Definition and use of video group consultations

Understanding how VGCs were defined was central to the use of the approach, determining its purpose and scope in practice. The terms ‘video group consultation’ (n=22) or ‘video group clinic’ (n=12) were reported most by the participants. Educational therapy (n=5), support group (n=6) and group therapy (n=1) were also reported as features of VGCs, yet also became a defining characteristic for some participants. Shared medical appointment (n=1) was not chosen as a widely used definition for VGCs.

Participants were asked, ‘How would you define how you use VGCs in your practice?’ The most frequently reported definitions of use was for long-term condition reviews (n=25), detailing several conditions, including diabetes (n=4) and cancer (n=1). Terms such as ‘management’ (n=2) and ‘chronic disease’ (n=1) were also identified in relation to long-term condition reviews.

The principles of ‘group support’ and ‘health promotion’ were also used to define the use of VGCs. Group support included ‘providing discussion’ (P19_GP), ‘interactive questioning’ (P19_GP), ‘another method of connecting’ (P15_GP) and ‘experience sharing’ (P34_GP). One participant defined a VGC as ‘an online group that enables discussion among a group of patients with similar health issues’ (P14_general practice nurse (GPN)). Health promotion included goal setting (n=1), coaching (n=2), promoting health (n=1) and providing information (n=9). Lifestyle medicine (n=8) was also viewed as an aspect of health promotion as a means of lifestyle advice (n=4), for example for patients with rheumatoid arthritis (n=1), weight management (n=1), cognitive behavioural therapy in menopause groups (n=1), postnatal care (n=1) and mental health (n=1). One participant defined VCGs as ‘providing information on a dietary approach to diabetes plus supporting patients if they chose to follow that plan in de-medicating’ (P31_GP).

The scope and role of VGCs extended to the management of conditions, mostly identified as type 1 and type 2 diabetes (n=25, 27%) and weight management (n=16, 17%) (Figure 1). However, support for the use of VGCs in various patient groups was usually dependent on organisational and practice support in that ‘practice is keen to support cohorts such as those with pre-diabetes, mental health so we have explored using VGCs to offer targeted support to these individuals’ (P30_social prescriber).

Figure 1.

Conditions managed using video group consultations (n =92)*

Participants were asked, ‘Do you manage any other conditions through VGCs?’ Two main categories were identified related to health prevention (n=10) or health promotion (n=2). Health prevention included conditions such as diabetes, including pre-diabetes and newly diagnosed diabetes (n=3); men’s health and women’s health, including menopause (n=4); cancer (n=1); dementia (n=1) and postnatal care (n=1). Conditions and/or activities related to health promotion included exercise classes (n=1), with the aim of disease prevention (n=1). However, one participant described how the topics included in VGCs was determined by the patients themselves, stating: ‘we allow patients to leave a message requesting a topic they want group clinics to cover, and we will offer group clinics in any area requested by the patient’ (P01_GP).

Staff and patient motivations for using video group consultations

Participants talked about their motivations and their perceptions of patient motivations for the use and uptake of VGCs in practice. Of the participants, 27 (75%) currently used VGCs, while nine (25%) had previously used the approach and stopped. Participants were asked, ‘If you have previously used VGCs and stopped, why have you stopped?’ Two reported that VGCs were not continued if a ‘specific programme ended’ (P23_social prescriber) or ‘the health coach who was providing the facilitator role moved away’ (P33_GP).

Uptake of VGCs was therefore dependent on staff and perceived patient motivations. In terms of staff uptake of VGCs, ‘challenging doubters’ (P21_advanced clinical practitioner/advanced nurse practitioner (ACP/ANP)) was an issue, with some participants citing difficulties in ‘changing perceptions of group consultations’ (P21_ACP/ANP) and ‘reluctance of certain clinicians to engage’ (P28_GP). One participant identified that reluctance to change was grounded in individuals ‘being stubborn’ (P03_ACP/ANP) and the belief that ‘most people working in primary care already have the necessary skills’ (P06_GP).

