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Teamworking in Primary Healthcare
           REALISING SHARED AIMS IN PATIENT CARE

                                      ...
COMMENTS TO:
   Head of Practice,
 Royal Pharmaceutical
Society of Great Britain,
1 Lambeth High Street,
   London, SE1 7J...
PREFACE



The challenges of healthcare are increasingly complex and subject to frequent change. Meeting these
demands req...
2
FOREWORD



‘Professionalism has contributed a great deal to modern health care, but has inhibited the ability to
achieve ...
4
EXECUTIVE SUMMARY



q   The Forum on Teamworking in Primary                              of the team and adequate time an...
q   The aspirations of the professions and of                  q   A number of examples of teamworking
    individual prof...
SUMMARY OF RECOMMENDATIONS



TEAMS AND TEAM MEMBERS                                       available, where co-location is...
13. Impress upon Government the potential for                   post-basic training. (2.28, 2.33)
   primary healthcare te...
28. Acknowledge and promote the existence and
    value of various team compositions in primary
    healthcare, while acce...
10
1.      INTRODUCTION



1.1 The Forum on Teamworking in Primary                     Service. Teams are important because t...
1.7 The Forum used as its working definition of                time-limited. The different types of team
    primary healt...
1.10 The Forum adopted as its definition of                       eg. community psychiatric nurse, or in a
     teamwork t...
14
2.       EVIDENCE



2.1 Having agreed our definitions, we thought it               q   developing more comprehensive data...
More clinically effective and/or cost                             that it had reduced patients’ use of other
effective ser...
Barriers to teamwork in primary                            Internal team factors
healthcare                               ...
Professional divisions                                           education and training can contribute
2.21 Entrenched att...
Summary                                                      2.32 The absence of mutual respect between
2.29 The research ...
Team size and geographical location
2.37 Differentiating between stakeholder groups
     (having an interest in the servic...
3.      CONTEXT



3.1 The Forum identified a number of                           q National Service Frameworks (NSFs) and...
3.6 Many Community Health Councils are                          initiatives also illustrate the potential for
    represen...
Professional considerations
 ‘I am delighted that the Government has decided
                                             ...
3.16 Continuing professional development is an                    increasing emphasis on teamwork within primary
     esse...
3.21 In addition, there are advances assisting
     professional development, for example
     telemedicine and video conf...
26
4.       TEAMWORKING INITIATIVES



4.1 The Forum was keen both to acknowledge                   maintained in partnership...
The topic areas were chosen to be as inclusive and           North Staffordshire Health Authority established a
 relevant ...
PRACTICE EXAMPLE:                                              PRACTICE EXAMPLE:
 New lifestyle clinic in South Wales     ...
internet version of the scheme, while use of
 PRACTICE EXAMPLE:
                                                          ...
4.13 A third wave of Personal Medical Services
     pilots will go live in April 2001. The first
     pilots are reported ...
32
5.      CONCLUSIONS AND RECOMMENDATIONS



5.1 These have required very careful                       3. Agree set objecti...
Teamworking
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  1. 1. Teamworking in Primary Healthcare REALISING SHARED AIMS IN PATIENT CARE Final Report 2000 Published by the Royal Pharmaceutical Society of Great Britain and the British Medical Association
  2. 2. COMMENTS TO: Head of Practice, Royal Pharmaceutical Society of Great Britain, 1 Lambeth High Street, London, SE1 7JN. Telephone/voicemail: 020 7820 3399 ext 305 Facsimilie: 020 7582 3401 e-mail: vgreen@rpsgb.org.uk
  3. 3. PREFACE The challenges of healthcare are increasingly complex and subject to frequent change. Meeting these demands requires that health professionals work in partnership with each other, with other professionals such as social services staff, and with patients and carers. The value of working as a team has already been recognised. We now need to strengthen and develop teamworking within primary healthcare to provide modern health services for the future. The Forum on Teamworking in Primary Healthcare was convened as a result of a joint initiative between the Royal Pharmaceutical Society, the British Medical Association, the Royal College of Nursing, the National Pharmaceutical Association and the Royal College of General Practitioners. An expanded group of organisations was then brought together, under the chairmanship of Dame Deirdre Hine, to address the practical aspects of teamworking in this context. This report represents the findings of that group. It is addressed to those who lead and who work within teams in primary healthcare, and to the national organisations that represent them. We are grateful to all who have contributed their time and effort to this important report. Mrs Christine Glover Dr Ian Bogle President Chairman Royal Pharmaceutical Society British Medical Association of Great Britain 1
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  5. 5. FOREWORD ‘Professionalism has contributed a great deal to modern health care, but has inhibited the ability to achieve cross boundary solutions based on team work’1. This observation is from an Australian article on the future of hospitals in the next millennium, which was written in 1995. It is surely also true of primary healthcare in some places within the United Kingdom even now that we have reached ‘the next millennium’. An ageing population with complex clinical and social needs, rapid developments in our ability to deliver more and more care outside hospitals and, not least, major new Government-led policy initiatives, make the understanding and removal of such ‘inhibitions’ in the field of primary healthcare an urgent priority. That was the task which this Forum on Teamworking in Primary Healthcare accepted from its sponsoring organisations. We approached it by: gathering and appraising evidence to support the thesis that teamworking in primary healthcare is beneficial both to patients and team members and that it can be cost effective; exploring and analysing factors which promote as well as those that inhibit teamworking, and by identifying and celebrating some of the achievements of teams that have succeeded in overcoming inhibitions and obstacles in their determination to achieve shared goals for patients. The task was not easy. This report is a consensus arrived at only after spirited discussion by members, whose views often differed and occasionally conflicted. I would wish to pay tribute to the honesty, courtesy and constructiveness of the way in which they made their contributions. I trust that we have achieved a report which is greater than the sum of its parts and thus a good example of teamworking at its best! The Forum owes an immense debt of gratitude to its secretariat, which was provided by Christine Gray and Barbara Stewart, without whose skill and hard work the report could not have been produced. They patiently absorbed the ideas of both Chairman and members and have distilled these into a document, whose recommendations to both primary care team members and to the organisations responsible for the individual professions will, I hope, be read and acted upon. I further hope that the progress made will be reviewed to ensure that teamworking in primary healthcare continues to evolve and advance. Dame Deirdre Hine Chairman Forum on Teamworking in Primary Healthcare October 2000 3
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  7. 7. EXECUTIVE SUMMARY q The Forum on Teamworking in Primary of the team and adequate time and resources are Healthcare was convened as a result of a joint also important factors. initiative between the Royal Pharmaceutical Society, the British Medical Association, the q Teamwork does not necessarily follow from Royal College of Nursing, the National professionals working alongside one another. Pharmaceutical Association and the Royal Structural, historical and attitudinal barriers can College of General Practitioners. The Forum and do contribute to difficulties which inhibit was also supported by the Patients Association, teamwork. Problems can arise from competing British Dental Association, Institute of demands, diverse lines of management, poor Healthcare Management, Association of communication, personality factors, plus status Directors of Social Services, Association of and gender effects. Community Health Councils for England and Wales, Doctor Patient Partnership and q The Forum identified a number of contextual Community Practitioners’ and Health Visitors’ issues which were likely to impact on Association. Membership of the Forum is listed teamworking in primary healthcare in the UK. in Appendix 1. The Forum was jointly These embraced the changing health and social sponsored by the Royal Pharmaceutical Society environment, new Government policies, and and the British Medical Association. professional and technological developments. Empowerment of patients to make informed q The remit of the Forum was: ‘to examine the decisions about their wellbeing, health and practical aspects of teamworking in primary healthcare social care will require a more sophisticated and to bring forward proposals by which the national approach to teamworking to meet patients’ organisations representing primary healthcare needs and expectations. professionals can support and promote this concept’. It was hoped that when the report was q There has been a series of Government produced, the national organisations would initiatives which could have a major impact on adopt its recommendations and thus teamworking in primary healthcare (Appendix demonstrate a high degree of joint ownership. 