Video Group Clinics Can Improve Patient Access And Help Reduce NHS Backlogs

GP surgeries and hospital outpatients across the country are currently experiencing significant and growing strain dealing with backlogs caused by the rising patient demand. This insightful thought leadership article from Georgina Craig – discusses how the Covid-19 pandemic has taken its toll, and why, as we move into recovery, we are storing up health problems for the future unless we start to support and care for people in new and different ways.

With most non-COVID services shut down since the first wave, NHS Guidance states that ‘doing things differently’ is critical to successful recovery.

• The Institute for Public Policy Research (IPPR) estimates that there has been a decline of between 29% – 40% in cancer surgery, with the most deprived areas bearing the brunt of the cancellations[1]
• The NHS is reporting up to 4.7 million people waiting to start hospital treatments
• The BMA estimates that in March and April 2021 there were 3.37 million fewer elective procedures and 21.4 million fewer outpatient attendances scheduled[2]

Opinion leaders are now calling for systematic implementation of innovations in care pioneered over the last 12 months, with digital health and care models at the forefront and seen as a positive and a lasting legacy of the COVID experience that could help improve access and efficiency[3].

There are also calls for a new mindset in relation to perioperative care and what it means to ‘wait’, with this time redefined as ‘preparation time’ when both patients and clinical teams are supported to improve postoperative clinician and patient reported outcomes[4].

Around 15% of all patients (250,000 people) undergoing elective surgery are at a high risk of postoperative complications. Those most at risk of adverse outcomes are older, multimorbid and frail. Those who smoke, drink excess alcohol, or have low or high body mass index and lead sedentary lives are also at high risk.

As waiting times will inevitably remain extended for several years, redefining this time as ‘preparation’ and supporting people to proactively to self-manage risk by optimising management of underlying health conditions, and changing their lifestyle; increasing exercise, addressing smoking and alcohol use, and working towards a healthy weight could impact hugely on post-operative recovery and outcomes.

Known as “prehabilitation”, preoperative support programmes reduce postoperative complications by between 30 and 80%[5] and reduce hospital stays by one-two days on average. Several studies have also shown a reduction in postoperative mortality rates. Supporting and embedding lifestyle change will reap long term health benefits long after the person recovers from surgery, and merit attention. 

Connecting with patients whilst they wait also provides an opportunity improve informed shared decision making and reduce “surgical regret’ experienced by, on average, one in seven surgical patients[6].

Seeking to understand what matters to patients as they prepare for surgery will improve trust and mutual understanding of the benefits, risks of surgery and alternative options for the individual person, including options for non-surgical management. Successfully making lifestyle changes may impact on how some people view and value surgery. Deeper discussion and a greater sense of shared decision-making may reduce surgical regret, harm, and improve quality. 

The potential of video group clinics

One innovation that has taken off during the pandemic in England and Wales is video group clinics (VGCs) or virtual shared medical appointments[7].  Already well-established as an alternative to one-to-one appointments in the ‘real world’[8] [9], VGCs have quickly been adopted across England, Wales and in the United States and Australia

In 2016, a systematic review by the National Institute for Health Research found there was evidence suggesting that face-to-face group clinics for Type 2 Diabetes might be better than one-to-one appointments in improving blood sugar levels and blood pressure in some patients[10]. This may be because the cornerstone of diabetes management and improving these biometrics is lifestyle change; something that is well supported by being part of a group. VGCs have proven as effective as their face-to-face equivalents for weight loss and management of Type 2 Diabetes in small-sample, retrospective studies[11][12] and so there is every reason to believe that VGCs could help and support many people to prepare for surgery and make lifestyle changes that would help manage their long term health issues and keep them well.

Evaluation of face-to-face group clinics have also shown they increase access and reduce clinic backlog without increasing clinic time, whilst supporting stressed clinicians to regain control [13].

One of the early pioneers of group clinics in the United States – Ed Noffsinger – evaluated the productivity and efficiency gains for clinicians and calculated a 300% increase in productivity and a reduced need to hire additional clinical staff at the margin[14]. Case studies of VGCs in England and Wales are finding similar impacts on clinic efficiency in the virtual world[15].