Participants described several attributes that staff would require to use VGCs (Box1). These attributes ultimately helped in ‘believing in the model’ (P03_ACP/ANP) and ‘confidence in getting the change project up and running’ (P04_GP).

Several training needs were also identified by participants and deemed important for staff motivation to use VCGs, mostly related to facilitation skills, including the ability to facilitate a group session, and manage group dynamics and challenging circumstances. One participant stated that the delivery of VGCs was dependent on ‘someone who understands the tech and can act as a master of ceremonies’ (P19_GP). However, facilitation skills (n=32) were also considered more broadly, in terms of presentation skills (n=3), IT skills (n=6), digital literacy (n=2), coaching skills (n=3), group management skills (n=11), communication skills (n=5), administration skills (n=1) and a variety of content to ensure adaptability (n=1). Five participants listed the need for facilitator training and increased ‘IT literacy for when things go wrong’ (P08_GPN). However, another argued that ‘time needs to be given so clinicians can understand the benefits’ (P28_GP) and therefore make sense of the skills and training needed to deliver a VGC.

Despite this, participants perceived that patient motivation was key to the use and uptake of VGCs, with one stating ‘our local population was “Zoomed” out [an expression of overuse of virtual platforms including Zoom] and haven’t taken up the opportunity for VGCs as enthusiastically as they took up the invitation for face-to-face GCs’ (P31_GP). Attendance by patients was therefore identified as a major issue, with one participant stating ‘we will often recruit eight or so patients but none will attend after multiple reminders’ (P09_health coach).

Participants also perceived patients’ use of technology as central to suboptimal uptake. It was perceived that the ‘older population rejecting the idea of “new-found” tech’ (P05_GPN) related to a high VGC ‘did not attend’ rate. One participant stated, ‘while most patients have access to a compatible device, many lack confidence in technological ability and declined or came into difficulties joining or during the VGC’ (P20_allied health professional (AHP)). Participants (n=32) identified the patient age group most commonly using VGCs were those aged between 40 and 50 years.

Some participants related perceived suboptimal patient uptake to access issues, rather than motivation, identifying that ‘patients frequently declined on the basis of availability’ (P20_AHP) because ‘only one VGC date was confirmed at a time with no indication of the next’ (P20_AHP). However, ‘some patients are pro VGCs, as they see it is a time saver’ (P36_social prescriber).

Other perceptions related suboptimal patient uptake to the choice of face-to-face or VGC. There was a perception among participants that when given the choice between face-to-face consultations or VGC, patients preferred face to face, with one participant stating ‘we are planning to run a pre-diabetic VGC but are debating this in-person rather than tech as our patients appear to prefer in-person options’ (P30_social prescriber).

In addition, perceived patient uptake of VGCs was dependent on preference for a group versus an individual approach, as one participant noted that it was ‘slow starting to get the numbers for our group consultations as still offering 1:1’ (P10_ACP/ANP), while others noted that ‘some love and some prefer individual input’ (P08_GPN) and ‘others prefer in-person, as they like the companionship of others’ (P34_GP). Uptake was therefore dependent on targeting the appropriate patient population and acceptance of a new consultation model.

Workload and practice priorities

Workload and practice priorities were key to the set-up and delivery of the VGCs approach. The lack of facilitation and support were the main reasons why practices stopped delivering VGCs, including clinical support (n=1); technological support (n=1); administrative support, such as preparation of resources (n=2); time intensity (n=1); additional workload (n=1); and lack of capacity (n=1). One participant stated that ‘they [VGCs] are time intensive for small turnout in terms of prep of resources, tech support, two clinicians presenting and someone on the chat box’ (P30_social prescriber).

The time taken to deliver each VGC was identified as between 60 and 90 minutes (n=24, 67%), predominantly involving either four to six patients (n=14, 39%) or six to eight patients (n=13, 36%). Therefore, ‘having the time to build these sessions’ (P27_non-clinical) was paramount because ‘once foundations are in place some sessions can run on self-referrals, reducing admin processes’ (P21_non-clinical). However, one participant stated that this relied on ‘having more people to help than just one person doing it’ (P07_GPN).

