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Forward integration 

Forward integration
Forward integration

Steve Iliffe

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Under a banner headline ‘get competitive or go under’ Doctor Newspaper reported RCGP Chairman Professor Mayur Lakhani as saying: ‘The future will be competition on quality, not price–the laissez faire practice will be toast. The practice that succeeds is one that is patient-centred, focused on quality and has a learning culture.’

Doctor (8 May 2007)

British general practice faces three problems that are proving difficult to solve. The first is the growing volume and complexity of demands for medical care by citizens, driven by the forces discussed in Chapter 7. The second is the ageing of the workforce, with different career patterns built around part-time working and job mobility, and with pockets of recruitment difficulties emerging in both medicine and nursing.1 The third is the failure of general practice to maintain its gatekeeper function for specialist services. This chapter will explore the third problem, considering its causes, reviewing solutions to it that have largely failed, and analysing three aspect of industrialization that may solve it and that are now well underway: skill mix changes, substitution of doctors by nurses, and the specialization of general practitioners (GPs) and practice or community nurses. These three approaches to changing work patterns are all part of the process of ‘forward integration’, and raise important questions about the ways in which team working will evolve.

Within an industrialized health service the purpose of ‘forward integration’ is to reposition all available resources so that they can be used to maximum technical efficiency (desired quality at lowest cost) as well as allocative efficiency (optimal mix for demand). ‘Forward integration’ of general practice within the health service seeks to make a whole and coherent production process out of disparate components, and requires changes in who does what, where; and in how they are organized, managed and, if necessary, paid.

The failure of gatekeeping

The failure of gatekeeping seems to be a failure that dare not speak its name, and discussions of specialization in general practice such as that of Nocon and Leese, published in the British Journal of General Practice in 2004,2 are so detailed in their dissection of ‘general practice with a special interest’ (GPwSIs) that the reasons for its emergence as a policy concern are almost obscured. Yet the accounts of how GPwSIs can do some of the work of specialists, and the insistence that such endeavours are supplementing specialist care, not substituting for it, are indicators of high levels of inappropriate referrals and poor responses to management of long-term conditions in the community. At least a quarter of GP referrals to hospital chest clinics could be dealt with in general practice3 (if it were more skilled and better organized), and 40–80% of ENT referrals may be similar.2

Let us look at another clinical example, the diagnosis and management of heart failure, a common clinical problem with a high morbidity and mortality, which can be successfully palliated with medication. The diagnosis cannot be made by clinical signs alone, requiring an echocardiogram. Management of heart failure in general practice is poor across Europe, and echocardiography is underutilized.4 GPs attribute their overall poor performance to limited access to the crucial diagnostic test, lack of time, lack of expertise and anxieties about initiating treatment with angiotensin-converting inhibitors inhibitors.5 The question is, why does a discipline that has a great deal of discretion in the way it works and organizes its time, and the freedom to invest its resources (money, time, and staff) as it chooses, not remedy this situation? Investment in the technology may be not something that individual practices would consider, but the aggregates of practices that made up multifunds in the first phase of industrialization and the locality commissioning structures that emerged then and are reviving now would be capable of such investments. The educational steps needed to know more, feel more comfortable with the diagnostic difficulties and the treatments available, and organize systematic care of this very needy patient group were all reinforced by the National Service Framework for Heart Disease. We shall see in Chapter 4 how variable responses to National Service Frameworks were.

The joint guidance from the department of Health and the Royal College of GPs lists 11 domains where there are ‘access problems’ to specialist care or where national priorities required greater medical input.6 They are shown in Box 3.1

Most of medicine is inside the box, only respiratory diseases, endocrine disorders, and neurology being domains that are not apparent in the list, and even some of them may fit within ‘care of older people’. What the list says is that large parts of medical practice currently carried out by hospital specialists are within the competence of GPs interested enough to acquire a little extra knowledge and some extra skills. That interest exists within general practice. One estimate (published in 2002) suggested that there were about 4000 GPs already working as if they were GPwSIs, of whom only 19% had a contract with a primary care trust, health authority, or community trust. Most were working as hospital practitioners or clinical assistants, but a third had no contractual commitment to specialize, they just did it.7 The question is, why are there not more GPwSIs already? If there are serious access issues to specialist care in some disciplines or areas, and the skills are within the range of GPs (4000 have already achieved it, to some extent), what has held back the development of specialization? We all know from experience about the frustration that patients express at having to wait a long time for, say, an ENT appointment is conveyed to their GP. We might add our own frustration, when we realize what is done in the ENT clinic is in part within the capabilities of general practice. What is hindering the rapid uptake of new knowledge and new roles?