Conclusion

To support recovery, the NHS needs to learn from the innovations that have been tried and tested over the last 12 months. VGCs are one. VGCs leverage digital technology that is low cost and widely available in the NHS and greatly increase telehealth capacity by increasing reducing waiting time and increasing clinic capacity. They may also help those at highest risk to take control and improve their lifestyle so that whilst they wait, they can prepare for surgery and better outcomes.

History has a lot to teach us. In 1905, the physician Joseph Pratt switched to group clinics to address health inequalities in patients with tuberculosis[16]. He described how the members of the group discovered “a common bond in a common disease”.  Later, a shortage of psychotherapists and psychiatrists to help traumatised civilians and soldiers during and following World War II led to the invention of group psychotherapy[17] [18], which has since proven to be effective in the treatment of depression and is a recognised and well- established way to practice[19].

We are just emerging from fighting a world war against COVID-19. Perhaps group care can help NHS care catch up and fight an even more insidious pandemic – the pandemic of social isolation that has been taking hold in our communities over the last 12 months? By bringing clinicians together with patients in similar situations in VGCs, we can ensure that an innovation that offers so much potential becomes a lasting legacy that will support person centred care for years to come.

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[1] https://www.ippr.org/research/publications/state-of-health-and-care

[2] https://www.bma.org.uk/advice-and-support/nhs-delivery-and-workforce/pressures/pressure-points-in-the-nhs

[3] https://www.nature.com/articles/s41591-020-01187-4.epdf?sharing_token=T2KyF7a_Lbd4BKFXyx88hdRgN0jAjWel9jnR3ZoTv0MAe8L6uiBv8ntbc4RtOGjWnqiy6f2vxBSF-6o9XFQplMYozx3snEvV_e1JMv7KSyN2vIk7GnTJKPUUT_UYl1yZb1Q2t9uuIA60PWlNEW-bG7bVsmpu4MzouGyuJC3o1KA%3D

[4] https://blogs.bmj.com/bmj/2021/04/15/to-tackle-the-backlog-we-need-to-transform-how-we-wait-for-surgery/

[5] IMPACT OF PREHAB

[6] ONE IN 7 PATIENT SURGICAL REGRET

[7] Ramdas, K., Ahmed, F. & Darzi, A. Lancet Digit. Health 2, e288– e289 (2020)

[8] Noffsinger, E.B. Running Group Visits in your Practice (Springer Science & Business Media, 2009).

[9] Jones, T. et al. Future Healthc. J. 6, 8 (2019)

[10] Booth A, Cantrell A, Preston L et al. What is the evidence for the effectiveness, appropriateness and feasibility of group clinics for patients with chronic conditions? A systematic review. Health Serv Deliv Res 2015;3:1-194.

[11] Shibuya, K., Pantalone, K. M. & Burguera, B. Endocr. Pract. 24, 1108–1109 (2018).
12.

[12] Tokuda, L. et al. Int. J. Med. Inform. 93, 34–41 (2016)

[13] Cabral J. A new paradigm: shared appointments in diabetes. Cleveland Clinic, USA https://professional.diabetes.org/admin/UserFiles/CE/South%20Florida/Workshhop%20D-3%20Team%20Approach%20to%20Diabetes.pdf

[14] Noffsinger, E (2013). The ABC of group visits. Springer, USA http://www.springer.com/gp/book/9781461435259

[15] Case studies available at: www.redmoorelc.co.uk

[16] Pratt JH. The class method of treating consumption in the homes of the poor. J Am Med Ass 1907;49:755-759.

[17] Jones E. War and the practice of psychotherapy: the UK experience 1939-1960. Med Hist 2004;48:493-510.

[18] Bierer J. Group psychotherapy. BMJ 1942;1:214-216.

[19] McDermut W, Miller IW, Brown RA. The efficacy of group psychotherapy for depression: a meta-analysis and review of the empirical research. Clin Psychol Sci Pract 2001;8:98-116.