3). Some policy changes might provide ‘windows of opportunity’ for enhancing and q The Forum adopted the World Health encouraging teamwork. The Forum has made Organisation definitions of ‘primary healthcare’ a formal request to the Department of Health and ‘teamwork’ (Appendix 2). for the evaluation of new initiatives, particularly Walk-in Centres, to include their impact, if any, q The available evidence of the effects of on professional teamworking. teamworking, as applied to primary healthcare, was reviewed. The report provides a commentary on the research background and evidence base. The Forum found evidence that effective teamwork is most likely to occur where each team member’s role is seen as essential, roles are rewarding and there are clear team goals. Effective communication, optimum team size, appropriate autonomy for members 5
  8. 8. q The aspirations of the professions and of q A number of examples of teamworking individual professional members are major initiatives in primary healthcare have been catalysts in the development of teamworking. brought together and these illustrate the Limitation of health resources has also spurred richness of opportunities which have been innovative approaches, eg. in the field of grasped in a variety of settings. medicines management. There are, however, indications now that continued shortage of q The Forum has produced two sets of resources is having a detrimental effect on recommendations: one set for teams and their development, particularly in the field of members currently engaged in hands-on clinical information technology. care, and another for consideration by national organisations with responsibilities for team q The number of professionals available currently, members. especially doctors, is unlikely to meet future expectations for timely provision of high quality care, if services continue to be provided in the traditional model. Workforce availability is therefore likely to shape patterns of service delivery in a way which maximises the contribution of scarce skills. Continuing professional development is essential, as professionals working together must have mutual confidence in their fitness to practise and in their ability to keep up-to-date. Joint training opportunities will be important in this respect and in building teams. q The Forum recognised the importance of ensuring that teamworking does not unnecessarily restrict the access of patients to the healthcare professional of their own choice. q There are many technological developments with the potential to influence, or even revolutionise the delivery of primary healthcare. Advances in telecommunications and information technology will increase the ease of information transfer between members of the healthcare team, reducing professional isolation. In addition there are advances assisting professional development and technological developments in patient care, eg. the shift of many aspects of care from the hospital to the home has been made possible. 6
  9. 9. SUMMARY OF RECOMMENDATIONS TEAMS AND TEAM MEMBERS available, where co-location is not practical. (2.25) These recommendations are intended to represent the principles for establishing a primary healthcare 7. Take active steps to ensure that the practice team and to describe what a team member should population understands and accepts the way in expect as the basis for successful teamworking. which the team works within the community. The team should: (1.12, 1.13) 1. Recognise and include the patient, carer, or 8. Select the leader of the team for his or her their representative, as an essential member of leadership skills rather than on the basis of the primary healthcare team at individual status, hierarchy or availability and include in patient-centred team level or at practice level. the membership of the team all the relevant (1.11) professions serving a practice population. (2.24) 2. Establish a common agreed purpose, setting out 9. Promote teamwork across health and social what team members understand by care for patients who can benefit from it, using teamworking, what they aim to achieve as a team members’ joint efforts to help to reduce team and how they propose to do this. (2.18) both ill health and social exclusion. (3.4) 3. Agree set objectives and monitor progress 10. Evaluate all its teamworking initiatives and as towards them. Build into its practice, a result, develop its practice on the basis of opportunities to reflect as a team on the care sound evidence. (3.7) provided and how it could be improved. All team members to be actively involved in the 11. Ensure that the sharing of patient information delivery of the agreed objectives and in the within the team is in accordance with current decision-making process. (2.19) legal and professional requirements. (2.34, 2.35) 4. Agree teamworking conditions, including a process for resolving conflict. Identify NATIONAL ORGANISATIONS predictable problems, which the team might The recommendations of the Forum to national encounter, and plan ways of managing these. organisations involve aspects of support for (2.24) national priorities, education, research and guidance. 5. Ensure that each team member understands They should: and acknowledges the skills and knowledge of team colleagues and regularly reaffirm what SUPPORTING NATIONAL PRIORITIES each member contributes. (2.24) 12. Promote and publicise interprofessional national initiatives designed to address health 6. Pay particular attention to the importance of priorities. (3.9) communication between its members, including the patient and off-site or peripatetic members, and use, to the full, technological developments to assist this as they become 7
  10. 10. 13. Impress upon Government the potential for post-basic training. (2.28, 2.33) primary healthcare teamwork in modernising the NHS and the importance that 21. Highlight in their educational and service Government guidance is seen to support such development initiatives the importance of teamwork whenever appropriate. (3.3, 3.7) organisational factors to the effectiveness of teamworking, including the provision of 14. Seek opportunities to discuss with protected time and resources. (2.15, 2.24) Government the cost-effective potential offered by the provision of appropriate RESEARCH resources in IT for facilitating teamworking in 22. Take positive steps to secure investment in primary healthcare. (3.20) research on teamworking and its impact on primary healthcare. (2.2) 15. Take full advantage of the opportunities offered by National Service Frameworks 23. Promote the evaluation of all new initiatives (NSFs) and national guidelines and give in teamworking by having an evaluation positive guidance to their members on component built into their design. Track developing teamwork to achieve the these initiatives, collate and publicise objectives of the frameworks. (3.9) evaluation results, and disseminate information on good practice to their 16. Seek to ensure that the knowledge gained members. (2.2) from effective teamworking is incorporated into the design of future public policy and 24. Give some priority to evaluating NSFs. (3.9) teamworking initiatives which include health and social care staff. (2.2) EDUCATION 17. Take active steps to facilitate interprofessional GUIDANCE collaboration and understanding through joint 25. When defining primary healthcare teams, conferences, education and training include patients and, where appropriate, initiatives. (3.16) carers, as full team members. (1.11, 1.12) 18. Establish an over-arching structure to help 26. Promote the development of information for provide continuing support and education for the public on the skills and knowledge of teamwork amongst the primary healthcare different health and social care professions, professions. (2.15, 3.16) what they do and the links which exist between them. Also explore ways of 19. Discuss with Government the resourcing of empowering people to care for themselves, facilitation and education on teamworking to when that is appropriate, to access primary ensure the most effective use of professionals healthcare services at the most appropriate in primary healthcare. (2.15, 2.17, 3.16) point, and to make effective and responsible use of services. (3.2, 3.4) 20. Within the responsibility of national bodies for, and their capacity to influence, 27. Publicise the value of teamwork and the undergraduate and/or postgraduate education factors that facilitate good practice in of primary healthcare professionals, recognise teamworking in their communications to that teamwork is a skill, which needs to be their members. (2.22, 2.24) taught and learnt, and build opportunities to develop this into relevant basic curricula and 8
