1. Shared Medical Appointments (SMAs)
Helen Martin BA MSc MBA
Research & Evaluation Co-ordinator
Partners in improving local health

2. 60 – 90 minute group appointment with embedded 1:1 consultations
What is a SMA?
60 – 90 minute group appointment with embedded 1:1 consultations
Group appointments
Self Help Groups
Patient Education Groups
Shared Medical Appointments
Support Groups
The term ‘Shared medical appointment’ used fairly consistently for 60 – 90 minute group appointment for patients with a particular disorder, e.g. diabetes, who require ongoing review. The group is run by a facilitator, and the clinician attends for 40 – 45 minutes during which time he or she consults individually with each patient, with the other patients observing. Possible benefits are improved patient health and wellbeing to include self management, efficiency gains, and improved satisfaction for staff.
The term ‘group appointment’ is also used, sometimes for SMAs, but also for groups which do not include clinical consultations but are patient education and / or support, and for other models of care which are not traditional 1:1 consultations. It may be worth considering ‘group appointments’ as a spectrum with SMAs at one end and self help groups at the other.
Partners in improving local health

3. Background
The current interest in SMAs for primary care stems from the rise in patient numbers and increasing complexity of patients health needs, increasing the pressure on GPs and primary care.
SMAs have been used in the United States for 20 + years, and more recently in Australia. Following a number of UK based reports, ‘group consultations’ have been included in the ‘Ten high impact actions’ for primary care.
However, there is no detail in the ‘Ten high impact actions’ reference materials about SMAs in particular, and as the term ‘group consultations’ has been used as opposed to SMAs, it seems to be supporting a range of group interventions and not just SMAs.
Partners in improving local health

4. Where are we now? Benefits for patients and staff
Diverse implementation
Can see more patients in a shorter space of time
Patient recruitment: time consuming & difficult
Slow uptake by practices
We know from the research to date that there are benefits for patients, to include:
enhanced learning (e.g. learning from questions other patients ask)
improvements in self management by building confidence and normalisation of their condition, and more creative solutions
improvements in health, such as improved blood sugar levels
Enhanced relationships between patients and professionals
Staff benefit from:
Less repetition
Variety in day
Team respect and bonding
You can also potentially see more patients in a shorted amount of time, e.g. a group of 12 patients taking less than 60 minutes of a GPs day.
However, the papers and reports published highlight the diverse ways in which SMAs and group work have been implemented and delivered, making it difficult to directly compare and identify the factors within the model which lead to benefit.
Difficulties recruiting patients have been reported, particularly in the UK, and that this is a very time consuming task.
Training has been provided for practices in the North East and Cumbria, from HEE NE, but implementation following this training seems to be patchy and slow.

5. What is happening now? trained SMAs
This map shows the practices which have been trained (in blue) and those where we know SMAs occur in red. There may well be more practices who are using SMAs, but this is showing the results from a brief survey carried out in the last couple of weeks for which there was a poor response. One could speculate that a lack of response indicates not activity in this area, but practices were asked to respond either way, and it may be the case that due to workload, practice managers have not yet had the opportunity to respond.

6. What is happening now? trained SMAs
CVD prevention, childhood asthma, osteoporosis, anticoagulants
Pain
COPD, Pain
Diabetes
This shows the clinical areas in which SMAs are being carried out in, showing quite a wide range. Some have been one offs to date, such as the osteoporosis, where as others are ongoing clinics, such as for diabetes.
In a couple of practices in Walker, there is currently a trial of a pain management clinic, with formal evaluation. The overarching aim is that patients have increased ability and confidence to self-manage their painful conditions, that the SMA model is acceptable and it has been hypothesise that the project may have additional positive effects on reducing reliance of prescription analgesics, with a consequent saving on drug costs and reduction in primary care consultations and referrals to secondary care. The trial is currently half way through. The driver for this trial was not to save GP time.
A practice in Chester-le-Street the driver has been to reduce waiting lists and they have introduced a number of different SMAs to include diabetes and asthma. Interestingly the SMA training has also stimulated thoughts of different models of care away from 1:1 appointments and set clinic schedules, and other clinic types have been introduced to include, for example, drop in blood pressure check clinics.
Diabetes, rheumatology, asthma

7. What do we need to do / know?
Implementation
Barriers
Drivers
Predictors of success
Which patients?
Which format / type of group work?
Staffing & skills, in particular the facilitator role
Benefits
GP welfare
Cost effectiveness
Comparisons to Patient Education Groups & other group work
So, I have tried to identify some of the main gaps in current knowledge regarding SMAs and possible research areas.
The uptake by practices has been slow, so what are the main barriers or reasons why group work has not been tried? If we are keen for group work to be tried more widely we first need to find out why progress is slow at present. On the converse side, what have been the drivers to those who have implemented SMAs,
Secondly, are there particular key factors required to make this a success from both the patient and practice point of view. As recruitment is time consuming and difficult, and typically a proportion of those who say they will attend don’t turn up. Is it possible to identify which patients are more open to group consultations so they could possibly be targeted. On the other hand it may not be these patients who would benefit the most, so knowing which types of patients benefit more and targeting them could lead to more improvement in outcomes. We also need to be mindful of the selection bias of majority of research to date, as it tends to focus on those patients who attend only, and not on those who don’t, so in effect research to date is only telling half the story.
Another area which has had very little investigation is cost effectiveness, yet it is quoted as being a way to make efficiencies. Very little data. Study quoted by NHS alliance not available so methodology etc. cannot be reviewed. Considerable time needed to set up, recruit and run group sessions, have all these costs been taken into account.
Another interesting area is the effects on GP welfare. Increasing pressures on time and relentless 10 minute 1:1 appointments has seen increasing reports in the literature about the negative effects this is having on the profession, to include retention resulting in further pressures on GPs. Anecdotal reports from GPs involved in SMAs are very positive and perhaps introducing such changes could make a positive difference to this downward trend. Finally, I haven’t found any studies comparing SMAs to other types of group appointments, looking at the added benefits of SMAs, which I think is an interesting area.