My name is Dr Michael Boyle; I am a GP at Birley Health Centre with an interest in Shared Medical Appointments.
The use of Shared Medical Appointments has been going on for some time in different parts of the world, mainly Australia and the USA. However, with the support of Dr Rob Lawson and the Royal College of General Practitioners (RCGP), we have developed a local knowledge and skills base in the application of Shared Medical Appointments in the UK.
Primary Care Sheffield has facilitated the commencement of SMA through the Hallam and South Locality (in the south east of Sheffield) where 10 Practices have engaged in SMA to deliver this innovative care to patients.
The basic premise is that the NHS can no longer meet everybody’s needs and that we have to make some efficiency gains. Shared Medical Appointments are all about empowering patients to learn about their condition; enabling them to self-manage and take more responsibility for their care but crucially to apply lifestyle changes which will facilitate improved levels of wellbeing. SMA have many applications across many medical topics; as an example, we have found that diabetes can be very effectively dealt with in a Shared Medical Appointment setting.
The SMA model: An example – Diabetes:
The SMA is led by a health professional; at the moment these are usually led by a doctor though can be facilitated by a nurse with a special interest in diabetes. The model includes having a health care assistant present who updates all the data in the patients’ notes. The advantages of an SMA are increased efficiency by seeing several patients at once and the practice can gain valuable data during the SMA. The patients who attend the appointment interact with and support each other and many questions are raised leading to an increased understanding of the condition for all who are present. Frequently the patients will provide solutions for each other from their own experience, which is a fantastic outcome! The facilitation of the appointment by a health professional is; of course, extremely important and training for this facilitation would be advantageous.
The advantage of SMA for the patient includes spending an hour with a GP and a nurse with a further half an hour prior to the appointment with the nurse. Satisfaction ratings for SMAs are very high and outstrip and satisfaction surveys for one to one consultations. There is evidence to show that the use of SMA reduces follow up rates and increases levels of self-management. In addition, SMAs are fun to do, for the doctors, nurses and patients involved, and they are relatively informal making a nice change to the traditional one to one GP surgery model. Other advantages include group learning and lack of repetition; in this setting we deliver the same talk to a group of 12 patients so there is increased efficiency gain.
How SMA is working at Birley Health Centre:
Examples of conditions that could be managed well by using Shared Medical Appointments include hypertension, diabetes, COPD and pain management though the model could be applied to many other common conditions. At Birley, we have embraced SMA and each of the GP partners are going to deliver a session in a different specialty. The appointments have been popular with our patients too and they have rated it very highly. One issue of concern for some is confidentiality however we ask each patient to sign a confidentiality disclaimer before they start the SMA.
The first part of the SMA involve our nurse getting the patients settled in and comfortable; getting them a drink and perhaps some healthy food. The nurse then asks the patients what ideas or concerns they have about their health condition, preparing them to ask any questions or seeking reassurance regarding the management of certain aspects of their condition. After 30 minutes, the GP arrives and consults each patient individually; the rest of the group can hear what is being discussed and this can generate a discussion where the patients provide their own answers. Of course, there are some scenarios where the GP has the answers and will provide them in a succinct manner. These discussions are recorded in the patients’ notes. For example, we would record in hypertension SMA that the GP: ‘educated the patient on their targets concerning Qrisk 2’ which includes cholesterol levels, the drugs and any adverse effects they may have and any lifestyle changes which could have a big impact on their own management.
SMAs naturally lead onto lifestyle matters and there is a great deal of evidence available on how simple lifestyle changes can affect the health of the individual. Smoking cessation is a clear example where, if we get the patient to stop smoking their blood pressure may go down; they reduce their risk of cardiovascular disease and increase their sense of wellbeing. In general, reducing salt, increasing fruit and vegetables, reducing waist size and walking 30 minutes per day have all been shown to improve health outcomes and this is just one example of many potential benefits of Shared Medical Appointments. We feel the optimum number of SMAs for a patient group to attend is 2 to 3. At the end of the day, the aim is to encourage self-management and not dependence.
An example in Sheffield that might have a big impact is the treatment of COPD. One idea would be to hold a post-admission COPD SMA, or, similarly, a post-admission asthma SMA. There is an electronic handbook, of about 50 pages, available from the RCGP which explains how to conduct SMAs; how to set them up in practices and how to provide the support necessary. SMAs are an innovative way of delivering medical care; there are many advantages to the patient in terms of increased knowledge, increasing self-management, empowerment and improving health–literacy. For the clinician, it saves repetition of the same fact to each individual and is also a light hearted way of delivering medical care which can be fun for the clinician involved. You can’t replace the one to one patient consultation of course but SMA can be another string to the GPs bow.
SMA at a National Level:
We now have a UK-wide Shared Medical Appointments Committee. We meet every 4 months to share ideas and innovation and you are very welcome to join us. A spin-off of the Shared Medical Appointment is the British Society of Lifestyle Medicine; an organisation that has been set up by 3 doctors and through which we try to convey widely the message that lifestyle has a huge impact on well-being and long term conditions. We understand that prescribing is not the only way to manage long term conditions and that there are many benefits to appropriate lifestyle self-management. There is a strong evidence base for improving lifestyle not forgetting that lifestyle management is cheap, if not free, and there are no side effects! There are broad benefits to be had and I would recommend to you the website British Society of Lifestyle Medicine. There is a Facebook page, making information very accessible, and the chance to be part of an international community that embrace lifestyle change. The British Society of Lifestyle Medicine was launched in Melbourne in Nov 2016. We are actively recruiting members and, as I see it, augmenting Primary Care.
I would also like to recommend to you the video 23 and a half hours which shows the impact on a range of conditions that can be altered by just walking 30 minutes per day.
For more information about Shared Medical Appointments, please see this article by Dr Rob Lawson.