  11. 11. 28. Acknowledge and promote the existence and value of various team compositions in primary healthcare, while accepting the importance of the general practice-based primary healthcare team. (1.12, 3.14) 29. Promote primary healthcare teamworking in partnership with social care, when appropriate for the benefit of patients. (3.4) 30. Take necessary steps to explore with the NHS Executive, NHS Wales and the Scottish Executive NHSiS, the issues of confidentiality and sharing of information as they relate to teams in primary healthcare, so enabling the provision of clear guidance to their members on these important and sensitive issues. (2.34, 2.35) 31. Provide guidance to primary healthcare professionals on legal and ethical aspects of sharing patient information between team members. (2.34, 2.35) 9
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  13. 13. 1. INTRODUCTION 1.1 The Forum on Teamworking in Primary Service. Teams are important because they Healthcare was established in 1999 by the allow those working in them to use their Royal Pharmaceutical Society of Great diverse knowledge, skills and experience to Britain (RPSGB) and the British Medical contribute to collective decision-making and Association (BMA). The Forum was achieving desired outcomes. This has convened as a result of a joint initiative obvious relevance to the provision of high between the BMA, RPSGB, the National quality health and social care to both Pharmaceutical Association (NPA), the individuals and populations. Royal College of Nursing (RCN) and the Royal College of General Practitioners 1.4 Over the past twenty years, professional staff (RCGP)2. An expanded group of in both primary and secondary healthcare organisations was then brought together have attempted to develop and practise including: the Patients Association (PA), teamworking in the care of patients. In the British Dental Association (BDA), Institute primary healthcare context much valuable of Healthcare Management (IHM), work has been done in promoting and Association of Directors of Social Services practising teamwork. This is especially so (ADSS), Association of Community Health within the groups of staff belonging to or Councils for England and Wales associated with Group Practices, in some of (ACHCEW), Doctor Patient Partnership, which the concept has been fully developed and Community Practitioners’ and Health and is working well to the benefit of patients. Visitors’ Association (CP&HVA). The Teamwork has more recently been extended membership of the Forum is detailed in in some instances to include social care staff. Appendix 1. The Forum held five meetings between October 1999 and June 2000. 1.5 However, teamworking within healthcare settings is more complex and difficult to 1.2 The terms of reference of the Forum were achieve than is commonly understood. Both ‘to examine the practical aspects of the structure and processes of primary teamworking in primary healthcare and to healthcare have features that constitute bring forward proposals by which the barriers to interprofessional co-operation and national organisations representing collaboration and that impede effective team primary healthcare professionals can decision-making. support and promote this concept’. It was hoped that when the report was produced, 1.6 The members of the Forum had the task of the national organisations would adopt its identifying the factors that promote or recommendations and thus demonstrate a alternatively impede the full development of high degree of joint ownership. teamworking in the care of patients in a primary healthcare context. One of the first 1.3 The importance of teamworking in tasks was to agree a set of definitions from achieving the aims of organisations was among the plethora of those available in the established at least seventy years ago3. literature (see Appendix 2). However, only in the past twenty years has that idea been acted on widely by large organisations, including the National Health 11
  14. 14. 1.7 The Forum used as its working definition of time-limited. The different types of team primary healthcare ‘the first level contact of were characterised by their differing intensity individuals, the family and the community of communication between the members - with the national health system which intermittent in the networks; tighter, though brings healthcare as close as possible to broad, communication in the practice-based where people live and work, and teams and frequent, full, but narrower and constitutes the first element of a continuing more specific communication in the patient- health process’ (WHO declaration of Alma- centred team. Ata, 1990)4. 1.9 We concluded that the concept of the team 1.8 There was more difficulty with the definition in primary healthcare was a dynamic rather of the primary healthcare team, since it than a static one, changing to meet the seemed to us that various levels of team could changing needs of patients and groups of be described: from networks which included patients in different situations and reflecting to both health and social care staff, through the some extent the changing nature of health more formally structured teams based around care delivery. Individuals could therefore be general medical practices, to small individual contributing as members of different teams at patient-centred teams, often task-based and different times, or even simultaneously. Teamworking in primary healthcare COMMUNITY MEDICAL SPECIALISTS Teamwork in primary healthcare is flexible and PODIATRIST SOCIAL CARE WORKER dynamic, centred on the needs of patients and GP PRACTICE carers. This diagram OPTOMETRIST NURSE illustrates how teams MIDWIFE DISTRICT might form around a NURSE DENTIST particular patient, for PATIENTS & example to provide CARERS NHS DIRECT services to: WALK IN DIABETIC DIETICIAN CENTRE NURSE a person with diabetes PHARMACIST a parent with young THERAPIST children MENTAL a person needing dental HEALTH CONTINENCE treatment NURSE HEALTH NURSE a person with mental VISITOR health problems 12
  15. 15. 1.10 The Forum adopted as its definition of eg. community psychiatric nurse, or in a teamwork that of the World Health voluntary organisation eg. a palliative care Organisation: ‘Co-ordinated action nurse. carried out by two or more individuals jointly, concurrently or sequentially. It 1.12 Developing further the theme of the patient implies common agreed goals, clear as a team member, other scenarios for awareness of and respect for others’ roles involvement include: membership of a and functions’. A fuller description can be service team eg. patient participation groups found in Appendix 2. at a GP practice; and/or membership of a policy-making and monitoring organisation 1.11 One important point emerging from this within a Primary Care Group/Trust discussion was that few, if any, definitions of (PCG/PCT) in England, Local Health the primary healthcare team included the Group (LHG) in Wales or Local Healthcare patient as a member. It was clear that using Co-operative (LHCC) in Scotland. The patient needs and preferences as a starting vital role of carers and the contribution they point could change the perception of team can make to complex packages of care composition. For example, many patients should not be overlooked. Patients (and with short term or acute conditions might carers) should be the centre of attention for interact primarily with a very small team all primary healthcare service provision. consisting of receptionist, doctor and possibly, pharmacist. However, patients 1.13 The Forum concluded that the concept of with longer term or chronic illnesses might the primary healthcare team could be need a wider team including the practice applied to a spectrum of groups in primary nurse, district nurse, physiotherapist or healthcare with members being drawn from other profession allied to medicine, different organisations, while recognising pharmacist and social care worker, with that for most members of the public the more intermittent involvement of the most easily recognised and understood team doctor. In still other cases, the team, even is that based around the general practice. though delivering care to a patient in his or Our discussions embraced all these levels her own home, might include a carer as from networks to task-related, patient- well as members based in secondary care, focused teams. 13
