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. 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. 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

4. 2

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

6. 4

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. 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. 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. 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. 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

12. 10

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. 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. 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

16. 14

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 26

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. 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. 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. 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. 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

34. 32

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