Summary of evidence on the effectiveness of group clinics
Health outcomes
By far the majority of studies examining clinical outcomes relate to diabetes and focus on basic biomedical outcomes that are relatively easy to monitor routinely. It is, therefore, difficult to extrapolate these effects to other chronic conditions.
Diabetes
Although there is consistent and promising evidence in favour of an effect of group clinics for basic biomedical measures, particularly haemoglobin and systolic blood pressure, this evidence does not extend to other important biomedical considerations such as control of cholesterol. Group-based training for self-management strategies in people with type 2 diabetes is effective by improving fasting blood glucose levels, HbA1c and diabetes knowledge and reducing systolic blood pressure levels, body weight and the requirement for diabetes medication.
Disease-specific quality of life improved significantly in a small number of studies and yet this effect was not found to be as significant for generic health-related quality of life.
Other conditions
For other conditions in older adults benefits have been observed with regard to positive effects on patient experience with group clinic approaches, compared with usual care. However, no difference from usual care was reported for overall health status, functional status and biophysical outcomes.
Health service outcomes
Diabetes
Effects of group clinic approaches on hospital admissions and emergency department visits were explored in five studies on patients with diabetes.20,58,69,81,86 In three of these,58,69,82 admission rates were lower with group clinic approaches, but the result was statistically significant in only one study.20 Two studies found that emergency department visits decreased significantly with group clinic approaches.69,86
Other conditions
Two trials in older adults showed fewer hospital admissions for group clinic approaches and a statistically significant decrease in emergency department visits for group clinic approaches, compared with usual care.65,79
Summary of evidence on the feasibility, acceptability and meaningfulness of group clinics
Practical concerns remain. A practical impact of seeing patients individually over separate consultations is a spreading of workload demand on laboratory and other diagnostic services. In contrast, a group clinic relies on all patients having their results available for the same clinic. To what extent is this feasible given the heavy time and workload pressures on diagnostic services? In mitigation it should be said that we found little reason to believe that the actual burden of workload would be any greater as a result of seeing patients as a group rather than individually; batches of diagnostic test results could still be processed within the intervals between clinics. However, there would be a need for improved record keeping. Perhaps more significantly, the expectations of patients that their test results will be available will be shaped by ‘normalisation’ alongside others in attendance at the group clinic. Nevertheless, for conditions such as diabetes, a significant part of the interaction is derived from self-monitoring and not from external test results.
Confidentiality is another important consideration, and its full impact has been masked by methodological issues: those with significant concerns may well refuse to enrol in trials or qualitative studies in the first place. Furthermore, their concerns may be neglected in studies if they withdraw and are consequently lost to follow-up. On a positive note, Wong et al.107 concluded that confidentiality can be addressed and was not a major concern for either patients or providers. In fact, they observed that patients adopted strategies to address their own and others’ concerns regarding confidential health information. In turn, health-care providers used multiple strategies to maintain confidentiality within the group, including renegotiating what information is shared and providing examples of what information ought to be kept confidential. These practical considerations should be contemplated by anyone planning group clinic-type approaches.
Summary of evidence on the cost-effectiveness of group clinics
The eight relevant studies examining the cost-effectiveness of group clinics were all associated with settings that are not directly comparable with a UK setting (i.e. seven were from the USA58,62,79,86,117,135 and one was from Italy133). In addition, some studies relate to time periods that do not reflect current clinical practice. Medical conditions at which group clinics were targeted were diabetes (five articles)58,62,79,86,133 comorbid diabetes with hypertension (one article)133 and complex behavioural health and medical needs (two articles),79,136 resulting in very narrow coverage of clinical areas that potentially could be explored in a group clinic context.
The heterogeneity of the included studies and their different time and geographical settings explain, at least in part, the uncertain effects of group clinic interventions on costs saved. A full economic analysis of group clinics, along with the robust collection of costs data alongside group clinic interventions, is recommended. A full economic analysis would accommodate data included in RCTs, such as the type of clinician delivering the intervention and how long each group clinic lasts, to derive a richer picture of the costs of group clinics. Research bringing together information on the running of group clinics and potential cost savings in a UK NHS context would be particularly valuable.
Certain costs were not explicitly identified within the included studies. For example, it is likely that a group clinic intervention may require the specialist training of health-care staff, particularly in relation to facilitation skills.