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  17. 17. 2. EVIDENCE 2.1 Having agreed our definitions, we thought it q developing more comprehensive databases important that our discussions should begin leading to better identification of health with a review of the available evidence of the problems, leading to effects of teamworking as applied to primary q developing better and more healthcare. comprehensive healthcare plans. 2.2 The Forum recognised that much of the More responsive and patient-sensitive research data on teamworking was ‘soft’ services compared with published clinical data: 2.4 A team approach to primary healthcare can qualitative rather than quantitative and with improve accessibility for patients. Much of few, if any, randomised controlled trials. the research evidence centres on reducing This section of the report, therefore, the general practitioner’s workload and provides a commentary on the research thereby increasing the number of patients background and evidence base rather than a who can be seen5 and reducing the length of comprehensive critical appraisal. On behalf time patients need to wait for an of the Forum, the Health Policy and appointment, or enabling a more ‘patient- Economic Research Unit of the BMA centred’ consultation6. reviewed the published research literature on the value of teamwork in primary healthcare. 2.5 GPs sharing home visits with other team Individual members also drew our attention members may make it possible to increase the to published work. As stated in the average number of contacts patients have Introduction (1.10), the definition of with a health worker, thereby improving teamwork was taken as that given by the patient satisfaction. Teamwork can enable the World Health Organisation (Appendix 2). expansion of the range of services available to patients. This offers more integrated care, Benefits of teamwork in primary reduces duplication and can be more healthcare convenient for the patient5. Teamwork can 2.3 The review of the research evidence showed also enable doctors to manage larger list sizes that benefits of teamwork could be classified and, through sharing home visits, increase as: intensive home care to patients who are q a more responsive and patient-sensitive seriously ill, potentially reducing referral rates service to hospital5. q a more clinically effective and/or cost effective service, and 2.6 Many Community Health Councils (CHCs) q more satisfying roles and career paths for have made a positive contribution to GP primary healthcare professionals. services in their area7. For example, a model The most frequently cited advantages of team care of partnership for Primary Care Groups and over traditional care were: CHCs in West Sussex has been developed, which includes looking at potential q aspects of improved organisation and difficulties and mutual gains, while making planning proposals for effective joint working8. q avoiding duplication and fragmentation 15
  18. 18. More clinically effective and/or cost that it had reduced patients’ use of other effective services practice services20. Practice pharmacists can 2.7 The advantages to patients of a team promote rational prescribing, manage the approach are said to accrue through a group drugs budget, and develop and implement process of ‘co-operation’, ‘co-ordination’ or repeat prescribing policies21. A pharmacist- ‘collaboration’9. When care outcomes of managed, practice-based anticoagulant teamwork were measured, the benefit to the clinic has reduced waiting times and patient of professionals working together was travelling costs for patients, while improved greater than would have been achieved had communication between the GPs and they worked in isolation. The best patient pharmacist reduced the risk of toxicity and outcomes were achieved after contact with treatment failure22. Aside from their role the least hierarchical team model9. Effective with patients on prescribed medicines, team care for chronic illness often involves community pharmacists are readily professionals outside the group of individuals accessible to the public for consultation working in a single practice10. about self-limiting conditions and some chronic conditions, a quicker option than 2.8 Secondary care examples may provide useful seeing a doctor23. models for primary healthcare. Some Enhanced job satisfaction randomised controlled trials11,12 have shown that patients treated by a multidisciplinary 2.12 Teamwork can reduce work-related stress team in a geriatric unit had a lower mortality among general practitioners by reducing rate than controls, while team-care of stroke workload. Being able to spend more time patients resulted in significantly higher scores with patients may also reduce stress for the for motor performance and functional ability GP24. A large research study on than traditional care patients. teamworking in the healthcare setting, where the team was defined as ‘a group of 2.9 Organisational advantages of people with shared objectives and a unique multidisciplinary teamwork have impacted contribution from each other’, showed that clear favourably on: health surveillance, benefits of teamworking were improved management of chronic disease, terminal care staff wellbeing and with it, increased and the psychosocial impact of illness13; in performance25. Holland a general practice diabetic clinic14; a practice-based cervical cancer screening call 2.13 Nurses’ involvement in teamwork should system15 and preventive care of patients in a increase job satisfaction by reducing severely deprived area of England16. perceived alienation, although the extent to which nurses and other members of the 2.10 Some studies have identified improved team participate in decision-making efficacy through deployment of the skills currently varies between teams26. A and expertise of primary care professionals, research project, which explored the role of for example, evaluation of nurse-run asthma shared learning involving clinical team case and hypertension clinics17,18,19. studies, showed that, in those teams where there was more collaborative working, 2.11 As well as medical practitioners, other team there were clear benefits for patients, carers members can and do contribute directly to and the team itself27. making primary care services more cost- effective. A recent audit of the introduction of a home-based counselling service found 16
  19. 19. Barriers to teamwork in primary Internal team factors healthcare 2.17 Internal factors include people’s inertia, 2.14 Teamwork does not necessarily follow from satisfaction with the status quo, and an professionals working alongside one inability to attract support for innovation. another and some researchers have observed Recognising when facilitation can make a that the path to achieving teamwork may be useful contribution can help to overcome a long and difficult one28. Structural, these factors35. historical and attitudinal barriers contribute to the difficulties. In some circumstances 2.18 The existence of clear objectives, full teams may perform less effectively than participation, an emphasis on quality and individuals working alone29. The published support for innovation have been found to literature30 provides evidence of the account for a quarter of the variation problems of: between teams in their effectiveness. In q competing demands particular, clarity of and commitment to q diverse lines of management team objectives was key in predicting the q poor communication overall effectiveness of the primary q personality factors, plus healthcare team32. ‘Bad processes rarely q status and gender effects. produce good outcomes’36. Organisational structure 2.19 A study of competencies in primary 2.15 Potential organisational obstacles include healthcare teams found that the majority of different lines of management into primary teams had a strong commitment to healthcare teams, which can undermine developing teamwork and learning. attempts at teamworking29,30,31. Added to However, many experienced difficulty in this are different payment systems associated planning strategically for the team’s with the independent contractor status of development. Competing demands were some team members. A further barrier in implicated and, from some team members, primary healthcare is the lack of any over- particularly GPs, lack of appreciation of the arching structure, which could provide need for strategic planning37. continuing support and education for teamwork. As with so many areas of work Time constraints in healthcare, inadequate staff and resources 2.20 Insufficient time for formal and informal may also constitute a barrier. meetings of the team, and the contractual obligations of some important off-site team Size and location of teams members, can lead to individual team 2.16 Team size can be a critical factor; the members not having the appropriate level of increasing size of some extended teams can contact to fulfil their own and the team’s be disadvantageous32. Experience suggests needs. ‘Teamwork takes time because each new that large teams (greater than 20) are less team member multiplies the need for effective than smaller teams, where it is communication and co-ordination’33. easier to engage members and communicate effectively33,34. Geographical separation can be an issue for some teams and/or members. Teams in general practice may be small when formed around the needs of individual patients. 17
