Additional notes for the lifestyle medicine framework

Group consultations are a structured and well-evaluated new model of care (Wadsworth et al., BMC Family Practice (2019)). The most evaluated model of consultation is where up to 15 patients are seen together in a series of steps supported by a trained facilitator and a clinician. Usually, these patients share similar concerns or conditions, for example asthma, menopause concerns or metabolic ill health (obesity and Type 2 diabetes etc).

Consulting in this way has been part of medical practice for over 30 years in the USA and Australia and the past 5-10 years in the UK. Evidence suggests that consulting in this way can improve clinical outcomes and people’s confidence and ability to manage long-term conditions. (D. Edelman et al. Shared Medical Appointments for Patients with Diabetes Mellitus: A Systematic Review (2015)).

This evidence is particularly strong for people with Type 2 diabetes. There is some evidence for improved clinician satisfaction and indications, particularly from US models, that these could result in cost and time savings (B. Hayhoe et al., Shared Medical Appointments; A promising response to escalating demand for health care (2017)).

In the UK group consultations have been used in primary and secondary care: Introducing group consultations for adults with Type 2 diabetes, NHS England. During COVID-19, video group clinics were used and continue to be an option. 

Group consultations usually start with the facilitator explaining confidentiality, agreeing on how the group might behave and some common 'group understandings'. The facilitator also explains what participants should expect in the session and the role of the clinician. In some groups, with permission of each participant, clinical biomarkers or results of questionnaires may be shared.  Each patient is encouraged to come up with questions about their results and focus on what health goals they would like to achieve and how the clinician might help them achieve this. After a short tea break whilst the facilitator briefs the clinician on the group results and questions, the clinician joins the group for around an hour and consults 1:1 within the group with each patient to answer their concerns. There are often key themes that are identified as priority topics by the patients and a well facilitated group often encourages patients to share ideas and support each other to solve problems. 

The facilitator wraps up after the clinician has left and then supports patients to set their own health goals. They may sign-post to other support within the practice or community. Some patients may be encouraged to attend a 1:1 follow-up appointment to discuss more complex issues that arose or issues they did not want to share within a group setting. Text messages can be used to follow-up or act as a shared plan between the facilitator and participant. Recording in the medical record happens as it usually would after a consultation and the clinician may be able to prescribe, alter or stop medications, arrange further tests and make referrals if needed. If appropriate, certain examinations or procedures such as vaccinations can also occur in a group setting if the participants are happy with this. 

NHS England has further information on the evidence for group consultations, and a toolkit for setting up video group clinics.

Group education 

Group education tends to follow a less formal or tried and tested structure than group consultations, although structured group education has a good evidence base. 

In the United Kingdom's primary care system, group education and group consultations are distinct yet complementary approaches to healthcare delivery. Group education typically involves informational sessions conducted by healthcare professionals to disseminate knowledge and encourage healthy behaviours among participants. These sessions often take the form of workshops or seminars focused on specific health topics. In contrast, group consultations involve a healthcare provider meeting with a small group of patients who share similar health concerns. During group consultations, participants can discuss their individual health issues, share experiences, and benefit from the collective expertise of the healthcare professional. While both group education and group consultations promote patient engagement and peer support, the former emphasises the dissemination of information to a larger audience, while the latter emphasises personalised care within a supportive group setting. Together, these approaches contribute to a comprehensive and patient-centred primary care system in the UK.

As a GPwERLM you may be well placed to support several additional roles within your practice/network/cluster when delivering lifestyle medicine. 

• NHS England supervision guidance
• NHS Scotland guidance
• Northern Ireland guidance
• The Welsh guidance is not exclusively about additional roles but does offer information on supervision of wider team members.

Mental wellbeing

• Warwick-Edinburgh Wellbeing Score
• The Flourishing Scale
• EUROQOL
• The PERMA-profiler

Sleep quality

• NHS sleep self-assessment tool
• Pittsburgh Sleep Quality Index (PSQI)
• The Sleep Condition Indicator (SCI) to assess insomnia
• For suspected sleep apnoea: the Epworth Sleepiness score or the STOP-BANG questionnaire.

Healthy relationships

• The UCLA 3-items Loneliness scale
• Questions used in the Office of National Statistics Community Life Survey (external PDF)

Healthy eating

• Diet metrics such as the DASH-diet metric
• A 24-hour dietary recall, the Automated Self-Administered 24-Hour Dietary Assessment Tool (ASA24)
• The American Healthy Eating Index (HEI) can assess intake of individual dietary components and overall diet.
• Use of apps such as Diet ID (assesses how close dietary intake is to a whole-food plant based dietary pattern) and MyFood24 (allows assessment of a variety of healthy eating patterns, personalised nutrient targets and tracking of progress).