It is not difficult to see how this has come about. It may not be possible for generalists to expand their practical knowledge across the range of medical problems that they encounter, as fast as the science itself evolves. Even if the pace of professional development could, in theory, keep up it would require the re-routing of time, energy, and money (for equipment) on a scale that is unlikely in a discipline organized in a way that favours conservative investment decisions. Some specialization occurs, of course, as professional enthusiasm drives individual GPs and whole practices to adopt new ways of working and new techniques for engaging with their clinical task, but it has not matched the scale of change in medical knowledge and technology. Our conservatism in making investment decisions results in a relative underskilling compared with specialists, who may collude with this underskilling (while also regretting it) because it keeps their expert identity secure and perhaps also their private practice plump. A different funding system, and a less securely subordinate relationship to specialists, might have produced a different outcome, as in Germany, where the well-equipped practice will have direct access to diagnostic resources (e.g. ultrasound) and treatment options (e.g. physiotherapy) on a scale only imaginable in Britain.

Failed responses

Two responses to the growing demand for attention in general practice and the fragility of the gatekeeper function were tried, one before industrialization gained energy and one in its early phase. The first was to reduce general practice list sizes so that more time could be given to individual patients, particularly those with more complex problems. The second was to move specialists into general practice, in the kind of outreach arrangements that fundholding embraced.

Reducing list sizes was an ambition in general practice just before the industrialization process became overt, in the early 1990s. Many GPs seemed to believe that a reduction of list sizes towards 1700 patients per doctor was conducive to both better treatment for patients and better working conditions for doctors, the assumption being that patient demand shaped clinical activity and that GPs had little control over their work. Duncan Keeley, a London GP writing in the British Medical Journal8 soon after the unilateral imposition of the first industrializing contract on general practice, quoted Professor Butler of the Health Services Research Unit at the University of Kent at Canterbury as saying: ‘the argument that a continuing reduction in list sizes is a necessary precondition for an extension of a general practitioner's responsibilities is difficult to dispute’.

The government of the day did dispute it, stating in the Green Paper Primary healthcare: an agenda for discussion that: ‘there is … little evidence of a direct link between list size and the quality of care, and consequently there is little to indicate what might be the optimum list size’. Professor Butler and his colleague Michael Calnan published studies that tended to support the government's view, providing evidence that time released by list size reduction would be used to increase consultation rates (not lengths) and to reduce the length of the working week.9 The demand-led model that GPs used to argue their case for improving the quality of care by reducing list sizes provided only a partial explanation for variations in time allocation in general practice.10 In other words GPs had more control over their working time than they seemed to believe, or were prepared to speak about.

Duncan Keeley was prescient about the changes coming in general practice.8

We are seeing the possibility of a major redefinition of the role of the general practitioner principal. The emphasis would be less on ‘personal primary and continuing care of individuals and families and more on organizing the work of a team of (hierarchically inferior) health workers, deciding how the money for the healthcare of our patients should be spent, and keeping that expenditure within limits.’

Personal care, which has been something of a touchstone for general practice, was already fading away in group practices when he wrote. George Freeman, then an academic GP in Southampton, demonstrated in a study of four group practices that personal continuity of care was fairly low, especially for younger and healthier patients registered with practices with combined lists.11 A decade later a large survey covering 53 general practices in four regions of the UK suggested that list sizes over 6500 were associated with marked reductions in personal continuity.12 The prospect of improving the quality of care in general practice through list size reduction disappeared in the early phase of industrialization, and personal care—although still central to the ideology of general practice—is peripheral to its actual development.

Hospital outreach by specialists became popular as a potential solution to the skill shortage in general practice, particularly during the fundholding period. The logic seemed to be that moving specialists nearer to the ‘coal face’ (as if they did not work at one already) would function as a kind of triage for further investigation and educate the GPs at the same time. There is some evidence that the processes of care (waiting times, patient satisfaction, convenience to patients, follow-up attendances) were better in outreach clinics than in outpatient clinics. However, waiting lists were usually not reduced by organizing outreach clinics, costs (in travelling time) for specialists increased and a two-tier service threatened.13 A later review of the evidence suggested that specialist outreach did not reduce outpatient demand, but did improve access in remote areas, while the quality of care could deteriorate if GPs undertook more minor surgery.14 It is hardly surprising that outreach by mainstream specialists has dwindled, to be replaced by nurse practitioner outreach for specific conditions, such as heart failure and respiratory diseases, which we will return to later in this chapter.

There remains an increasingly urgent need to re-establish a gatekeeper function, while at the same time responding to the understandings and expectations of an increasingly knowledgeable, articulate and assertive population. As the composition and strengths of local primary care workforces vary so much, there is no logical reason to think that any one approach will fit all. Inevitably commissioners of primary care will need to try different models for size and fit in their workforce, and this is exactly what the national health service (NHS) is attempting through changing skill mix, attempting the substitution of GPs by nurses and the supplementation of specialist care by generalists. Even if the evidence base for each is thin, these approaches seem worth considering because of their plausibility and intellectual coherence, their concordance with current policy objectives and their potential to meet several different needs simultaneously.