  20. 20. Professional divisions education and training can contribute 2.21 Entrenched attitudes of team members can positively to strengthening group lead to team conflict. These can include processes36. lack of understanding and respect for other professional roles. Some individuals or Communication groups may be unable to relinquish 2.25 Agreed and easy to use communication positions in a team to other more suitable channels are essential for successful members, holding on to power or status29. teamworking, particularly when individuals are not normally located in close proximity Factors which promote teamwork to each other. Mistrust, apprehension 2.22 The published literature supports the view regarding role encroachment and a lack of that effective teamwork is most likely to understanding of other professions may well occur where: be a direct result of previous poor q each team member’s role is seen as communication40. essential q roles are rewarding, and Team members q there are clear team goals. 2.26 People who work best in a team environment are those who are not only Other factors important in promoting teamwork are: capable of performing their own tasks but q effective communication who also possess knowledge, skills and q optimum team size attitudes that support their team29: q recognition of team members’ q supporting and building on the work of professional judgment and discretion, and others q adequate time and resources. q getting along with others, and Teams could be helped by: q managing conflict. q having a shared learning process, and Multidisciplinary education, training and q working on team development36. continuing professional development (CPD) 2.23 The creation of integrated nursing teams (INTs) represents one example in the 2.27 Collaborative practice and work-based development of more integrated primary learning enable practitioners to learn more healthcare38,39. Integration has been effectively together41. There are defined as ‘bringing into equal partnership’ opportunities for teamworking through and teamworking as being about ‘sharing CPD linked to current healthcare skills, not preserving existing roles’. initiatives, for example through the clinical governance agenda and the work of local Group processes Primary Care Groups. 2.24 Good working relationships are built and 2.28 Guidance on the general clinical training of maintained by team members doctors during the pre-registration year understanding and acknowledging each reiterates the importance of building on the other’s skills and roles. Team leadership teamworking skills learnt as an skills are required. Agreeing a process for undergraduate42. resolving conflict assists the identification and management of predictable problems25,29. Multidisciplinary activities such as audit, pilot projects, and joint 18
  21. 21. Summary 2.32 The absence of mutual respect between 2.29 The research background and evidence base professional groups and, at its worst, the has confirmed the potential for perception within individual professions teamworking in primary healthcare and has that they are ‘demonised’ by others, can also identified factors which can help its inhibit teambuilding. promotion. A number of barriers to co-operation and collaboration in the 2.33 Renewed and more effective attention to delivery of primary healthcare are teamworking in undergraduate and acknowledged. However, the evidence pre-registration education was thought to suggests that these can be overcome. be required. Discussion Information sharing and confidentiality 2.30 The review of the evidence during 2.34 It was felt that greater sharing of patient meetings of the Forum generated much information within the team had lively discussion. Members contributed implications for issues of confidentiality and additional points from their own experience patient consent. There is potential for on the following issues: conflict between ‘sharing information’ and q specific conflicts in practice ‘preserving confidentiality’. Uncertainty q information sharing and confidentiality amongst professionals about legal and q the patient’s perspective, and ethical aspects of sharing patient q team size and geographical location. information amongst the team, important for teamworking, can create barriers. Specific conflicts in practice 2.35 Following publication of the Caldicott 2.31 The Forum considered whether the Report (1997), local ‘Caldicott Guardians’ inclusion in teams of independent have been appointed to safeguard contractors (dentists, GPs, optometrists and confidential patient information. The new pharmacists) alongside employees could national Confidentiality and Security create friction. It was recognised that, with Advisory Body should ensure that all NHS a predominance of self-employed or bodies have robust guidance on how to independently contracted professions in handle confidential information43. primary healthcare, there were areas from which a financial conflict of interest could The patient’s perspective potentially arise. However, the Forum received no evidence that any perceived 2.36 Clearly, charging for care services can be a conflict of interest worked against the best barrier within the wider team, from the interests of either patients or of the taxpayer. patient’s perspective. This may arise Indeed, rather than being a barrier, between health services and social services independent contractor status may confer as the latter are often means tested. Also, freedom to provide flexible solutions. By while younger users of services may expect contrast, commercially sponsored a team approach, older patients may be practitioners, for example some specialist accustomed to an individual approach and nurses, were seen by some as a possible may be resistant to teamworking. threat to teamworking and thus to optimal care. 19
  22. 22. Team size and geographical location 2.37 Differentiating between stakeholder groups (having an interest in the services provided but not directly providing or receiving them) and members of the team is important, as the former are appropriately represented in a steering group but not necessarily in the ‘working team’. 2.38 It was reiterated in discussion that the issue of location was important to some professionals, for example community pharmacists, who often need to be situated within high street or housing estate locations to satisfy patient/client demand and expectations. But this physical separation has caused problems of isolation, which have adversely affected the profession’s ability to maximise its contribution to healthcare. 20
  23. 23. 3. CONTEXT 3.1 The Forum identified a number of q National Service Frameworks (NSFs) and contextual issues, which were likely to clinical governance impact, whether positively or negatively, on q Health Action Zones (HAZs) and Healthy teamworking in primary healthcare. These Living Centres (HLCs) embraced the changing health and social q quality initiatives in organisation and environment, new Government policies, and service provision, for example support for professional and technological developments. PCTs and PCGs from the A brief résumé is presented in this section. multidisciplinary National Primary Care Development Team in England. The changing health and social care The development of ‘intermediate care’ in the environment community could potentially have major impacts 3.2 Issues include: on primary healthcare teams. q demographic changes, which are likely to increase demand 3.4 Primary Care Groups in England, Local q development of consumer/patient power Health Groups in Wales and Local Health through both greater access to Care Co-operatives in Scotland are intended information and cultural changes to provide a direct means by which GPs and q the acceptance of a patient-centred community nurses, working in co-operation approach to healthcare with other health and social care q concern about standards of physical care professionals, voluntary organisations and lay of elderly people people, can lead the process of securing q preventive care with recognition of wider appropriate, high quality care for their determinants of health at local and community. practice population level q changes in the provision of education, 3.5 New initiatives such as: Health Action transport and social services, and Zones; Healthy Living Centres; Walk-in q the care of deprived groups being more Centres; Personal Medical Services (PMS) dependent on partnership between health pilots, and NHS Direct should stimulate and social care. innovative approaches to providing Patients are being empowered to make informed healthcare in the community. In particular, decisions about their well-being, health and social there is potential for integration of NHS care. Meeting their needs and expectations will Direct and Walk-in Centres with other demand a more sophisticated approach to services, for example the formal referral of teamworking using different models. patients by NHS Direct nurses to community pharmacists or the potential use of clinical Government policy decision support systems by a range of 3.3 There has been a series of Government different health professionals in a number of initiatives which could have a major impact settings, facilitating appropriate referrals. on teamworking in primary healthcare However, there is also the potential for a (Appendix 3). These include: two-tier system to develop, with the young, q establishment of PCGs/PCTs in England; healthy and employed being well served by LHCCs in Scotland; LHGs in Wales Walk-in Centres, while others with q NHS Direct and Walk-in Centres significant health problems remain more reliant on traditional-style primary healthcare. 21