Participants were asked, ‘What other factors have played a role in the set-up of VGCs?’ Although participants did not have to answer this question, 26 did. More than half of responses (n=14/26, 54%) related to organisational and practice support, including practice and/or group support (n=3), administrative support during and in the initial work-up (n=3), support from GPs (n=1) and commissioning investment (n=4).

Participants were also asked, ‘Did your practice already deliver group consultations before offering VGCs?’ Of the participants, 22 (61%) responded ‘no’, 13 (36%) answered ‘yes’ and one (3%) responded ‘not sure’. Successful workforce planning was therefore identified as crucial (n=18), due to the unestablished nature of the VGC model and the associated workload required to get the approach ‘up and running’. Planning (n=3), time (n=4), availability and scheduling (n=7), training (n=2), and administrative support (n=2) were all factors that the participants stated could contribute to the ability to provide VGCs as an alternative model of consultation. However, ‘a lack of investment in staff who are able to do the VGC’ (P14_GPN) meant that participants noted issues with the viability of the approach, stating ‘[I] wish I had more protected time’ (P32_practice manager), that there was ‘no time for planning recall of patients’ (P03_ACP/ANP) and that there were challenges with ‘getting certain members of the practice on board’ (P04_GP). One participant also identified that ‘staff training and availability is a huge challenge, as is getting allocated time for VGCs within the clinical day’ (P33_GP).

Training was identified as key to the use and uptake of the VGC approach, with most participants being involved in formal training sessions (n=24, 67%). Formal training (n=22), including the need for ongoing support and accreditation (n=2), was identified as a necessary requirement for the delivery of VGCs. However, one participant stated that VGCs ‘can be easily done without the training too’ (P35_GP), while another stated that ‘the best training is to “just do it”’(P31_GP).

Participants provided more than one answer to the question on barriers to the use of VGCs with the total number of responses reaching 100. The use of technology was identified as the second largest barrier to the use of VGCs (n=22/100, 22%).

Microsoft Teams was identified as the most favoured platform to deliver VGCs (n=28, 78%). However, one participant stated that ‘the technology [is] still not mature enough’ (P15_GP) to deal with newer ways of working, ultimately leading to a lack of confidence in systems such as the digital platforms used to host VGCs.

Using pre-existing and new networks to sustain video group consultations

The lack of sustainability when using VGCs was reported as a challenge. One participant described ‘primary care being “stuck in a rut”’ as practices were ‘too busy to innovate’, ‘GDPR [General Data Protection Regulation] stifling innovation’ and a ‘lack of funding to do things differently’ (P01_GP). Another participant described sustainability as dependent on a ‘culture shift’ (P28_GP). The sustainability of VGCs was also seen as being dependent on organisational support, with participants stating that ‘we were commissioned to provide the service for a primary care network’ (P31_GP), and with some practices having ‘CCG [clinical commissioning group] locally commissioned services incentivising group consultation delivery’ (P33_GP).

Participants who managed to sustain VGCs identified the need to use pre-existing and new networks. Techniques such as liaising with other practices and using experts already running VGCs were echoed across participants’ responses as a way of ‘showing how others are run’ (P07_GP). This also included the need to use a formal VGC training provider and incorporate established consultation models such as a long-term condition review or lifestyle medicine template into any VGCs.

When implementing VGCs, participants also described the benefits of ‘training in delivery’ (P11_ACP/ANP), stating that ‘it was useful to have the training of flow’ (P35_GP), and that ‘training on the technical side was very helpful’ (P30_social prescriber) alongside ‘on-going support/accreditation’ (P01_GP). Participants further identified the need for whole-team ‘buy-in’ rather than having an individual champion to initiate, deliver and sustain the VGC approach, due to the associated workload.