Changing the skill mix

Changing the composition of a workforce by altering the proportions of different skills has been found to be effective, especially in nursing,15 but it is difficult to know if it is cost-effective because the economic consequences of releasing one professional's time are complex and not always well understood. For example, a reduction in the proportion of one professional group—say, district nurses—and their replacement by cheaper healthcare assistants may seem ‘economic’, but savings may be offset by the need to use incentives to attract district nurses into such a re-configured team. The prospect of managing a small team of assistants may seem more attractive than carrying a large case load of hands-on work, but this satisfaction could be reduced if the assistants are poorly trained or inexperienced, if they stay only a short time in the job (because of its difficulties, the low pay and the hours), or if the case load is too large and the team is spread too thinly. The more expensive option—having an experienced, high-grade nurse manage a case load directly—might be the more stable arrangement that provides higher quality care and produces the most job satisfaction. GPs will have encountered this problem many times, with locums who see the requisite number of patients but create more work for the practice through referrals that subsequently seem unnecessary, or through re-visits by patients who did not get their usual care. A GP Registrar or an FY2 (Foundation Year 2) doctor may seem to be an asset, in terms of helping reduce the workload, but that all depends on their clinical and interpersonal skills, and the degree of supervision they need.

The size and mix of the primary care workforce in any locality are determined by factors that are ‘historical and irrational at best’.16 As workforce planning rises up the agenda for primary care organizations (including large practices) in response to rising demand, local organizations become more complex, which complicates planning. A single-handed GP can make decisions about practice management and organization without consulting anyone, and can therefore make rapid changes. A small team will have a short decision-making cycle, but this will lengthen as the team size increases, and become more complex if the range of disciplines increases. A large medical centre with GPs as the ‘owning’ co-operative, plus practice nurses, psychologists or counsellors, management and administration staff as employees, and other doctors, health visitors, district nurses, and community psychiatric nurses in attached or liaison roles, is likely to have a long decision-making cycle and consultation processes that can easily go wrong.

The problem with the skill mix concept is that it has a limited evidence base. There is a lack of clarity about the strategic objectives of changing skill mix, and it is much harder to see the real differences between disciplines (for example, doctors and nurses) than the professions like to think.17 The strongest evidence for changing the skill mix is the growth in the numbers of nurse practitioners and physicians assistants in the USA. These two disciplines make up one-sixth of the US healthcare workforce and offer a range of services equivalent to 90% of a family physician's role. Their education time is approximately half that of physicians and their entry into the workforce is less restrictive. Fifty per cent of physician assistants and 85% of nurse practitioners work in primary care services, compared with only 30% of doctors.18


There are different estimates of the amount of work done by GPs that could be done by nurses. One study found that 39% of GP consultations contained at least one task that could be done by a nurse, and 17% were entirely suitable for a nurse,1 although with significant misgivings in both disciplines.19 Another estimate suggested that between 30% and 70% of tasks undertaken by GPs could be carried out by nurses.17

Substitution of nurses for doctors has the potential to reduce both GP workload and costs, but not in all settings. The workload of the GP may remain unchanged because nurses are deployed to meet previously unmet need or because nurses generate demand for services where previously there was none. Savings will depend on the magnitude of salary differences between nurses and doctors—which may change according to supply and demand—and may also be offset by the lower productivity of nurses.20 There is, however, only fragmented evidence to support such an approach to professional substitution, which is not necessarily cost-effective, or necessarily a source of better care, or even (for nurses) an automatic gain in professionalism.21 The substitution of nurse's labour for doctor's labour may not be real, despite the intention, and may change into supplementation of medical care by a different, perhaps more advanced, form of practice nursing.22 Some technologies may have the potential to facilitate substitution of one practitioner by another. For example, telephone consultation (by nurses) appears to reduce the number of surgery contacts and out-of-hours visits by GPs, but its effects on wider service use, safety, cost, and patient satisfaction need further study.23

Outside the clinical domain, in the management of services, GPs and primary care nurses may well be interchangeable, but even then the differences in professional cultures show through, with nurses being oriented more towards fostering teamwork and GPs focusing on leadership and delegation.24 Although the boundaries of substitution are not known, there are strong arguments for adequate training, assessment and quality control systems if advanced roles for primary care nurses are to be widely introduced,25 all of which are likely to reduced productivity and increase costs. The logic of substitution is, nevertheless, very attractive because it offers the possibility that some (undesired) work can be taken away from GPs, allowing more time for more appropriate or interesting work. Anxious parents with hot and miserable children, for example, can be seen, reassured and treated by a nurse practitioner trained in the management of minor illness, while the GP gets on with work that demands more medical expertise. In all this we need to remember the exemplary story of the Langwith village surgery, first mentioned in the introduction. It was the failure of a nurse-led service established by the Primary Care Trust to provide adequate care, together with the reluctance of local GPs to get involved, that led to the involvement of the private company United Health Europe, and the subsequent mobilization of professional and public opinion around an NHS solution.26

General practitioners with a special interest

GPwSIs may need to be very political creatures. Their success is likely to depend on gaining trust and credibility27 and negotiating their way into local services,28 but also with an eye to national priorities for health service development which will favour GPwSI deployment.29 GPwSIs will need to tread carefully. Their special interest groups make it clear that they should not attempt to substitute for real specialists,30 as such a challenge would probably provoke a response from hospital doctors that would jeopardize the further development of specialist roles for generalists.2 Although there is little evidence that GPwSIs can improve quality of care or mediate in primary/secondary care boundary setting, they are nevertheless being promoted to reduce both waiting times and the use of secondary services.31 The optimism about GPwSIs is grounded in their availability (in some places) to attempt to achieve policy targets such as waiting time reductions, their ability to improve the accessibility of specialist services,32 and their potential as recruiting agents for general practice.

