Virtual group consultations offer continuity of care globally during Covid‐19

Abstract Covid‐19 has led to virtual care (mainly telephone consultations) becoming a default worldwide, despite well‐documented shortcomings. Published evidence on virtual group consultations is limited, although interest and front‐line experience have grown substantially since pandemic onset. Unpublished data are summarised showing feasibility of transitioning care to this model across different countries, care settings and conditions. An international webinar series has supported development and sharing of best practice and representative data on spread and utilisation of virtual groups. This model of care creates time and space for more questions and answers, so once engaged patients become staunch advocates. Group care supports personalised care and lifestyle medicine, which is growing very rapidly. In the current context, even healthcare providers under pressure can implement virtual group consultations. Most virtual group consultations have a facilitator, so this allows roles to be extended and support education of both students and new team members. These can confer greater access, continuity of care, peer support and timely information about Covid‐19 and may result in better health outcomes. Given the rapid and widespread implementation of virtual care during this pandemic, data should be shared effectively and methodologically sound observational studies and clinical trials to test safety and effectiveness should be promoted now.


INTRODUCTION
Rapid pandemic spread of Covid-19 has outpaced hospital and healthcare systems' ability to respond. They have had to adapt quickly to provide testing, treatment and contact tracing for those infected or at-risk.
Concurrently, they have removed vulnerable populations from potential exposure, thus deferring all non-essential care. Mobilizing healthcare's digital revolution 1 and rapid conversion to virtual practices 2 have been deemed essential with virtual care becoming a new default worldwide 3 both for those who may have Covid-19 4 and other patient groups. 5 Individual telephone consultations have expanded rapidly to triage clinical needs, monitor, coordinate testing and treatment.
Although essential, these have limited engagement and require frequent repetition of core messages to each patient. Video consultations improve engagement but do not address repetition or embed peer support. 6

VIRTUAL GROUP CONSULTATIONS
Some limitations are addressed by virtual group consultations: the overarching term encompassing ways of delivering care virtually with groups of patients rather than one-to-one, including virtual/video shared medical appointments. 7 During this pandemic, innovative global solutions are required. Virtual group consultations can provide better access to services, decrease healthcare rationing, avoid healthcare provider burnout and may result in better health outcomes. Given the rapid and widespread implementation of virtual care during this pandemic, methodologically sound observational studies and clinical trials to test safety and effectiveness should be promoted now.

PUBLISHED EVIDENCE
The strongest published evidence on virtual group consultations comes from one small (N = 100) non-randomised mixed-methods study of a pharmacist plus nurse practitioner-delivered model for managing patients with diabetes (HbA1c ≥ 7%). 8 Patients received virtual shared medical appointments or usual care and were followed for 5 months.
This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

CLINICIAN DEMAND
After receiving numerous enquiries about virtual group consultations in the time of Covid-19, we came together to share best virtual group consultation practice with other healthcare providers. Our goals were to consult on how best to: • manage Covid-19 symptomatic patient triage safely and efficiently; • provide continuity of care and peer support for chronic disease patients normally seen face-to-face; • consider virtual groups for antenatal care, which cannot be suspended; • motivate/engage self-isolating/infected staff to contribute by safely delivering care; • inform and empower patients at high risk for Covid-19; and • assist post-Covid-19 pandemic care for patients with deferred routine care.

WEBINARS
An initiative supported by major international lifestyle medicine organisations to share best practice and support clinicians worldwide to deliver virtual group consultations had strong uptake within the first months of the COVID-19 pandemic. We organised three 60-min webi- There are no data yet on whether this will change behaviour positively: the immediate focus is rightly on prevention, testing, treatment and risk reduction. Perhaps over time, these healthy behaviours (especially an emphasis on daily exercise) could improve health, analogous to wartime rationing improving nutrition.

EDUCATION AND ROLE EXTENSION
The pandemic has also had massive impact on both undergraduate and post-graduate education. This has included service pressures and the need for social distancing both restricting educational opportunities and compelling an increasing proportion of education being delivered online. 16 Virtual teaching has both advantages and disadvantages, 17 with advantages including the variety and accessibility. Virtual group consultations are a very feasible teaching platform and are one of the 'new interactive forms of virtual teaching. . . to allow patient interaction from the student's home' . 17 Given that student numbers attending in person group consultations has been a limiting factor for use of this model in undergraduate and interprofessional education, 18 the ease of groups of students from the same or mixed disciplines attending and potential for small groups discussion in breakout rooms are further advantages.
This is also an opportunity for teams to work more closely and effectively together, rather than into silos, and for receptionists, health care assistants and physicians associates to extend their roles as group facilitators and spend time delivering care with clinicians.
So postgraduate education is also supported 7 and there is now a pathway to accreditation for in person and virtual group consultation facilitators (https://bslm.org.uk/group-consultations-facilitatoraccreditation/), enabling them to secure recognition for their knowledge and skills.

SCALING AND ADOPTION
In addition to Covid-19 prevention and care, it is critical to maintain systems for those who need care for non-infectious disease during this epidemic, those who are pregnant or those struggling to manage with on-going chronic disease or mental illness. Virtual group consultations have the potential to deliver more care to more people, provide peer support which is lacking during this time of social isolation and prevent burn-out by re-engaging clinicians from multiple disciplines in collaborative care. This is another example of clinicians leading service reconfiguration during this crisis. 19 We invite healthcare workers to adopt and patients to ask for virtual group consultations; we believe that they are as good or better than current alternatives. Implementation resources have been developed, for example resources for virtual and in person group consultations across different settings developed with the support of Sir Jules Thorn Trust, and these can be used freely in exchange for key data to build the evidence base (https://bslm. org.uk/vgc). In addition, we must implement integrated data systems to measure efficiency, effectiveness and outcomes compared to telephone consultations, one-to-one video consultation and in-person visits. Funders should recognise and incentivise adoption of virtual group consultations.

CONCLUSIONS
Interest in group consultations before Covid-19 was driven by two key editorials 3 years ago. 20 and result in better health outcomes. It is intriguing that scientific convergence and this crisis are leading video consultation and group consultation researchers to both move into the virtual group consultation field along with many others. Cross-fertilisation and collaboration have the potential to boost productivity and implementation science, scaling up to spread essential health innovations. 22 We must set aside inertia. Given rapid and widespread implementation of virtual care during this pandemic, methodologically sound observational studies and clinical trials to test the safety and effectiveness of virtual group consultations should be promoted now.

CONTRIBUTORS AND SOURCES
FB had the idea for the article and is guarantor. The manuscript was drafted by FB and JI, with critical input and review by all authors, who agreed the final version and are jointly accountable for its contents.
Each author has more than a decade of group consultation experience in their own field (aside from the patient panel lead who has > 1 year) and has important experience of training for delivering or assessing virtual group consultation models. The authorship team is international, multi-professional and collaborative, just like the virtual group consultation model espoused and the Lifestyle Medicine readership.