Physical activity

There are several validated tools and questionnaires used in healthcare to assess physical activity levels. These tools are designed to provide reliable and standardised measures of an individual's physical activity. Here are some commonly used validated tools.

International Physical Activity Questionnaire (IPAQ)

The IPAQ (external PDF) is a widely used self-administered questionnaire that assesses physical activity across various domains, including work, travel, and leisure time.

Short Form of the International Physical Activity Questionnaire (IPAQ-SF)

IPAQ-SF is a shorter version of the IPAQ and is commonly used in research and clinical settings to assess physical activity levels over the past week.

Godin-Shephard Leisure-Time Physical Activity Questionnaire

The Godin-Shephard questionnaire focuses on leisure time physical activities and is particularly useful for assessing activities of moderate and vigorous intensity. A simple method to assess exercise behaviour in the community. (1985)

Accelerometers

While not a questionnaire, accelerometers are devices that measure movement and provide an objective assessment of physical activity. They are often worn on the body and can provide detailed information on the duration, intensity, and frequency of physical activity. From watches to chest straps and even phones more and more patients will be able to track activity levels in a great deal of detail. This also allows tracking over time to assess against any agreed goals.

The Physical Activity Scale for the Elderly (PASE)

PASE is designed specifically for older adults and assesses physical activity in various domains, including household, leisure, and work-related activities.

Global Physical Activity Questionnaire (GPAQ)

Developed by the World Health Organization (WHO), GPAQ assesses physical activity in various settings, including work, travel, and recreational activities.

General Practice Physical Activity Questionnaire (GPPAQ)

GPPAQ is a screening tool designed for use in primary care settings to assess the physical activity levels of adults. It is embedded in most primary care clinical systems and is included in new patient registration forms. 

It categorises individuals into one of four physical activity categories:

1. Inactive: Those who are not achieving the recommended levels of physical activity.
2. Moderately inactive: Those who are doing some physical activity but not enough to meet the guidelines.
3. Moderately active: Those who meet the recommended levels of moderate-intensity physical activity.
4. Active: Those who exceed the recommended levels of moderate-intensity physical activity.

GPPAQ is a simple and quick questionnaire that healthcare professionals can use to identify individuals who may benefit from interventions to increase physical activity.

Avoidance of harmful substances and behaviours

• Alcohol, Smoking, and Substance Involvement Screening Tool (ASSIST-Lite)
• Fagerstrom Test for Nicotine Dependence (FTND) – Addiction Research Center, UW Madison
• Pack-years (lifetime tobacco exposure)
• Tobacco, Alcohol, Prescription medication, and other Substance use tool (TAPS)
• Alcohol Use Disorders Identification Test (AUDIT) (external PDF)
• CAGE questions for alcohol use and screening for problem drinking - NICE
• Drug Use Disorders Identification Test (DUDIT)
• Drug Abuse Screening Test (DAST-10)
• Problem Gambling Severity Index (PGSI)
• Gambling Disorders Identification Test (GDIT)
• Internet Addiction Test (IAT)
• Ten-Item Internet Gaming Disorder Test (IGDT-10)
• 7-item Gaming Addiction Scale (GAS-7)
• Bergen Social Media Addiction Scale (BSMAS)
• 19-item Compulsive Sexual Behaviour Disorder Scale (CSBD-19)
• Sexual Addiction Screening Test (SAST)

Case studies have been collected by the BSLM and are hosted on Lifestyle Medicine in Practice - British Society of Lifestyle Medicine (bslm.org.uk)  where you can find more examples. 

North Lewisham PCN Lifestyle Medicine Service 

GP Dr Camille Hirons set up the North Lewisham Lifestyle Medicine Service in the seventh most deprived London borough. 

You can see the full North Lewisham case study on the BSLM.

The Leamington Spa primary care network Personalised Care Hub and Lifestyle Clinic 

This clinic is an example of an interdisciplinary primary care team in England that provides assessment, guidance and support to individuals seeking to address deteriorating health through lifestyle changes. 

You can see the full Leamington Spa case study on Pulse.

West Wales Type 2 Diabetes Remission and Lifestyle Medicine Clinic

GP Dr Nerys Frater set up and supervises a multi-disciplinary team which includes a diabetes specialist nurse, lifestyle coach, a dietitian and herself (a GP with an interest in obesity, weight management and Type 2 diabetes remission).

You can see the full West Wales case study on the BSLM.

County Durham Lifestyle Medicine long COVID service

GP Dr Caroline Gibson set up the long COVID service in County Durham and Darlington NHS Foundation Trust. This clinic embedded a personalised care and lifestyle medicine approach throughout.

You can see the full County Durham case study on the BSLM.