  24. 24. 3.6 Many Community Health Councils are initiatives also illustrate the potential for represented on NHS Direct Boards, and interprofessional collaboration on a national CHCs have received largely positive level to address health priorities. Both NSFs feedback from patients: faster access to health issued at the time of drafting this report care and satisfaction with the quality of (Coronary heart disease and Mental health) advice given. However, a number of issues refer explicitly to standards in primary have been raised, for example the need for healthcare. careful integration of multiple primary healthcare services44. EXAMPLE: NSF for Coronary Heart Disease ‘OCTOBER 2000 PRIMARY CARE 3.7 The Forum has made a formal request to the MILESTONE - Clinical teams should meet as Department of Health for the evaluation of a team at least once every quarter to plan and new initiatives, particularly Walk-in Centres, discuss the results of clinical audit and, generally, to include their impact, if any, on to discuss clinical issues. PCGs/PCTs and professional teamworking. We were pleased hospitals that together form a local network of to receive assurance that the research cardiac care should have effective means for protocol agreed for the evaluation of agreeing an integrated system for quality Walk-in Centres would take account of the assessment and quality improvement. issues raised by the Forum. Only full evaluation of Walk-in Centres will PRIMARY CARE NSF GOAL - Every demonstrate whether they enhance or detract primary care team should ensure that all those from effective teamwork. with heart failure are receiving a full package of appropriate investigation and treatment, 3.8 A first year evaluation of Personal Medical demonstrated by clinical audit data no more than Services (PMS) pilots45, where GPs are 12 months old’46 . salaried practitioners, indicates that the majority of sites (in the study) have an 3.10 The prescribing and supply of medicines is internal focus and are using PMS to develop an important element of primary healthcare. A primary healthcare services within the report commissioned by the Department of practice. Developing a more community- Health47 recommended an extension of oriented focus and links with other NHS and prescribing authority to further groups of non-NHS organisations has been achieved in professionals with particular training and expertise only a small number of pilots. Of particular in specialised areas. The review team’s significance has been the introduction of new recommendations included the supply and roles for nurses. A third round of PMS pilots administration of medicines under patient group has been approved with a view to them directions, where appropriate, in limited going live in April 2001. circumstances. Extending the scope of nurse prescribing should mean more specialist nurses 3.9 NSFs, if properly resourced, together with (for example in asthma or diabetes) being able to the guidance produced by the National treat more patients with a wider choice of Institute for Clinical Excellence (NICE) for medicines than they are able to do at present. The England and Wales and clinical governance, Department of Health will be considering as reviewed by the Commission for Health legislation to allow ‘supplementary’ prescribing by Improvement (CHI) in England and Wales, other health professionals, such as pharmacists, together with their equivalent, the Clinical physiotherapists and chiropodists, for example Standards Board for Scotland; are likely to where repeat prescriptions are provided or dose enhance and encourage teamworking. These adjustments are made. 22
  25. 25. Professional considerations ‘I am delighted that the Government has decided 3.13 Issues include: to take forward the recommendations of the q numbers of professionals available, Review of prescribing. I have no doubt that the planning for future demand, and changes that are being introduced will improve our skill mix to maximise effectiveness of care of patients, make better use of the skills and care professionalism of staff and encourage more q maintenance of professional effective teamwork.’ Dr June Crown, March competencies and life long learning 2000, referring to Medicines Control Agency q rapidly expanding and changing consultation MLX 260. professional knowledge q lack of clarity of clinical responsibility in 3.11 Extending prescribing rights to more health multiprofessional teams professionals carries with it the real problem q achieving co-ordination of care. of maintaining communication between all those involved. The need for relevant 3.14 The number of professionals available patient records to be accessible to all currently, especially doctors, is unlikely to prescribers, together with effective meet future expectations for timely communication between ‘independent’ and provision of high quality care, if services ‘dependent’ prescribers is highlighted in the continue to be provided in the traditional Crown report47. Independent prescribers are model. Workforce availability is therefore those responsible for the assessment of likely to shape patterns of service delivery in undiagnosed conditions and for making a way which maximises the contribution of decisions about the clinical management scarce skills. These factors are bound to required, including prescribing; while encourage greater use of delivery of care by dependent prescribers are responsible for the teams. This will involve ensuring that the continuing care of patients who have been skills of all team members are used by clinically assessed by an independent allowing them to contribute to their full prescriber. potential. However, it is important to ensure that teamworking does not 3.12 Some policy changes might provide unnecessarily restrict the access of patients ‘windows of opportunity’ as PCGs, LHGs to the healthcare professional of their own and LHCCs present opportunities for choice. improving teamwork - ‘a coming together of equals’48. However, there are some 3.15 The aspirations of the professions and of differences in the current representation of individual professional members, some of various team members on PCG/LHG/ whom have been described as ‘leading edge LHCC boards. For example, pharmacists practitioners’, are major catalysts in the and others are represented as of right on development of teamworking. Somewhat Welsh LHG boards but not on PCG boards paradoxically, limitation of health resources in England. Lay members are represented has also spurred innovative approaches, for on PCG/PCTs and LHGs as of right and example in the field of medicines hence involved in strategic decision-making management. The evolution of primary for the local population. In Scotland, there care pharmacists was stimulated initially by is no ‘blueprint’ for lay inclusion on LHCC the need to introduce additional expertise boards but a requirement for membership to GP practices on prescribing issues and to reflect local need. These differences through this, teamworking has been illustrate factors which are arguably not developed and supported. conducive to teamworking. 23
  26. 26. 3.16 Continuing professional development is an increasing emphasis on teamwork within primary essential supporting feature of clinical care and ‘seamless care’, patients must benefit governance. Professionals working together from the integration of pharmacists into the must have mutual confidence in their fitness ‘extended’ diabetes team...in the same way that to practise and in their ability to keep local optometrists, podiatrists etc are’. up-to-date. Skills must keep pace with new thinking and new techniques. Joint training Technological developments opportunities will be important in this 3.19 Issues include: respect and in building teams. q potential for IT to improve communication between team members 3.17 The RCGP’s current quality initiatives q more complex care being provided close include: Quality Team Development; the to home, demanding more teamwork Quality Practice Award, and Fellowship by q developments in clinical genetics (it is Assessment. In developing these initiatives unclear how much of this will be the College has worked regularly with undertaken in primary healthcare and other organisations and has drawn on its how this might impact on teamworking) Patient Liaison Group to ensure the q telemedicine and video conferencing. contribution of patients. With support from the NHS Executive, the Quality Team 3.20 There are many developments with the Development programme provides potential to influence, or even revolutionise continuous assessment and accreditation of the delivery of primary healthcare. The use primary healthcare teams. of IT has major potential to facilitate the development of teamworking in primary The Quality Practice Award (QPA): healthcare because it provides an answer to ‘An award presented to a practice in recognition of the problem of immediate communication its achievement in meeting criteria that reflect a between team members who are not high quality standard of patient care provided by geographically co-located, whether the the whole primary healthcare team. QPA has district nurse on her round of patients in specific recognition of the working environment their own homes or the pharmacist within general practice and the increasing inter- on the high street. Advances in relationship of all members of the primary telecommunications and information healthcare team in delivering quality patient care. technology will increase the ease of Recognising this teamwork and its benefits to information transfer between members of patient care is the ethos behind QPA. By January the healthcare team, reducing professional 2000, 12 practices had achieved QPA and isolation. Mobile telephones and e-mail commonly reported the experience to have led, facilities are obvious examples, while the amongst other things, to better teamwork. A electronic patient record, when achieved, further 82 practices had notified their intent to should also contribute enormously to apply for QPA.’ RCGP 200049. improved communication. 3.18 Recent practice guidance from the Royal Pharmaceutical Society on the care of patients with diabetes50 encourages community pharmacists to become members of the extended diabetes team: ‘To date, pharmacists have not actively pursued membership of the diabetes team but with an 24