Perceived and actual benefits and disadvantages of a group consultation when compared with an individual consultation
Although crude analyses compare the number of patients seen within a group session with the number of those seen individually in the same time period, such an approach is inadequate for the purposes of a rigorous evaluation. There is substantial evidence that provision must be made for individual consultations and also that costs may be displaced to other parts of the health-care system. The cost of individual consultations must factor in the provision for such consultations within the group session, for those who are displaced to sessions outside the group clinic and for those for whom group provision is either inappropriate or unacceptable. Although one assumption encountered in the literature is that the reduction of health costs will take place over an extended time period, studies that have been conducted to date have not covered a long enough evaluation period to demonstrate this realisation of cost benefits.
The value of group education
The cost benefit of group clinic approaches depends on whether or not current provision (usual care) includes existing group education provision and, specifically, whether this is delivered by health professionals or by lay peer supporters. Group education has been found to have an effect on some of those biomedical measures addressed by group clinics but not typically to the degree realised by most group clinic studies. The cost issue, therefore, becomes ‘what is the demonstrable cost–benefit to be realised by delivering the specific group clinic intervention compared with the individual consultation plus group education sessions?’. As indicated by some of the foregoing, this question is complicated by the issue of what can be quantified as benefits. In particular, is the evaluation framework to be exclusively that of cost savings – in which case group clinics are unlikely to deliver against this agenda – or is the evaluation to be situated in the context of joined-up improved-quality interprofessional care?
The value of multiprofessional approaches resulting from simultaneous clinical involvement
We found some evidence that involvement in group clinics may have accrued particular advantages in relation to interprofessional team working and mutuality:
[T]he flexibility of the individual team members is manifest during the SMA sessions. A weekly meeting . . . continues to occur to discuss patients and processes to assure that all team members have an open forum to voice concerns and make group changes.7
The literature around uni-professional, multi-professional and inter-professional working emphasises flexibility of roles and a degree of interchangeability as the means by which interprofessional working might be achieved.138
Issues emerging from the evidence?
The large majority of studies have been conducted within the disease area of diabetes. Diabetes appears particularly suited to the group clinic approach; it is a chronic condition that requires regular monitoring, and a high number of potential complications are common to the experience or concerns of a large number of patients. For the clinician, the attractions of a group clinic approach for diabetes are quite compelling. As one of our clinical advisors noted, successful management of the condition requires patient co-operation in the provision of their clinical data and their participation in self-management. The consequences of non-participation may be serious in terms of both effects on health and utilisation of emergency departments or other specialist services.
The majority of studies of group clinic type approaches have been conducted in the USA. Although this is typically an underlying concern for all health service and delivery topics we found evidence that it may be particularly significant for this topic area. The US health-care funding system is very prescriptive in terms of acceptable models of GMV for the purposes of reimbursement. Extensive research and evaluation has been conducted but in only a very limited range of possible models. Such prescription is likely to result in a stifling effect with regard to experimentation and innovation, potentially denying a range of possible models from which the NHS might conceivably benefit. Our clinical advisors have highlighted that, in NHS patient culture, there is significant expectation of receiving an individual consultation, as well as a reluctance to participate in group care activities and an appetite for only minimal requisite levels of patient information and education.
A major limitation of this review is that it has not been able to examine the evidence base for the individual components of the group clinic intervention, such as the individual consultation, group education, self-monitoring, peer support, etc. We concur with Edelman et al. that:
Without further, more mechanistic studies that attempt to elucidate the key components of an SMA intervention, implementation of a diabetes SMA or design of an SMA for another condition will be at least partially based on reasoned judgment rather than strict evidence-based decision making.18
Our review was unable to find data to address some very critical key questions in relation to group clinic provision. The evidence base is insufficient to address the issue of what constitutes either a minimally effective or an optimal dose with regard to the duration, intensity and content of the GMV. Furthermore, we detected a tension between what care providers consider to be an optimal curriculum to be covered in the educational component of the GMV and the expressed requirement for a programme to be coproduced in order to meet participant needs. It would be particularly helpful to be able to answer questions regarding the time period over which clinically significant outcomes are achieved, the time period for which any positive outcomes are sustained while the participant is receiving the intervention and the ‘washout period’ following cessation of the intervention, after which effects are no longer achieved. Related to this final point is the effectiveness of top-up or refresher sessions, together with questions about the duration, intensity and content of any refresher provision. The discussion with our clinical advisers suggested that answers to some of these questions may be linked to research findings for group education provision more generally, although (1) data of the particularity specified above are not typically contained in published reports and (2) group clinics engage, at least in theory, with additional mechanisms when compared with group education, and so their effect might be underestimated if this source of data is used.
