Sharing is good. We’re brought up to believe that almost everything is better if shared - food, toys, music, books, life’s highs and lows. For some people nothing seems to remain private – especially on social media. But for most of us some things remain off-limits for sharing – personal information like PIN numbers and website passwords, a virus (our own or our computer’s), a consultation with our GP.
“Not necessarily,” claims Kamalini Ramdas, Professor of Management Science and Operations and Deloitte Chair of Innovation and Entrepreneurship at London Business School (LBS). She says we automatically assume that the best healthcare comes from one-to-one time with a doctor: “It’s because of how we’ve been brought up – what the norm is.”
For over a decade Professor Ramdas has been at the forefront of research into Shared Medical Appointments (SMAs), an innovative approach to patient care that’s already proved successful in the some US and Australian hospitals. Although embracing SMAs requires a “brain shift” by doctors and patients alike, she says it’s a model that’s been long tried and tested in education – “I never think twice about walking into a class where there are 60 students. They’re all getting a ‘group delivery’.”
Group delivery could be a way to help the NHS face challenges never foreseen at its inception seven decades ago - an ageing population and an increase in people suffering from long term conditions (like diabetes, hypertension, liver disease and arthritis ) that require regular monitoring and take up over 50% of GP consultations.
Usually attention centres on the “free” part of the NHS’s founding principle of “free at the point of delivery” but Professor Ramdas’s research is revealing that shifting focus instead onto the method of delivery and shaking up long-held beliefs about how health care is provided might be a way to safeguard the ‘free’.
So how does an SMA actually work? The first hurdle to overcome when introducing the concept is the suspicion that they involve baring your all in a room full of strangers. “One of the things you need to realise is that you’re not going to be sitting in your underwear if you’re in a shared annual physical exam appointment,” says Professor Ramdas. “You’re going to be in a very socially acceptable setting.”
A shared appointment usually involves a group of around eight to 12 patients; depending on the specialism and group size it lasts for around 90 minutes and is run by a doctor assisted by another member of the practice staff who takes notes and keep records. Any tests or examinations are done privately and then the doctor sees each patient individually but with other group members present and listening to the consultation. Patients, like the medical professionals present, are bound by confidentiality agreements.
Group delivery could be a way to help the NHS face challenges never foreseen at its inception seven decades ago
As everyone in the group probably has similar questions, the doctor avoids repeating the same information to each patient and has time to answer more questions in more detail. SMAs also mean, perhaps counter-intuitively, a more personal touch for each patient than during a standard 15 minute individual appointment.
“Doctors report that they have more time to ask a patient about other things, for example, ‘How’s your dog doing?’” says Professor Ramdas. “That can actually be more important than telling them all about their medications because now the patient knows that the doctor cares.”
Of course not everyone is able to commit to a 90 minute appointment. “But think of a retired person who is lonely,” says Professor Ramdas. “They might be very happy to spend 90 minutes. And if all those retired people went to shared appointments, all of us would also benefit because shared appointments are more efficient – the doctor does not need to repeat common advice. There is a system effect. The doctors suddenly have more time so they are able to see everyone faster and waiting times for appointments of all kinds would be reduced.”
The maths is obvious. Doctors can see the same number of patients in much less time. Although savings and efficiencies are almost immediate SMAs are not just a way of bundling everyone together to cut costs. Professor Ramdas says that a more subtle consequence - with additional inherent savings - is increased patient engagement.
Patients regularly attending the same group for a shared appointment benefit from hearing each other’s experiences and a little healthy competition (literally) may result. “Imagine the doctors told you to lose some weight,” suggests Professor Ramdas. “At the next shared appointment, you don’t want to be the slacker who hasn’t lost any weight. Alcoholics Anonymous and Weight Watchers have used this group peer pressure and peer support for many years but it hasn’t been used in situations where you have a medical doctor giving a one-on-one in a peer group.”
Camaraderie and solidarity within the group helps patients to help each other. “Seeing a doctor can be intimidating,” says Professor Ramdas, “especially if you are from an impoverished area. The doctor in the white coat may be very different from someone from your milieu.” One patient may be able to describe a symptom that another struggles to articulate; someone else might be inspired to take their medication regularly.