GPwSIs may enhance job satisfaction in general practice, and so improve recruitment and retention in the discipline, and could even become part of an increasingly flexible career structure that sees GPs and specialists have much more interchangeable career paths.33 The integration of specialism and generalism need not be restricted to clinical domains, public health could also benefit from having GPwSIs.34 However, the risks that GPwSIs run are also numerous. Not only might they deskill their colleagues without special interests, but they may also appear more frequently in areas of lowest need,33 so adding to the irrationality of the primary care workforce rather than subtracting from it. They may turn out to be more expensive, as in one study of dermatology GPwSIs,35 and require increasing amounts of resources in training, support systems, and the paraphernalia of clinical governance.27 Finally, and crushingly, they may increase the overall workload by treating previously undertreated or even untreated conditions33 and fail to reduce demands for specialist care.2

Case management of long-term conditions

If the benefits of encouraging GPs to become quasi-specialists are uncertain, could the NHS use nurses to do something similar? Nurses are certainly seen as a group that might take ‘naturally’ to case management approaches that focus clinical effort on managing complex people with complex problems. The management of long-term conditions and chronic diseases is arguably the main challenge for primary care, worldwide.36 Individuals with long-term conditions consume a large proportion of health and social care resources, including 60% of hospital bed days in British hospitals,37 and 78% of all healthcare spending in the USA. It is estimated 17.5 million adults in the UK are living with a chronic disease and that the incidence of chronic diseases and disabilities (long-term conditions) among those aged over 65 will double by 2030.37,38

Given the distribution of disease and disability a focus on later life is appropriate. In the early phase of industrialization this focus was managed badly, by pushing policy far ahead of evidence. As a result clinical practitioners in Britain may be wary of approaching systematic approaches to a whole population group such as those with chronic conditions, given the failure of population screening for untreated morbidity in older people. Not only did the ‘75 and over checks’ introduced in 1990 have little discernible impact on the health of older people,39 but the recent Medical Research Council trial of screening older people showed no benefits from such screening.40 Neither GPs nor specialists in care of older people performed well in the Medical Research Council trial, suggesting that medical management of problems revealed by screening is essentially ineffectual. However, there is some evidence from studies in the USA that targeted needs assessment of older people followed by active management may improve both survival and functional ability.41

In North America comprehensive geriatric assessment with subsequent systematic management reduces hospital admission rates, and models of chronic disease management have evolved to exploit this impact and contain care costs for an ageing population. Whole systems approaches in the USA, using case management methods,42,43 have been championed as a means of ensuring continuity of care, improving patient outcomes and achieving efficient management of resources.44 The core elements of any case management activity are: identification of individuals likely to benefit from case management, assessment of the individual's problems and need for services, care planning of activities and services to address the agreed needs, referral to and co-ordination of services and agencies to implement a care plan, and regular review, monitoring, and consequent adaptation of the care plan.

The NHS is being encouraged to embark on a chronic disease management programme built around fostering self-management, enhancing disease management in primary care, and introducing case management for individuals with complex problems who make high use of hospital services.37 The Royal Colleges of Physicians and of GPs and the NHS Alliance have endorsed this programme and have made proposals for joint clinical directorates and clinical governance, across the specialist–generalist divide.44

In the UK nurses are seen as the professional discipline with the abilities to carry out and co-ordinate chronic disease management, and chronic disease management is seen as one of the three core roles of primary care nurses. This is logical, as nurses have always been involved with people with chronic diseases through health promotion, patient teaching, direct nursing care, and the application of medical treatments. The current expectation that nurses will take greater responsibilities for the day to day care for people with chronic diseases, long-term disabilities, and complex needs is only an extension of a familiar role. This expectation is expressed in England by the drive to appoint 3000 ‘community matrons’ to support people with complex long-term conditions using case management techniques, by 2007.38 Their task will be to identify need, achieve continuity of care, promote coherence of services and review the quality of the care provided.45

Is this new approach to healthcare a decisive breakthrough in person-centred service provision, and are new case management roles for nurses in the community likely to be welcomed, effective and worthwhile? While there are good reasons for exploring the potential for nurse-led case management, we should be cautious about the political emphasis given to chronic disease management and expectations of nurse-led case management within it. Chronic disease management remains problematic as a model of care, with evidence from the USA of limited effectiveness, reliance on traditional forms of patient education, poor linkages to primary care and dependence on referrals rather than active case-finding approaches.46 In the UK primary care organizations should be able to overcome some of the negative features of American experience, simply because we still have an integrated and resourced system of primary care, with a relatively influential discipline of public health. But we may not be able to overcome them all, for a number of reasons.