Discussion with our clinical advisors also revealed an evidence gap with regard to longer-term attendance. Published research studies tend to interpret attendance in a forgiving manner; some even considered that attendance at a single clinic constituted a patient being an ‘attender’. More typically, an aggregate of attendances per person is given, which does not allow us to detect a decay in attendance and commitment over time. Furthermore, attendance patterns may be confounded by the flexibility or otherwise of the clinic, the number of alternatives on offer and other issues relating to access and alternative health-care provision.
Under what circumstances do patients with chronic conditions agree to participate in group clinic approaches?
From the theoretical literature, we have identified four principal components of a group clinic approach, as follows:
Monitoring: this is a traditional activity in the individual consultation but there is some evidence that group clinic approaches may turn this into more of a shared activity between the patient and clinician, with the patient becoming involved in some of the monitoring activities.
Self-management: the group clinic approach encourages patients to become more active in managing their condition. In contrast to an individual consultation, the group-based approach may offer both role models in those who manage their own condition and tips on techniques and resources acquired from fellow patients.
Peer support: this is a completely discrete activity from the individual consultation and one which offers additional sources of support beyond the clinician and the significant others of the patient. Commonly in the UK there is a separation between clinical activities and group education approaches.
Education and information: quantitatively, there is the opportunity for the clinician to share information with several patients at the same time, reducing duplication and repetition, and resulting in greater consistency in information provision. Qualitatively, patients may respond better to information shared in a less didactic manner or to information originating from fellow patients. More reticent patients may benefit vicariously from questions asked by more proactive members of the group, in effect becoming ‘lurkers’ within the group.
Typically, patients with chronic conditions appear to make an overall assessment of the benefits of participation before agreeing to participate. There is some evidence that the disadvantages of participation are not adequately explained to participants by clinical staff. A significant proportion of those invited to participate decline, largely because they do not recognise the benefits of group clinic approaches against the perceived advantages of an individual consultation. Expectations of being seen in an individual consultation, whether specified by a health plan as in the USA or through cultural conditioning in the UK, appear to militate against the use of a group clinic approach. Alternative provision will probably be required for this sizeable group of patients and the very availability of such an alternative may have a negative effect on uptake.
Having agreed to attend group clinics, why do some patients with chronic conditions decide not to attend any group clinic sessions?
Constraints related to the logistics of attending the group clinic appointment (e.g. timing, other commitments, etc.) play a major role in determining whether or not patients with chronic conditions will attend. However, these same constraints are also present for those seeking individual appointments. The primary consideration, therefore, appears to be the flexibility of attendance patterns. In particular, attendance may depend on whether group clinics employ a closed cohort-based approach or more of a drop-in model.
Having started to attend group clinics, why do some patients with chronic conditions discontinue a group clinic programme?
There is some evidence to suggest that some patients will attend with a specific goal of receiving sufficient information for self-management of their condition. Once they feel that they have obtained this information, their motivation for attendance wanes. For others, the social aspect of a group is particularly important and this may contribute to their motivation for ongoing attendance, even if the other benefits of attendance degrade over time. Finally, there are others for whom the sense of shared community persists, which is recognised from their transition from being beneficiaries to becoming donors to the overall group process.
Which is the most sustainable model of group clinic delivery?
The identified research literature does not support a detailed analysis of sustainability. Most initiatives were evaluated over only a relatively short time period. For example, Cohen et al. claimed to have demonstrated ‘that the pharmacist-led group intervention program was an efficacious and sustainable collaborative care approach’ and yet only evaluated the initiative over a period of 2 years.63 In fact, within the context of group clinics such an evaluation period is comparatively long. Housden et al.53 reported that 15 out of 26 studies were 12 months or shorter in duration, and six studies were up to 2 years in duration. The study with the longest duration followed patients for only a period of 5 years after the intervention. We conclude with Housden et al. that:
. . . the long-term or sustainable outcomes of group medical visits are unclear, and it is difficult to know if the outcomes were maintained for a substantial length of time after the intervention.53
Qualitatively, there is very little discussion in the published literature about the practicalities of managing different models of group membership. Such contrasting models have considerable implications for facilitation, educational content and the group dynamic. These are now briefly discussed, together with their possible implications.