  27. 27. 3.21 In addition, there are advances assisting professional development, for example telemedicine and video conferencing. These advances might provide better opportunities for consultation between, and joint education and professional development of, primary healthcare professionals. 3.22 Technological developments in patient care have stimulated a major increase in the number of patients, particularly the elderly, on complex regimens at home or in the community. Near-patient testing; hospital at home; parenteral nutrition; aspects of home-based palliative care: all include such technological developments with direct benefits for patients and also a requirement for effective teamwork. 25
  28. 28. 26
  29. 29. 4. TEAMWORKING INITIATIVES 4.1 The Forum was keen both to acknowledge maintained in partnership with the patient important work being done on aspects of and the process enables electronic clinical teamworking and to encourage primary information to be shared across the primary healthcare teams to build on successful healthcare team at the point of practice. A examples. The following are a small sample standard clinical language is used. SCIPiCT of teamworking initiatives, drawn from the is a consortium between the primary literature or suggested by Forum members. healthcare team (centred on Arwystli Medical Practice in Llanidloes & Caersws), Communication the local NHS Trust and County Council, 4.2 Agreed and easy to use communication commercial suppliers and academic partners. channels between health professionals are The rural geography had contributed to essential for successful teamworking, difficulties of traditional information transfer particularly when individuals are not and communication, particularly for normally located in close proximity to each peripatetic staff. An ongoing core activity of other. the project is the development of a multidisciplinary clinical information system PRACTICE EXAMPLE: Joint workshops and piloting of applications and 52 Two pilot projects have helped pave the way to technologies . improving local communication between community pharmacists and GPs. The Multidisciplinary education, training and workshops, held in mid 1999 in Nottingham and continuing professional development Manchester, brought pharmacists and doctors together to discuss matters of common interest such 4.3 Organisations such as CAIPE (UK Centre as management of repeat prescriptions, self- for the Advancement of Interprofessional medication, co-operative working and the links Education) support the view that shared between pharmacists and PCGs. The workshops educational experiences lead to shared were organised jointly by the Doctor Patient understanding. Partnership and the Royal Pharmaceutical PRACTICE EXAMPLE: a collaborative Society. ‘These workshops have provided an ideal education and training initiative for forum to show how many common agendas there community pharmacists and GPs. are and how each profession can help the other, for patient benefit’51. An invited group of community pharmacists and GPs in the Greater Glasgow Health Board area shared a series of three direct learning courses commissioned from the Scottish Centre for Post PRACTICE EXAMPLE: SCIPiCT Qualification Pharmaceutical Education. The Consortium, Powys, Wales underlying goal was to promote better Sharing Clinical Information in the Primary understanding between the professions and to Care Team (SCIPiCT), an initiative of the explore methods of strengthening the primary National Assembly of Wales, is a 3-year healthcare team. demonstration project, which promotes a Course topics included: ‘cost of non-compliance in patient focus based on one multiprofessional hypertension’, ‘managing minor ailments’, and electronic clinical record. The record is ‘repeat prescribing and medication review’. 27
  30. 30. The topic areas were chosen to be as inclusive and North Staffordshire Health Authority established a relevant to the practice situation as possible. scheme for domiciliary visits by pharmacists, Course providers deduced from the evaluation of incorporating referrals from GPs, community the initiative: increased awareness of each of the nurses and social services. Patients’ medication- professional roles, more positive attitudes towards related problems were identified and each profession and the potential for collaboration. recommendations on changes in medicines made by The benefits of this initiative were found to be the pharmacists to the GPs55. mainly in terms of impact on the professionals themselves53. PRACTICE EXAMPLE: Glasgow repeat medication clinics EXAMPLE: ENB research project, Brighton University The aim of this study was to compare the impact of a pharmacist-directed medication review clinic A study involving analysis of the role of within a general practice setting to the practices’ collaborative/shared learning in pre- and post- usual system. The study design was a randomised registration education in nursing looked at the controlled trial, with control patients compared to a extent and nature of shared learning and the pharmacist intervention group (active group). Six problems related to its provision. The findings practices recruited to the study had a total practice revealed that very little of the current provision of population of 26,000. All patients aged 20 years multiprofessional education in universities or more and who were receiving four or more addressed inter-professional issues. But medicines on repeat prescription were invited to professional bodies were not identified as creating attend a pharmacist-directed medication review barriers to shared learning27. clinic. The pharmacist reviewed the case notes and computer-held records of patients before each New services; new roles interview to determine the continued appropriateness of the medicine regime. All drug- 4.4 Medicines management is a problem that related problems in the active group were identified concerns all those involved in primary and and referral made to the GP with specific community care but it affects vulnerable recommendations. For the control group, the process people and their carers most of all54. The was identical except that the care issues were frail, the elderly and those with learning recorded but not passed on to the GP. All difficulties or mental health problems are recommendations agreed with the GP were particularly prone to poor medicines implemented by the pharmacist. Outcomes, management. There is a strong rationale for including cost effectiveness and measures of health attempting to address the problem because gain, were measured at 6-12 months after the consequences are so costly in both implementation of changes. financial and human terms. The referral rate was high (63-94%) and the 4.5 Medicines management is an ideal example rejection rate low at only 3%, indicating that GPs of teamworking between health and social were receptive to the pharmacist recommendations. care. Several examples, which follow, The study demonstrates that a pharmacist-directed illustrate a variety of such developments in medication review clinic, within the GP practice practice. setting, can reduce inappropriate prescribing. The results contribute to the evidence base on which to PRACTICE EXAMPLE: develop the proposed ‘dependent prescribing model’ Improving medicines management for the contained in the Crown Review on the prescribing elderly and housebound and supply of medicines56. 28
  31. 31. PRACTICE EXAMPLE: PRACTICE EXAMPLE: New lifestyle clinic in South Wales Hillingdon Health Authority, 1997 Three GP practices in South Wales have teamed The authority developed extended primary care up with a local pharmacist to try to improve their teams, consisting of GPs, nurses, administrative patients’ lifestyles. Patients are being referred to a staff, wider nursing services (school nurses, new lifestyle clinic in Neyland, run by a local community mental health nurses, Macmillan community pharmacist. The clinic is aimed at nurses and midwives) as well as other specialities people at risk of heart disease. Referred patients such as podiatry, physiotherapy and pharmacy. have their general health and risk of heart disease Evaluation demonstrated improved communication assessed by the pharmacist. The scheme is being within the extended team and much closer working run as a pilot scheme initially, with financial between practice and attached nursing staff 38. assistance from Dyfed Powys health authority57. 