Our evidence synthesis of group clinics for young adults with diabetes was underpinned by a theory-driven realist methodology. Realist reviews consider the mechanisms by which a programme (in this case, group clinics) works (or not) and the contexts in which these mechanisms are triggered to produce certain outcomes. Realist reviews (and evaluations) have been extensively applied in health services research.
A realist review was performed to synthesise findings from existing literature to understand how group clinics may work for young adults with diabetes and other complex needs. This detailed evidence synthesis followed the approach and standards of the NIHR-funded Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) project to understand ‘what works, for whom, under what circumstances’ in group clinics for young adults with diabetes.42,43 The review synthesised existing qualitative, quantitative and mixed-methods studies relevant to this topic area. The findings of this evidence synthesis supported the empirical research undertaken subsequently, including the co-design and context-sensitive development of a group clinic model and its implementation and evaluation within the NHS.
The realist review is presented as a published paper and includes a detailed description of its methodology and results.44 Its findings highlighted four main principles that should be taken forward in the contextualisation and design of group clinics to support engagement from young people:
emphasis on self-management as practical knowledge
development of a sense of affinity between patients
provision of safe, developmentally appropriate care
the need to balance group and individual needs.
The realist review highlighted that the implementation of group clinics within health systems was rarely, if ever, straightforward. Numerous adjustments were needed to existing operational and clinical processes to deliver high-quality care through group clinics, and there was substantial ‘hidden’ work (i.e. work that was not recognised, measured or rewarded, and which was often carried out by relatively low-status staff in their own time) involved in doing so. Finally, it was noted that group clinics worked best alongside individual care and there was no evidence to suggest that they offer a means to replace it.