The ongoing cohort
Explicit to the chronic care clinic and group visit models is the idea of the group representing an ongoing cohort of patients who have the opportunity to ‘grow’ together. However, there is no discussion in the included research studies about the implications of withdrawals and dropouts for the group viability and for its dynamics. Clearly, in an older population, or equally for those with a chronic condition, the likelihood that the numbers in attendance will diminish, either through natural wastage or through the utilisation of alternative inpatient or long-term care health services, poses a significant challenge for the ongoing sustainability of a particular group. Increasing numbers of patients with the chronic condition means that there is further need for extra facilitators, additional training and greater utilisation of premises.
‘Out with the old, in with the new’
Another potential model of group membership, given that resources for facilitation and group processes are likely to be finite, would be to work with a particular group to a pre-defined temporal or developmental point and then to disband the whole group and return to individual consultations. This model was not identified in the literature, although it is unclear if this is because it is not prevalent or if the relatively short research and evaluation time frame precludes the study of its longer-term sustainability. This model assumes that the initial life of the group is a key point in the disease trajectory, that the curriculum is relatively finite and stable and, importantly, that there is a carry-over of the group effect beyond the lifespan of the group. Such a group model makes unchallenged assumptions about shared information needs and a common pace of learning for all group members. Maintaining a group for a finite period, identified a priori, may help to sustain the impetus of the group but, paradoxically, may reduce people’s commitment to the group. One challenge for the facilitator is in identifying an optimal lifespan for the group, an issue not addressed by the literature.
Periodic group replenishment
A final model would be to treat the group as a more fluid vehicle, with patients being able to leave or join at any point, subject to the accommodation of numbers within the group membership. From an efficiency point of view such a model is attractive, as it ensures that provision is sustainable and safeguards against the attrition of members. However, this ‘mixed’ model may present challenges to facilitation, both in terms of building up relationships from new with facilitators and with existing group members and, educationally, in terms of planning of content for a group with heterogeneous learning needs and varying experiences. One study of this kind of fluid group, for people with haemophilia, measured discernible differences in the perceptions of the value of group attendance between parents of less experienced and parents of more experienced members of the group:
The majority of parents (62%) did not regard the additional time investment for GMA as inconvenient (74% less experienced, 30% experienced; P-value 0.023).96
This was further reflected in differences between the patients themselves in terms of learning:
In children < 12 years, all less experienced adolescents reported learning of new aspects of their disease, unlike the 75% of experienced adolescents who reported no learning effect (P-value 0.011).96
It is true that more experienced group members could be harnessed as a resource to be utilised by the facilitator to benefit newer members:
Several veterans enthusiastically volunteered to attend future group clinics to share their chronic disease self-management experience.99
However, the fluidity of group membership may have adverse effects in terms of commitment to the group ‘community’.
Strengths and limitations of this review
This was a protocol-driven review conducted by multiple investigators. The information specialist conducted a very comprehensive subject search of bibliographic databases and this was supplemented by the extensive pursuit of references and use of citation search techniques. In particular, this allowed us to identify clusters of associate studies reporting more complete data where available.38 We believe that we have identified more published trials than any previous review; this has meant we have included more studies and have been able to review reports included in previous reviews but excluded from our own inclusion criteria, together with reasons. We performed a rigorous process of checking for inclusion and subsequent quality assessment. In implementing an innovative methodology of ‘progressive fractions’ we extended the review resources beyond a narrow focused question defined by the term ‘group clinics’ to engage with a wider body of the most relevant literature with a range of synonyms. We also employed exhaustive supplementary search techniques such as follow-up of references, citation searching and searching for study clusters. We are, therefore, confident not only that we have identified the most significant literature related to the review question but also that we have minimised the risk of missing relevant qualitative, cost and UK studies.
The time scale of this review, telescoped within half the time period of a conventional systematic review, and its ambition in covering feasibility, appropriateness and meaningfulness in addition to the effectiveness and cost-effectiveness most typically covered by comparator reviews have prompted the use of several rapid-review methods. For example, our approach was to examine the extent to which recently published evidence from RCTs has made a supplementary contribution to the existing evidence base. In actuality, because of the relatively small number of recent trial reports and the extensive quantity and coverage of previous reviews, this additive contribution has not been as significant as was initially anticipated. As this was a rapid review we were unable to perform independent double data extraction and quality assessment. However, frequent iteration between extracted data and the full text of articles minimises the likelihood of important errors.