4.6 Problems with repeat medication are PRACTICE EXAMPLE: generally recognised. An increasing number Downfield Surgery, Dundee of pharmacists are employed by GP practices An upper GI clinic run at the surgery has and PCGs, PCTs, LHCCs and LHGs. These provided early serological testing for Helicobacter primary care pharmacists have a legitimate Pylori. The protocol has involved each patient role in contributing to cost-effective presenting with symptoms of dyspepsia being prescribing and medicines management. reviewed by the GP. Patients on long-term treatment with H2 antagonists or proton pump PRACTICE EXAMPLE: inhibitors have also been reviewed. Following North Yorkshire community pharmacist assessment and initial treatment, the patient has been managed by the practice-based pharmacist, A community pharmacist is employed by her local being referred back to the GP for a clinical medical practice to spend half a day a week decision in difficult cases or where no diagnosis rationalising the practice’s expenditure on drugs, has been confirmed by endoscopy. Patient appliances and special feeds. She has also advised counselling has been an important component for a rural dispensing practice on matters relating to successful outcomes as eradication of Helicobacter the Drug Tariff, labelling of medicines and buying is dependent on patient compliance with prescribed stock. The work is ‘rewarding and fascinating and medication. gives a wealth of new professional contacts: GPs, The Golden Helix Quality Award (run by community nurses, practice receptionists and Manchester University’s health services health authority advisers’58. management unit) was awarded to the pharmacist- led team at Downfield Surgery for the work of this 4.7 The creation of integrated nursing teams clinic60. (INTs) in primary care has required devolving budgets to team level, removing hierarchical restrictions, and implementing training to enhance the change process and Perceptions and understanding the concept of self-management. A 4.8 There is evidence from practice to show that monograph on INTs59 stresses the changes in perceptions are taking place importance of teamworking and the among primary healthcare professionals. Pilot necessity of time for team-building activities projects can be successful engines for change. and for developing lines of communication between nurses and with the wider primary healthcare team. 29
  32. 32. internet version of the scheme, while use of PRACTICE EXAMPLE: interactive digital television technology is St Helens & Knowsley HA multidisciplinary likely to be harnessed to further extend the programme for the management of scheme in the future. ischaemic heart disease. The success of a GP-pharmacist prescribing 4.11 Healthy Living Centres initiative over a 3-year period provided the foundation for this feasibility/pilot study. PRACTICE EXAMPLE: The ways in which community pharmacists could The Bromley by Bow Centre positively contribute to the care of community- Britain’s first healthy living centre, described as ‘a based patients with stable angina, when working jewel in an east end London sea of congested roads with GPs in their practices, was explored. Six and tower blocks’, is seen as a prototype for the evidence-based interventions and pharmacist-run Government’s healthy living centres. At the heart review clinics were utilised. Pharmacists’, GPs’ of the Centre is a primary healthcare team and patients’ perceptions relating to the review bringing together not just GPs, nurses and health clinics were explored. visitors but also complementary therapists, artists, Findings from this pilot study show that a number nursery workers, benefits advisers and other of community pharmacists were motivated to community workers. The Centre’s health centre extend their professional role and were able to has an open and integrated approach, where work in harmony with co-operative GPs. This receptionists help patients access a range of enabled the delivery of a defined community-wide services: the GPs, the nursing team and the secondary prevention programme for patients with Centre. A ‘health market place’ offers a wide angina. This was accepted and valued by the range of services in an accessible way. Patients patients who participated in the study. The are involved in their own care and are used as a outcome in terms of the six interventions was potential resource linking health professionals with improved patient management and quality of the community62. life61. 4.12 Beacon Awards New policy initiatives in primary care 4.9 Teamworking in smoking cessation can be PRACTICE EXAMPLE: seen in Health Action Zones, where Beacon Award winner innovative smoking cessation services are being developed. Many agencies contribute ‘The NHS Beacons Services programme to the services. There is some evidence from celebrates success and spreads best practice’. trials to show that most involve referral to A decade of development has culminated in a community pharmacists as a service element. Hertfordshire surgery gaining beacon status for its integrated and inclusive approach to service 4.10 The NHS Direct initiative, whose provision. The culture of the partnership is one of telephone helpline is staffed by nurses, team working, promoting life-long learning and works alongside existing health services. continuous service improvement. The practice has The accompanying Healthcare Guide adopted a multidisciplinary approach to meet the publication is available to the public from needs of the local community. Extended services community pharmacies. A project in Essex include physiotherapy, travel, Citizens has piloted formal referral of callers to the Advice Bureau satellite, counselling, and a patient helpline to community pharmacists for library 63. further advice/assistance. A further development is NHS Direct on-line, an 30
  33. 33. 4.13 A third wave of Personal Medical Services pilots will go live in April 2001. The first pilots are reported to be making real differences in tackling health inequalities and improving access for patients64. Innovative PMS pilots have been offering new and flexible ways of delivering primary healthcare services. PRACTICE EXAMPLE: Isleworth, West London Hounslow and Spelthorne Community and Mental Health Trust and Ealing, Hammersmith and Hounslow Health Authority have identified a major gap in the provision of primary care services in Isleworth. A new, trust-run, PMS practice in Isleworth provides accessible primary, community health and social services under one roof in a deprived area with diverse need. The practice team consists of a salaried GP, a primary care clinical nurse specialist, other health professionals and social services, operating as an integrated team. The scheme is intended to complement local GP primary care provision65. 4.14 Many of the initiatives described in this section will influence the development of teamworking over the coming years. In view of the rapid pace of change and, at the time of drafting, the imminent publication of a national plan for the NHS, we believe that this topic should be revisited in three years’ time to assess progress. 31
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  35. 35. 5. CONCLUSIONS AND RECOMMENDATIONS 5.1 These have required very careful 3. Agree set objectives and monitor progress consideration by the Forum. The evidence towards them. Build into its practice, we have been able to adduce during our opportunities to reflect as a team on the care deliberations has confirmed the thesis that provided and how it could be improved. All high quality primary healthcare can best be team members to be actively involved in the delivered by effective teamworking. We delivery of the agreed objectives and in the have found many good examples of this in decision-making process. (2.19) practice. It is clear that some teams have been able to surmount the quite formidable 4. Agree teamworking conditions, including a barriers that we have also been able to process for resolving conflict. Identify identify and it is likely that many other teams predictable problems, which the team might are struggling to do so. encounter, and plan ways of managing these. (2.24) 5.2 We were asked to bring forward proposals by which the national organisations representing 5. Ensure that each team member understands primary healthcare professionals could and acknowledges the skills and knowledge of support and promote teamworking in team colleagues and regularly reaffirm what primary healthcare. However, we feel that each member contributes. (2.24) we can best assist the development of teamworking by providing two sets of 6. Pay particular attention to the importance of recommendations: one set for teams and communication between its members, their members currently engaged in hands- including the patient and off-site or peripatetic on clinical care and another for the national members, and use, to the full, technological organisations with responsibilities for these developments to assist this as they become professionals. available, where co-location is not practical. (2.25) Teams and team members 5.3 These recommendations are intended to 7. Take active steps to ensure that the practice represent the principles for establishing a population understands and accepts the way in primary healthcare team and to describe what which the team works within the community. a team member should expect as the basis for (1.12, 1.13) successful teamworking. The team should: 8. Select the leader of the team for his or her leadership skills rather than on the basis of 1. Recognise and include the patient, carer, or status, hierarchy or availability and include in their representative, as an essential member of the membership of the team all the relevant the primary healthcare team at individual professions serving a practice population. (2.24) patient-centred team level or at practice level. (1.11) 9. Promote teamwork across health and social care for patients who can benefit from it, using 2. Establish a common agreed purpose, setting out team members’ joint efforts to help to reduce what team members understand by both ill health and social exclusion. (3.4) teamworking, what they aim to achieve as a team and how they propose to do this. (2.18) 33
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