Vegetación del bosque ripario

Feasibility conflates many issues, such as acceptability to patients and providers, practicality in terms of required procedures (whether alongside or as a substitute for existing practice) and affordability, in terms of financial considerations and available equipment and premises. The evidence to be mapped against this domain is drawn from qualitative studies of provider and patient attitudes, implementation studies not otherwise included in this review and an overall picture of likely cost-effectiveness, as has emerged from Chapter 4. Feasibility includes general issues to be considered within any context for implementation of group clinics and specific issues relating to implementation within a NHS context.

What are the key considerations regarding feasibility?

Key to a consideration of feasibility in this context is affordability. Although claims are made of cost savings these are based on either (1) US studies of limited geographical or temporal relevance or (2) a simplistic argument of more patients seen by a clinician per hour. In particular, there is limited evidence of cost implications in a UK study. Indeed, although the insights from group acupuncture clinics are informative in terms of the group interactions and dynamics within a UK context, the actual assessment of costs would be potentially misleading. As will be explained later in this report the achievements of the group

acupuncture clinics are located within a‘work smarter’treatment delivery model. These otherwise

promising achievements have, therefore, limited relevance to the monitoring model that is fundamental to group clinic provision.

A further concern relates to acceptability. Our clinical advisers point out that there is a strong expectation in the NHS of being seen by a specialist clinician within an individual consultation. Even if group clinic provision were to become the default position, a sizeable proportion of the population would still require access to the more traditional model, perhaps because of the complexity or severity of their condition or

because they would demand it through exercising patient choice. Such preference may be affirmed on commencement of treatment or, as illustrated by UK group acupuncture clinic qualitative data, may emerge following patients’experience of the group clinic provision. In particular, the willingness of patients to try a new modality of service provision should not be interpreted as those patients’commitment to that service modality on a long-term basis.

Practical issues relate to the requirement to be able to access all patient records and results in advance of a single SMA. This may place a burden on diagnostic services but may also prove problematic for the individual specialist, who would have to make time for review of the notes. The latter factor is examined in a US context of uncompensated clinician time.132

Other feasibility concerns relate to the need for clinician training, particularly in group facilitation, and the need for suitable premises. Within the wider picture of feasibility it would be worth exploring whether or not the individual components considered essential to the group clinic approach could be delivered in an alternative format. For example, in some circumstances the socialisation or the interaction with a group facilitator could be offered virtually, offering the opportunity for the clinical team to identify those needing particular help.

What evidence exists on the feasibility of group clinics?

Little evidence exists on the feasibility of group clinics, even though much of the literature suggests how they might be introduced. Particularly noticeable is a shortage of data from the UK. The wider

non-NHS-specific literature informs such aspects as implementation and confidentiality. A feasibility study104 revealed such positive aspects of GMVs as personalised attention (77%), self-care education (69%), access to medication refills and examinations (69%) and advice from peers (62%). Negative aspects included insufficient personal attention (23%), logistical barriers (8%) and loss of confidentiality.104

Kirshet al.27_{have explored implementation issues relating to SMAs. They identified such important} promoting factors as the formation of a core team committed to quality and improvement with strong support for the clinic leadership from other team members. Notably, tailoring had to take into account such‘key innovation-hindering factors’as limited resources (such as space), potential to alter longstanding patient–provider relationships, and organisational silos (disconnected groups) with core team members reporting to different supervisors. The last point emphasises that group clinics should be seen not in isolation but as a potential vehicle towards interprofessional team working, with all of the associated culture changes that this might necessitate.

Concerns relating to confidentiality were raised consistently in the reviewed literature. This issue was examined specifically in a study by Wonget al.107_{This study aptly highlights that GMVs can impact on the} clinician–patient relationship as patients are‘able to draw upon more informational resources and social support from attendees and often feel more empowered to pose questions to their providers than they might otherwise in individual encounters’.107_{However, providers reported that‘the most common reason} for not attending a GMV was patients’concerns about confidentiality and hence a preference for individual visits’.107_{Nevertheless, one overall finding from the study was that patients who did attend a} GMV consciously selected which information they were comfortable sharing in a group situation.107 Although it could be perceived as a drawback that patients filtered the information they felt able to share, some interventions included a discussion of confidentiality with practical examples as a component of the initial group clinic sessions.

Discussion

The review team has identified specific concerns relating to the interpretation of predominantly US data within a specific UK context. In particular, many of the interventions have been delivered within the context of health-care financing that determines the exact configuration of approved packages of group clinic provision and, for example, requires guaranteed access to an individual consultation if requested. Advice from our clinical advisers suggests that a model in which an increasing amount of the content of

the previous individual consultation is assumed in a group context, facilitated perhaps by a member of staff who is not the specialist clinician, may be an alternative form of substitution. This might facilitate shorter individual consultations, although this issue remains to be investigated. Importantly, however, such provision would need to be in a context where group education is seen as more central to the chronic disease management process and not as an optional extra.

Summary of included studies

Although the evidence from the USA and that from a UK group acupuncture clinic context does inform a discussion of feasibility, a specific need remains for further investigation of the monitoring model of group clinics within a UK context. This research requirement sits naturally alongside the suggestion made in the previous chapter for a full UK-centric economic evaluation and the need for qualitative exploration of the attitudes of NHS patients, providers and caregivers towards group clinic provision. In addition, there is a requirement to explore the feasibility of‘substitution’of specific functions from the individual consultation with a corresponding group-based provision, along with any training and role development issues this might occasion.

Chapter 6

Discussion

Summary of evidence on the effectiveness of group clinics