JOURNAL OF INTERPROFESSIONAL CARE, VOL. 9, NO. 2, 1995 95

Personal care and teamwork: implications for the general practice-based primary health care team

N. C. H. STOTT Professor of General Practice, University of Wales College of Medicine, Cardzff, UK

Summary Teamwork in general practice-based prima y care (PHCT) is high on the agenda of many countries but exceptionally well developed in the UK. Nevertheless there are problems associated with the optimum development of teamwork. Continuity of care, out-of-hours care, communication needs and team size are chosen as focal issues in this paper. A case is made to support the concept of a generic Core PHCT’ surrounded by specialised agencies holding a clear referral relationship with the Core PHCT. Size limitation on the Core P H C T is also proposed.

Key words: Communication; continuity; general practice; prima y health care; teamwork.

Introduction

The practice of medicine has always been associated with the tensions caused by competing priorities (Hopkins, 1973) and by trying to balance clinical benefit against risk or cost against health gain. It is particularly difficult to strike a balance between a general practitioner’s duty to the patient and duty to the community because these responsibilities can sometimes conflict (Herman, 1994).

One area of tension that characterises general practice and primary care in the 1990s is the apparent shift of the general practitioner’s role away from the personal doctor who provides first contact, continuing and comprehensive care irrespective of the patient’s age, gender, disease, organ or problem. An increasing need for chronic disease care and health promotion and the shift of acute health care from hospital to community have been associated with a rising emphasis on general practice-based teamwork, special interests, consumerism, infor- mation support systems and commercial incentives to conform to what government regards as appropriate clinical activity. The personal clinical generalist is encouraged to become system-centred: as purchaser of services (fundholding or commissioning), as an employer or contractor for many people in the professions allied to medicine, and even for some community specialties. There is a notable reluctance by the British Health Department to define general practice-based primary care in any way other than in terms of service contracts and market forces. The political rhetoric builds on the strengths of a traditional general practice-based National Health Service. The reality is a major lurch towards changing the doctor-patient relationship to provide a service to patients by a variable sized primary team.

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Correspondence: Professor N. C. H. Stott, University of Wales College of Medicine, Department of General Practice, Llanedeym Health Centre, Llanedeym, Cardiff, CF3 7PN, UK.

0884-3988/95/020095-05 C 1995, Marylebone Centre Trust

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96 N. C. H. STOTT

In this paper some of the more controversial issues in personal care and teamworking will be addressed.

Team-based continuity

Continuity of care within the traditional doctor-patient relationship was a feature that characterised advanced consulting patterns (RCGP, 1972) but delegated or shared continuity was strongly advocated and written about by Marsh (1976) Pritchard (1978) and others. The driving force towards more nurse-led continuity of care within general practice-based teams came from the increase in chronic disease care associated with an ageing population and shifts in two principles that had underpinned traditional general practice:

(i) opportunistic intervention that required few special facilities other than conscientious and competent professionals. This has been progressively displaced by organised intervention on a special clinic basis especially for chronic disease;

(ii) opportunistic health promotion that was simply fitted into appropriate slots in a general practice consulting discipline has been progressively displaced by organised health promotion by recall or outreach (Stott, 1983).

The increase of organisational and clinical workload generated by these two changes was actively promoted by the New Contract for British General Practice (1990) and began to institutionalise general practice with demands for greater uniformity of services.

General practitioners were, however, enabled to begin to retreat to a role in dealing with acute events and managerial/diagnostic/therapeutic problem-solving, while practice nurses began to take a larger share of the new responsibility for continuing care in chronic disease and health promotion. This can be viewed as a retreat from the clinical generalist and/or the expansion of specialist functions in the primary care team by delegation, sharing and teamwork.

Nurses have always had a greater role than doctors in continuous patient care in hospital ward or district nursing care. The step from intensive personal care of the bed-bounddis- abled to continuing care of the ambulant patient in a general practice context was easy for practice nurses. Hjortdahl & Borchgrevink (1 99 1) have questioned whether these changes in the care of people with chronic disorders can maintain the efficiency of personal continuity of care by generalist doctors, particularly as the effectiveness and efficiency of large primary care teams is not universally accepted (Stott, 1993). The best mix of skills in primary care is a vexed question that tends to favour the generalist, but not entirely. Starfield (1994) has recently reviewed how research focused on individual diseases may favour the specialist, whereas research looking at primary health care delivery, and broader resource effective health gain, tends to favour the generalist. In general she found that a detailed study of 11 countries revealed that health indices and total health service costs are most favourable where general practitioners provide a clinically competent gatekeeper function in relation to special- ist services, i.e. where the continuity of care is person-specific rather than disease-specific.

