse Partner
Premiere Health Team
delia.clarke2@nhs.net

Cath Whitrow
Senior Practice Nurse
West Gorton Medical Practice
catherine.whiltrow@nhs.net

Louise Brady
Nurse Lead Primary & Community Care and Greater Manchester Group Consultations Champion
Greater Manchester Health & Social Care Partnership
louise.brady2@nhs.net

Georgina Craig
National Director
The Experience Led Care Programme
georgina@elcworks.co.uk