First, there is some doubt about whether chronic disease management is wanted by all patients. Patient priorities may differ from those NHS managers and clinicians, and older people who may feel that their independence and autonomy are threatened by an intrusive care system.47 Nurses involved in public health drives such as influenza immunization, or disease management tasks such as diabetes and chronic obstructive pulmonary disease care, will have experienced the scale and persistence of resistance in people with long-term problems.

Secondly, there is the problem of how to identify those who are likely to need high levels of care, for there is no linear and unambiguous link between the presence of a condition that can be labelled chronic and the need for health or social care.48 Patients with multiple emergency admissions (‘frequent fliers’) are often identified as a high-risk group for subsequent admission and substantial claims are made for interventions—such as case management—designed to avoid such admissions. However, simply monitoring admission rates cannot assess the effectiveness of case management, as admission rates fall without any intervention.49 Promotion of case management on the basis of before and after comparisons of admission rates is, therefore, reliant on potentially flawed evidence.

Thirdly, case management as a technique is not a single or simple entity, there being several different types that require different types of work organization, demand different skills, and respond to different needs. For example, there are traditional forms of case management based on discipline or clinical speciality, such as district nursing; social services led care management, involving nurses; specialist nurses supporting people with particular diseases or conditions, such as heart failure or COPD nurses operating out of hospital departments or practice nurses focusing on care of patients with diabetes or asthma; and specialist nurses for the case management of people with multiple conditions. They are all carrying out different levels of case management work, but they are not necessarily interchangeable.

Finally, nurses may not be the best professionals to carry out chronic disease management as currently understood, despite the historic role of the discipline and the attractive logic of extending nursing roles. Studies that have compared nurse-led case management with case management led by other disciplines provide mixed evidence as to whether nurses achieve equivalent or better outcomes. Invariably, the studies lack detail about the nursing contribution, their exact roles, activities, and the expertise used.50,51 There is, therefore, an urgent need to study the actual content of case management activities, and to mount the comparative studies that will reveal the optimal configuration of competencies for chronic disease management.

The current policy emphasis on chronic disease management will require extensive changes in service provision, significant re-training of staff, and widespread re-negotiation of relationships between disciplines and agencies. The opportunities for innovation are huge, and the potential for rigorous evaluation of new approaches to care is great, so both primary care practitioners and researchers will be busy as the ‘community matrons’ get to work. The risks are equally great, for health service policy could be decided prematurely, so that particular models of chronic disease management are promoted on the basis of superficial assessment, political attractiveness, or organizational expediency. We are at risk of repeating the errors of the ‘75 and over checks’ policy, which was introduced in 1990 against the advice of the profession and took 14 years to undo. General practice as a discipline has one big advantage that may prevent another policy failure; its experience of team working.

Team working

If one of the persistent problems of general practice has been its conservative approach to investment, one of its strengths has been its interest in multidisciplinary working, once financial incentives were in place to sustain it. We might envy our German peers with their ultrasound machines in their offices, but we can be proud of the wide range of co-workers that we have and that European generalists (as a whole) lack. Collaboration and team work have long been advocated52,53 as a means of providing effective primary healthcare. However, there is an equally long history of critically assessing the reality behind the rhetoric of teamwork in primary healthcare,54,55 Many commentators have pointed to employment status differences, professional cultural differences, geographical separation, and membership of multiple teams as real barriers to team working.56–58

The most obvious example of team development in general practice is the shift in workload from GPs to practice nurses and nurse practitioners.59 The requirements of the 1990 GP contract, together with the administration of fundholding, led to the phenomenal growth in the direct employment of administrative staff and nurses in general practice.60 The emergence of the general practice as a powerful unit in purchasing and/or commissioning health services influenced closer working arrangements between community nurses and practices, including experiments with integrated nursing teams.61,62 Around the same time the NHS and Community Care Act 1990,63 legislated for collaboration in planning and delivering individuals’ care as well as service planning. This was later reinforced by the establishment of Primary Care Groups64 in 1997, based on collaboration between different professional groups in the planning, provision and monitoring of healthcare services for small populations.

In the first phase of industrialization the impetus to team-working was part pragmatic (with GPs delegating a widening workload) and part idealistic. There appeared at the time to be little direct evidence of benefits to patients from greater team-working in primary care,65 but from other domains there was evidence of more efficient healthcare delivery and increased staff motivation,66 and this was good enough to promote innovative ways of working. An intuitive list of the benefits of collaborative working included beliefs that:

  • Care given by a group is greater than that given by one.

  • Rare skills and knowledge are used more appropriately in teams.

  • Duplication and gaps in care giving and other activities are avoided by team-working.

  • Peer influence and informal learning occur within teams and raise standards of care.

  • Team members have greater job satisfaction and are better able to cope with the stresses of working in primary care.

  • Teams contain the potential for developing more creative and lateral solutions to problems.

