Group clinics for young adults living with diabetes in an ethnically diverse, socioeconomically deprived population: mixed-methods evaluation
Papoutsi C., Hargreaves D., Hagell A., Hounsome N., Skirrow H., Muralidhara K., Colligan G., Vijayaraghavan S., Greenhalgh T., Finer S.
Background Our research was based on the expressed need to evaluate the potential for group clinics to enhance care within the NHS for people with long-term conditions. Objectives We aimed to explore the scope, feasibility, impact and potential scalability of group clinics for young adults with diabetes who have poor experiences of care and clinical outcomes. We applied a participatory approach to the entire research process, where appropriate. Setting Four NHS trusts delivering diabetes care to young adults in ethnically diverse and socioeconomically deprived communities. Participants We involved 135 young adults as participants in our research (73 at two intervention sites and 62 at two control sites). Methods A realist review synthesised existing evidence for group clinics to understand ‘what works, for whom, under what circumstances’. Using the realist review findings and a scoping exercise, we used co-design to develop a model of group clinic-based care, which we then implemented and evaluated using primarily qualitative methods, with quantitative and costs analyses to inform future evaluations. Results Young adults reported positive experiences from the group clinics. However, across the group clinics delivered, only one-third (on average) of those invited to specific clinics attended, despite substantial efforts to encourage attendance, and only 37 out of 73 (51%) participants attended any group clinics. Social learning helped the acquisition of new knowledge and normalisation of experiences. Group clinics met previously unreached emotional needs, and the relationships that formed between young adults, and between them and the staff facilitating the clinics, were key. Clinical staff delivered the clinics using a facilitatory approach, and a youth worker helped to ensure that the care model was developmentally appropriate. Existing organisational structures presented substantial challenges to the delivery of group clinics, and there was considerable hidden work required by the staff delivering them. Group clinics may augment one-to-one care but do not necessarily replace it. The average cost of each group clinic, per participant, was £127–58. Limitations Engagement in co-design and the research process and participation in the group clinics was challenging, and limited our quantitative data analysis. These limitations had implications for the fidelity of the intervention and generalisability of our findings. During the research, we established that group clinics would not replace existing care, and that further work is required to understand the theoretical base of ‘blended’ models of care, and the potential of digital offers, before a definitive evaluation (a cluster-randomised trial) can be designed. Conclusions Our findings show that young adults with diabetes, including those in deprived and ethnically diverse settings, have positive experiences of group-based care, and it may augment existing one-to-one care. However, engagement with group-based care is challenging despite the participatory design. Future work Future research is needed to develop the group clinic model prior to definitive evaluation. Study registration This study is registered as CRD42017058726 and ISRCTN83599025. Funding This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme and will be published in full in Health and Social Care Delivery Research; Vol. 10, No. 25. See the NIHR Journals Library website for further project information.