Methodological limitations of the included studies
In conducting the review we identified a systematic bias in the reporting of group clinic interventions. Selection bias was very likely to occur; even though some studies made strenuous efforts to locate and collect data from patients who had dropped out, success was limited,97 making it ‘not possible to investigate the possible disadvantages that some patients might experience’.97 In addition, the positive group effect, particularly from qualitative studies, may well have been ‘influenced by the fact that those who do not gain benefit drop out, leaving only patients with a positive experience’.97 Furthermore, there is considerable under-representation of patients from UK relevant ethnic minority backgrounds (US studies include Latino/a and African American participants), making it ‘not possible to identify any potential differences that might be experienced by these groups’.97
Included studies and their corresponding inclusion in systematic reviews typically confused different models of group clinic provision. One economic attraction of a group clinic approach relates to a ‘substitution’ model, that is where patients attend a group clinic instead of attending individual consultations. It appears that the rationale underpinning a substitution model is flawed as (1) most US provision of GMVs/SMAs requires the provision of individual consultations in addition to group clinic provision, and (2) studies may report individual consultations at the time of the group clinic but are less likely to report these outside the group clinic session, resulting in an incomplete picture of resource use. One of our clinical advisers suggested that in a UK setting a different form of substitution might take place, in that the group clinic facilitator, typically a nurse or dietitian for primarily economic reasons, may fulfil several roles otherwise assumed by a clinician in an individual consultation (e.g. review of patient results). The challenge in such a UK substitution model lies in how to decide the extent to which the duration of the individual consultation might be reduced, the impact this might have on the topic content of the individual consultation and the logistics of co-ordinating the individual and group sessions. Unless a study demonstrates an explicit reduction within the experimental group in the corresponding time for the individual consultation input, compared with the control group, the model being described is essentially an enhanced care model (i.e. previous individual consultation enhanced by GMV).
Our typology of group clinics models characterised two further variations:
the group clinic plus model, where every patient is offered an individual consultation (i.e. universal same-session individual appointments) and savings are achieved for each patient who deems an individual consultation unnecessary
the group clinic triage model (i.e. an indicated simultaneous individual appointment), where a clinician offers a consultation only where the group session reveals a cause of particular concern and savings are achieved by not consulting with patients who do not merit special attention.
A disappointing feature of the evidence base relating to group clinics is the predominance of diabetes as a studied disease area. As Edelman et al.18 observed, little evidence is available for other chronic conditions of interest such as coronary artery disease, chronic heart failure, asthma, COPD, hyperlipidaemia or hypertension. In addition, the included studies focus on achievement of biomedical outcomes, with comparatively little information on organisational or system-wide factors.18
We approached this review with the perhaps simplistic expectation that group clinics would represent a genuine alternative to the individual consultation. In actuality, individual consultations continued to be delivered, mainly as a result of patient expectations and the stringencies of the US health-care system. The revised research questions, for which we have remarkably little evidence, relate to the extent to which the duration of an individual consultation can be reduced and the extent to which information from this consultation can be delivered by other, less specialist staff in a group context. A further disappointment relates to the lack of clarity with regard to intervention components and their corresponding mechanisms of action. It thus becomes problematic when seeking to identify which are the active ingredients, which components might be considered essential and to map which components address each requisite from the group clinic intervention. In addition, we have identified a research paradox, in that the effectiveness of the group clinic intervention is believed to be related to the degree of coproduction achieved by patients and clinicians in the group but such coproduction makes it correspondingly more difficult to ensure the fidelity of the intervention. In addition, to this evaluation challenge there are attendant consequences in terms of subsequent implementation.
Another methodological limitation relates to the outcomes being studied. Substantial variability in outcomes, together with the previously mentioned heterogeneity of interventions, makes it problematic when seeking to explain the observed variability in intervention effects. Generally, for this reason, we have resisted the use of meta-analyses using summary measures of treatment effect, as these may not adequately describe the expected effects of the intervention (cf. Edelman et al.18). Indeed, the main function of the availability of analyses for such outcome measures appears to be in developing a hierarchy of outcome measures according to how easy it might be to demonstrate an effect and, indeed the converse likelihood of a systematic measurement error. We also note the comparative absence of repeated measurements for outcomes making it difficult to isolate the point at which improvements take place and, indeed, the trajectory of the management of the disease. As mentioned above, this absence of outcome data makes clinical decisions, specifically about optimal dosage, intensity and duration, problematic. Furthermore, the limited time window covered by the included studies does not address the very important issue of the long-term sustainability of such an intervention.