The possibilities that arose from collaborative working between disciplines were attractive given the anxieties that were emerging about the sustainability of health service delivery in its usual forms. A joint statement on team-working in primary care published in 2000 by the Royal Pharmaceutical Society of Great Britain and the British Medical Association pointed out that the number of professionals (especially doctors) was unlikely to be sufficient to meet expectations for timely provision of high quality care if services continued to be organized in traditional ways.67 In other words, team-working was not just intrinsically desirable, but essential to avoid a crisis in primary care. However, the report also points out that, despite the catalytic role of some professionals in different disciplines in promoting team-work, the first major obstacle to collaboration was professionalism itself. The second was the lack of a shared information technology that would allow the emergence of a common electronic patient record. The potential for a coherent, efficient, and collaborative system of patient care existed, but the historically determined relationships between disciplines combined with the plurality of incompatible IT systems meant that this potential could not easily be realized.

If the report from the Royal Pharmaceutical Society of Great Britain and the British Medical Association is correct, overcoming the barriers to collaborative working is one of the main challenges for primary care, and so for general practice. Seen from the perspective of industrialization, it is a core component of ‘forward integration’. There seem to be three important aspects to team-working that need to be addressed; organizational forms and the distribution of managerial power between disciplines, location and team size, and the nature and depth of the desired collaboration.

Organization, management, and power

The Royal College of General Practitioners68 distinguishes between a core primary care team of GPs and employees of the practice and the wider multiprofessional network outside the direct control of the GPs. Those who are collaborators in the provision of health and social care for some or all of the practice population—community nurses and health visitors, midwives, psychologists, counsellors—but managed and paid by other organizations are likely to have different approaches to team-working than the core group, if only because their management can require them to work in ways that the GPs do not determine. There is also a second distinction to be made between the members of the core team who are partners in the financial business of the practice, and those who are directly employed by the practice. In an industrializing health service where efficiency is paramount, those inside the economic co-operative lose income if team-working does not deliver gains in efficiency and quality of care, while those who are employed by the co-operative continue to earn the same salaries. Similarly, salaried employees may increase the efficiency and quality of care, within a new division of labour between disciplines, and see the financial benefits go to the partners within the co-operative. We shall see how this occurred during the MMR controversy when health visitors came to experience themselves as agents of GPs driven by targets. These distinctions are one of the biggest potential sources of tension in the entity called a ‘primary healthcare team’, and are the subject of continuous debate within the industrialization process. GPs weigh up the merits of being salaried employees or dependent contractors, practices consider the kind of contract that they hold with primary care organizations, primary care trusts explore ways of divesting themselves of responsibility for managing community nursing and other disciplines and GPs think about employing physiotherapists or midwives.

Locality and team size

Physical proximity, social proximity, and positive motivation are prerequisites to collaboration and team working, as is (obviously) interaction between members.69 Repeated studies from the 1960s onwards have shown that collaboration is closest between GPs and district nurses and health visitors when the nurses are physically based in the same building and are attached to no more than two general practices.70 The ability to have an impromptu discussion in the corridor or the car park about a patient, or a decision that affects the team, must lubricate the processes of collaboration and add value to the ability to meet more formally and work through agendas, or at least so we think in general practice. Other disciplines may not agree. There is evidence from a study of collaboration between social workers and GPs71 that co-location is seen by social workers as potentially isolating, and a challenge to social work practice, because the team working desired by GPs required social workers to adapt their behaviour and thinking to those of family medicine. The shift in thinking was from the ‘holding’ orientation of social work to the ‘action orientation’ of general practice;72 the doctors wanted ‘something to be done’ while the social workers wanted to consider the options more carefully.

The size of the team's membership also appears to be an important factor, with three to six offered as the most effective group size for decision-making and communicating.73 This desirable size, which matches the optimal size for practices trying to maintain continuity of care, has implications for the much larger teams now emerging in general practice.

Levels of collaboration

There are different ways to think about and describe the levels of collaborative work in primary care teams.74 These range from complete isolation, where clinical information, referral or requests are passed between doctors, nurses, and social workers via administrative staff or relatives, so that the professionals never talk or meet, to full collaboration, where professionals’ work is fully integrated across disciplines, at the other end of the scale. Looked at another way we can define three levels of team working:75

  • The nominal team, characterized by isolated working by professionals.

  • Convenient teams, in which tasks are delegated down a hierarchical structure.

  • Committed teams, characterized by fully integrated working between disciplines.

All of these arrangements can be functional, both from the viewpoint of the professions concerned and from the perspective of those using services. In circumstances of high demand and relatively low resources streamlined working with limited communication is adopted for sake of efficiency. The most effective team-building work appears to take place when there is a clear practice-based project to be undertaken,76 so practices facing increasing demands to standardize and improve the quality of care have developed convenience teams to tackle Quality Outcomes Framework targets and manage patient demand. The committed team may emerge around a shared desire to optimize palliative care, or the management of patients with mental health problems, or the care of older people. What can be achieved in terms of collaborative working is dependent upon demand and resources, mediated by the enthusiasm of professionals for joint working, but we always need to be conscious of the limits of our knowledge. If we take collaborative working between primary care and social services as an example, we should recognize that there is as yet little evidence that closer working results in higher quality care, cheaper services, or more satisfied patients.77 This is not an argument against collaboration, but a reminder that all attempts at joint working, even within small groups where shared objectives are more likely to exist, are exploratory and experimental.