Following “doctor’s orders” makes more sense when a living example of doing so is sitting right in front of you. Professor Ramdas has witnessed the potency of a woman in an SMA telling fellow glaucoma sufferers that she had avoided going blind by conscientiously taking her eye drops for 20 years.
Similarly, a home truth is more effective when delivered from the mouth of someone suffering from the same condition. Professor Ramdas heard about a young woman who was complaining at length about her pain during an SMA in the US for arthritis sufferers. “Then this older woman just looked at her and said, ‘Honey, you’ve got to deal with it.’ That has impact!”
There’s a growing body of evidence of these sorts of positive patient outcomes but up to now it has been mostly based on small sample sizes. Professor Ramdas, together with Ryan W. Buell , UPS Foundation Associate Professor of Service Management at Harvard Business School, Nazli Sonmez, PhD candidate at LBS and glaucoma specialists Dr R Venkatesh and Dr S Kavithaare are conducting a three-year randomised trial of 1000 glaucoma patients participating in SMAs at Aravind Eye Hospital in southern India.
By videoing every appointment and then, to maintain patient confidentiality, working from a detailed transcript, Professor Ramdas and her colleagues are working to identify and explain the effects of shared appointments. Some effects are relatively straightforward to measure.
“We survey the patients after every appointment – a little quiz on glaucoma,” says Professor Ramdas. “We’re finding that knowledge improves. They are also more likely to take their medicines between the appointments and, if they have been coming with the same peer group, they are more likely to show up for a follow-up appointment on time.”
Other results are more nuanced. Professor Ramdas says that careful study of the transcripts reveals how the shared experience may subtly alter behaviour and improve patient-doctor interaction, which means more targeted and personalised care.
“For example, if the doctor is talking to one patient, what are the other patients doing? Are they nodding? Are they leaning forward? Are they also asking a question? We’re trying to measure that dynamic and engagement. For example, if Patient A was a woman and she asked a question, did that inspire another woman in the group to ask a question. That’s what happens in the MBA classroom too!”
As individual patients engage with managing their long-term conditions at regular SMAs their number of unnecessary visits to A&E (estimated at 40%) and surgeries is reduced. Not only a significant cost saving, this means avoiding – or at least postponing - traumatic, life-changing events such as blindness from unmonitored glaucoma and amputations caused by sores from unchecked diabetes.
With their seemingly obvious clinical and financial benefits SMAs look like a no-brainer but more work is needed before their widespread introduction. Professor Ramdas and her research collaborators are leading the way. Her article in the New England Journal of Medicine co-authored with Lord Darzi, (surgeon, Vice Dean of Health Policy and Engagement at Imperial College, London and former Under Secretary of State for Health) highlighted the need for more rigorous scientific evidence; piloting and refining the SMA model; regulatory change and incentives; and educating patients and doctors about the new system.
Isn’t it a courageous move to change such an entrenched system? Professor Ramdas thinks it’s not so much a question of bravery as of maintaining a long term focus. “When people talk about entrepreneurs they say, ‘Oh, they have so much courage; they take these huge risks’ but they’re not necessarily taking huge risks - they’re taking very small steps. At each step there is a small risk and by doing these small steps, you reduce the risk. And that looks courageous in the end but look at the little baby steps they’ve taken.”
A first baby step for hesitant patients might be to observe a shared appointment because, as Professor Ramdas says, “if you haven’t seen one, you’re imagining all sorts of things.” ‘Try before you buy’ is standard business practice – whether a trial session at a gym or a free sample of a new product to whet your appetite.
Professor Ramdas also thinks the grassroots movement of 250 GP practices around the country that have already tried SMAs is a valuable resource. “What if, starting amongst these early experimenters, we could get GP surgeries to offer SMAs as a default, where appropriate? It doesn’t mean that everyone will be forced into shared appointments. It just means that they will be offered shared appointments first.”
Winning hearts and minds will be a gradual process. “I think group delivery needs to be the default option for a long time so that people become a lot more accepting of it,” she says.
Professor Ramdas believes that shared medical appointments could play an important part in restructuring the way healthcare is delivered in the NHS. Pilot schemes already show significant benefits for patients, doctors and the public purse. There’s still a lot of work to be done – not least in education – and Professor Ramdas’ and her colleagues’ three-year 1000 patient study comes at just the right moment. She is looking forward to sharing the results.
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