Research implications
Although the review team identified a sizeable body of evidence around group clinic type approaches, the practical value of this research for the specific review question is limited. Much of the research has been conducted in the USA, within a different health system, often with a requirement to make provision for an individual consultation. The dominant model, therefore, is one of enhancement of interaction and not of substitution. There is therefore a need for research that specifically focuses on the role of group clinic approaches in substituting for identifiable components of, or the whole content of, individual consultation episodes. In addition, RCTs have been conducted predominantly in the context of diabetes and rigorous evaluations are required across a wider range of chronic conditions. Finally, the indistinct nature of the different service models, and a lack of clarity regarding their individual constituents, requires research that elicits more detail of individual service components, their putative mechanisms and their associated costs.
The team identified five ongoing trials in group clinic type interventions (see Appendix 6). However, none of these ongoing trials is taking place in the UK. Three of these trials relate to diabetes care, one relates to heart failure and one relates to the new disease area (with respect to group clinics) of atopic dermatitis. This research is unlikely to overturn any of the research implications or implications for practice, although the studies in the less investigated contexts of heart failure and dermatitis are to be particularly welcomed.
Numerous commentators have observed on the heterogeneous nature of group clinic type interventions6,135 and this has several implications for this review. First, although we may identify some overall biomedical effects from group clinic approaches across a wide range of settings, strengthening the likelihood of generalisability, it is correspondingly more difficult to isolate the ‘active ingredients’ of what are essentially complex multifaceted interventions.132
In an implementation context, given the typically poor standard of description of each intervention in included studies, ensuring the fidelity of a particular type of group clinic intervention is problematic:
Implementation fidelity is often presented as critical to achieving the levels of efficacy demonstrated in clinical trials. However, it became apparent that descriptions of SMA interventions provided insufficient detail to guide implementation into differing clinical settings.27
This heterogeneity provides operational challenges to the definition of interventions for inclusion in this review and also explains the apparent inconsistency of inclusions across previous reviews, which in turn may partially explain some of the reported differences in effect.
From a cost viewpoint we know little about the added benefit of incremental additions to a particular group clinic model. In fact, given that there is some evidence for the effectiveness of group-based education interventions accompanied by individual clinician visits, it is unclear what the superiority or added benefit of the more complex group clinic model might be over this comparatively simpler version.
At the same time, heterogeneity, although complicating the evaluation of group clinic-type interventions, may offer attractions in the context of innovation. One potential criticism for the preponderance of US-based models is that there is little evidence of genuine innovation around a familiar-looking menu of group clinic models, perhaps due to the characteristics of the US funding system. The UK offers considerable scope for innovation, provided that the components of each model are clearly identifiable, isolatable and costable.
With regard to future comparators of the group clinic-based intervention two technological developments require further investigation. With improved availability of internet technologies virtual clinics may offer a technology-supported alternative to members of a group being present in person.139 In addition, the relatively good performance of automated telephone disease management systems as a comparator for group clinics suggests that, for some patients at least, support might be offered via such technologies.77,78 These weekly, rotating automated (prerecorded) telephone calls take between 6 and 12 minutes to complete with any ‘out of range’ responses triggering a personal call back by a nurse manager.77,78 One attraction of these contrasting technological approaches is that they may cater for the needs of two quite different population demographics. Schillinger’s use of telephone support was particularly welcomed by those with language difficulties.77,78 These approaches need rigorous evaluation in the context of the UK NHS.
Further studies of different patient populations in various practice settings are needed to identify the best protocols and to assess the true benefits of group clinic approaches. It is hoped that these would reveal that complementary, innovative and evolving care approaches involving multidisciplinary teams are useful tools for meeting the significant challenges to access, cost and quality that now face the health-care delivery system.137 Our findings confirm that there are limited data on satisfaction, patient access and other key patient-centred outcomes.18
As with the most recent review identified by this project, our review ‘uncovered far more gaps in the literature than it found definitive results’.55 Gaps include the heterogeneity of the group clinic approaches intervention, characterised as a ‘black box’, with ‘many components that are hard to capture and tease out, even in a well-conducted analysis’.55 In seeking to add value by examining putative context-mechanism-outcome (CMO) configurations we attempted to advance an explanation for what makes particular group clinic type interventions successful.
In summary we have identified a requirement for future research to extend the breadth of chronic conditions within a wider evaluation framework in rigorously conducted trials in a UK context, to focus on benefits of substitution not enhancement, to characterise interventions by their components rather than their labels and to target these individual components for specific evaluation of both costs and benefits.