Conflict in teams

Paradoxically, while team work can contribute to high levels of job satisfaction it can also be a source of stress for individuals. Teamwork can expose role ambiguity and opposing values. It is, however, interpersonal conflict that can lead to the most intractable stress for individual members.78 In primary care, the multiple professional groupings add particular dimensions for interpersonal conflict and it would be naive to underestimate this. So not only are there possibilities for conflict within one group—(for example, the partners in the practice)—but also between groups, such as the practice nurses, district nurses, and health visitors, who are all technically nurses working in the community.

The corporate image of a team, according to Sennett, is ‘a group of people assembled to perform a specific, immediate task, rather than to dwell together as a village … a worker has to bring to short-term tasks an instant ability to work well with a shifting cast of characters’.79 The social skills needed must be portable (from team to team and project to project) and some detachment is required, so that the worker can stand back from established relationships and judge how they can be changed. This idea of a team fits to some extent with experience in group general practice. The specific and immediate tasks are not projects emerging in the market, but responses to the demands of a shifting cast of characters, the patient population. This population is shifting in all kinds of ways—in age, in knowledge and experience, in work, in relationships, and in domicile. However, the team may dwell together as a village, to some extent, although not literally. Working relationships may vary between close, extending outside work, to distant, with no extra-mural contact. Standing back from relationships with patients is problematic, as the knowledge acquired by both parties over a period of time can be important to the solution of problems—the succession of specific and immediate tasks. Part-time working, reduced hours (e.g. withdrawal from out-of-hours work) and group working all help to break up long-term relationships, contributing to the shifting cast of characters.

The US Secretary of Labor's Commission on achieving necessary skills, reporting in 1991, emphasized communication and facilitation in teams.80 Teamwork may be presented as ‘a culture of co-operation (promoted) through egalitarian symbols’,81 but may also function as a form of deep acting,82 creating masks of co-operation that establish the friendliness of the worker rather than his/her genuine concern with the other person's problem. ‘In a turnstile world of work, the masks of co-operativeness are among the only possessions that workers will carry with them from task to task.’83 General practice is very much a turnstile world. Do we struggle to promote masks of co-operation in reception staff? Even the appearance of co-operativeness may be difficult to sustain, given the tendency of people to fit their own anxieties to their work, and use work to resolve personal problems, sometimes through self-imposed impossible tasks.84

Team-working practices are a continuum, from uni-professional teams at the novice end, through multidisciplinary teams, to interprofessional working at the expert end of professional development.85 Interprofessional working implies a shared learning experience with, from, and about each other.86 Progression along the continuum involves a reduction in professional autonomy and an increase in shared expertise.87 Team tasks need to be clear, motivating, and consistent with group purpose,88 intrinsically interesting with meaningful and inherent rewards,89 and subject to shared concerns about quality, vision, outcomes, and evaluation.90 Team leadership involves focusing efforts towards a common goal.91 Models of shared, rotating or distributed leadership have merged in healthcare.92 Leadership requires the maintenance of a balance between the task, the group, and the individual,93 involving attention to team membership, integration, and management.94 However, the provision of health services is characterized by high levels of uncertainty and complexity, creating challenges for establishing clear goals95 (especially in general practice). Engel points out that, in healthcare, motivation needs to be essentially intrinsic and collaborating in teams offers only limited reward.96

One problem with modern teams is the repudiation of authority and the presentation of leaders as coaches or facilitators. This type of leadership shifts responsibility on to the workers’ shoulders and makes everyone contingent on change, de-personalizing power.97 This apparent neutrality is a form of betrayal, allowing those in control to focus on the present and act as they want without justification. This game of power without authority replaces the driven individual of the protestant work ethic with ironic man, who takes nothing and no one seriously because everyone is contingent. Such an individual is not quite real, and has no durable needs that others can meet; s/he cannot challenge power, and becomes self-destructive.98 ‘Irreversible change and multiple, fragmented activity may be comfortable for the regime's masters, … but it may disorientate the regime's servants. And the new co-operative ethos of teamwork sets in place as masters those “facilitators” … who dodge truthful engagement with their servants.’99

One issue that is avoided in the modern concept of teamwork is the importance of conflict. We are bound together more by conflict than by agreement, although we can reach agreement through conflict. Conflict requires harder work at communication, the rules of engagement bring people together, individuals and groups become better at listening and responding, and differences can be clarified even as agreement is reached.100 Strong communities address differences, over time, making current ideas of teamwork sources of weak community feeling. The evolving expression of disagreement engages people more than the declaration of correct principles.101

Pragmatic solutions

The temptation for practitioners is to anticipate that we can, individually, recapture the generalist ability to carry out many different tasks and be a Jack or Jill of all trades. It is possible to describe the variety of work in general practice in terms of the palette of skills that generalists master and deploy, as in this account: ‘Diverse diagnostic challenges such as reviewing the diabetic retina, inspecting the cervix, making sense of multiple non-specific symptoms, assessing the suicide risk in a depressed young man, and carrying out a developmental check on a newborn baby are just part of the normal working day for the medical generalist.’102

The problem with this inventory is that it may not actually fit with the ‘normal working day’ of many GPs, who have long since delegated the cervical smear test and the newborn baby check to practice nurses and midwives or health visitors respectively, while leaving retinal screening of patients with diabetes to ophthalmic opticians who have the necessary training and technology. It is difficult to see what advantage a GP has over a practice nurse in carrying out cervical cancer screening, or over a health visitor in carrying out child development assessments, and the performance of generalists in fundoscopy is poor enough to make it hazardous to leave this aspect of tertiary prevention to them. From this list only the diagnostic task—making sense of multiple symptoms—and the severity assessment (in depression) remain unchallenged within the generalist job description. These tasks, very much about interpreting situations and finding meanings, could be the only ones that we cannot delegate, and would therefore be the core business of general practice. We might add to the list of uncertainties the best way to prevent, identify, or manage diseases and disabilities in the community, returning once again to the arguments for integrating family medicine and public health in Tudor Hart's New kind of doctor.103

Perhaps the important point for us to remember is that we are not simply not specialists, but in some senses antispecialists (just as we are antimarket as long as we stay within the public domain). Anthony Giddens argues that the specialization that has made modern life in industrialized societies so rich also creates huge problems in interpreting knowledge, which in turn destabilize the understanding and confidence of many citizens. Specialization is a problem, as this quotation from Modernity & self-identity suggests:104 ‘… expertise itself is increasingly more narrowly focused, and is liable to produce unintended and unforeseen outcomes which cannot be contained—save for the development of further expertise, thereby repeating the same problem.’

The rumour of a connection between the MMR vaccine and autism, when given the authority of an expert medical journal, was enough to reduce vaccine uptake to levels low enough to permit re-establishment of the diseases in some places, just as Giddens might predict. I will return to the MMR episode when discussing consumerism, in Chapter 7. To close the gap between what is possible to do in community settings given the current level of medical knowledge, and the actual performance of GPs and community nurses, we need to embrace the agenda of forward integration. There is a spectrum of professional activity based on the complexity of the tasks and the individual's ability to manage uncertainty. We will need to take a pragmatic approach to thinking about changing skill mix, based on strategic aims, perspectives, opinions, scope, likely costs and local views and experiences.17

Payment systems

Given that new forms of organization of community services in general, and of GPs’ work in particular, are emerging, we may also have to consider different ways of funding our clinical, administrative and public health work. One argument in this chapter is that the franchise model of general practice, which had such advantages in the early period of the NHS by providing a localizing aspect to a nationalizing enterprise, lacks the mechanisms to support widespread and rapid changes in practice. The investment decisions that are typical of small-scale co-operatives working within a franchise structure to meet complex demands favour small-scale innovation, not system-wide modernization.

The puzzle that the NHS has now to work out is how to make investment decisions in primary care speedily enough for general practice to catch up with specialist medicine, without overburdening practitioners and losing their professional commitment, and without breaking the bank. One option might be to encourage salaried general practice, perhaps at locality level, to reduce the number of decision-makers in the field and give managers greater control over practitioners. Another—which has been adopted with the 2004 new General Medical Services contract -is to micro-manage consultations in selected clinical domains through a complex incentive system of targets. The policy problem for the NHS is that, when thinking of how to get the most appropriate package of skills within primary care, it needs to juggle productivity, professional enthusiasm, quality of care, and costs.

There is some evidence to suggest that the method of payment affects clinical behaviour. A systematic review of (rather meagre) evidence suggests that fee for service payments result in more primary care contacts, and greater use of diagnostic and curative services, but fewer hospital referrals and repeat prescriptions.105 A Norwegian study of parallel contracts in general practice showed that family doctors with a fee for service contract have more consultations than those with a salaried contract, partly because they work longer hours and partly through working more efficiently. Salaried GPs preferred shorter working hours and less intensive work. The authors calculate that a change from a salaried to a fee for service contract would increase productivity by something between 2 and 40%.106 An early comparison of PMS and General Medical Services practices in England came to a different conclusion, with no significant differences being found between the practice types in time worked, consultation lengths, prescribing, or referral rates.107 Fee for service payment systems appear to offer more advantages for the health service (through increased productivity) but possibly less patient satisfaction.108 There is little evidence to help decide whether target payment remuneration provides a mechanism for improving the quality of primary care.109 One view on getting the right balance of contractual arrangements would be to assign the responsibility for contract-setting to local rather than national authorities, tailoring the incentives in the contract package according to local supply and demand.110


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