The idout-of-hours paradox

The benefits of teamwork in general practice-based primary care are seldom extended to out-of-hours work. At night or weekends it is commonplace for the general practitioner to work alone in the front lines of a demand-led primary care service. This occurs despite the evidence from Spitzer (1 974) and Bowling & Stilwell (1 988) that adequately trained nurses can deal with many front-line calls. The problem presumably rests with the need for a clinical

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PERSONAL CARE AND TEAMWORK 97

training that is diagnostically deep enough to deal with all front-line calls and the fact that paired (team) cover may be more expensive than the present arrangements, unless ease of access is reduced by establishing out-of-hours centres manned by doctorhurse teams.

The historical evidence that continuity reduces unnecessary admissions to hospital is attractive to those who plan the expensive secondary care services, but the shifting boundaries of hospital (specialist) care call into question the continuing validity of this assertion. It is likely that most urban out-of-hours calls are already lost to the discontinuity of the deputising services and to specialist outreach in areas like midwifery and trauma. Out-of-hours primary care is thus already fragmented and so any concerted effort to involve the generic PHCT to a greater extent would be appropriate if not popular. The picture in rural practice is, of course, very different and the demands made by rural patients are far less than urban dwellers. Whether this should be viewed as unmet need or desirable independence is an interesting paradox (Phillips, 1986).

The teadtime paradox

Teamwork can expand the scope of care and relieve the doctor of some duties (Marsh, 1991) but it also creates a raft of new problems-notably in communication. Ball has used a mathematical formula to show staggering increases in time required for communication as team size rises:

Lines of team communication can be expressed as

where n is the number of team members involved (Table 1). If every line of communication is allocated only 10 minutes per week the resulting

opportunity cost to large teams becomes transparent and alarming. Any army solves this problem by maintaining a tight hierarchical structure that reduces every member’s lines of communication. Primary care teams do not operate in a tight hierarchical way because flexible response to varying public need requires something more like a rugby team than an army platoon. Belbin (1981) regards teams of six people as ideal for decision-making and 0vretveit (1 993) has produced evidence to show that good teamwork is highly unlikely with more than 12 people, furthermore formal meetings cannot replace the need for informal communication, particularly in a complex working environment like clinical generalist-based primary care. The team, however good, cannot be allowed to grow bigger and bigger in primary care (Stott, 1993).

(n2 - n) ___ 2

The core primary health care team (PHCT)

The concept of a ‘Core PHCT’ has been coined by a Joint Working Party (1994) and it is gaining ground to deal creatively with the issues discussed above. The Core PHCT is likely to consist of clinical generalists (medicine and nursing) with support from a manager and

Table 1. Lines of team communication

No. of people Lines of communication

4 8

12 16

6 28 66

120

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98 N. C. H. STOTT

administrative staff. The ‘Core PHCT’ is likely to work under the same roof, be accountable to one another (rather than an external manager) and share common goals. If the team size grows then sub-division is likely to be desirable to form more than one core PHCT. Pritchard & Pritchard (1994) favour teams of three to six people but he is not prescriptive and several core teams can function within the same practice or administrative framework. If a core PHCT develops kom a general practice base with a defined list of patients, a reasonable level of continuity of care becomes feasible. Interfacing with each core PHCT is a range of community or hospital-based specialties with a tradition for a much higher turnover of staff than is the norm in general practice.

W h o provides patient continuity in the PHCT?

Team care does dilute personal care but Mackichan (1967) described years ago how an agreed key worker can reduce this problem and most doctordnurses will quote examples of added value through team care with highly effective doctor-led or nurse-led continuity. The patient gets to know the professional of choice and ‘teamwork’ provides a safety-net for professional development, supervision and support. Continuity of care with an appropriate key worker becomes a function of the formula described above and even two professionals who share a key worker role can provide the patient with choice and a level of continuity that is only different from a single professional by up to a factor of one. The exponential rise of discontinuity that can occur as more professionals become involved with each patient is a threat to effective and efficient care for most common problems as well as providing too many opportunities for buck-passing.

Discussion

This paper has identified some of the problematic aspects of personal care and teamwork in the context of a general practice-based primary care team. The solutions are unlikely to include regression to an old style of single-handed clinical practice but they are likely to include two features:

(i) conceptual separation of ‘Core-PHCT’ from the rapidly expanding work-force of specialities that now outreach into the community but do not function as clinical generalists and have little true primary care function;

(ii) size limitation on the ‘Core-PHCT’ so the growth in the number of lines of communi- cation cannot swamp effective and efficient function, including personal continuity of care by doctor, nurse or other key worker.

Quality in primary care will eventually become more comprehensively measurable than is possible with the current tools and surrogate tools. It is possible that the apparent economies of scale of practice design in the 1990s will be looked upon with dismay in the future unless core PHCT size can be contained by divisions within bigger organisations, and PHCT strengths enhanced through imaginative approaches to human and structural resources without losing the two features described above.

The special needs of community nurses, dentists, opticians, pharmacists and others who provide elements of non-general practice-based primary care are not addressed in this paper. They are a proper subject for analyses by the practitioners in those disciplines. However, the close interfaces that exist between these practitioners and a core PHCT can be enhanced in many creative ways once clear vision exists for the protection and development of core PHCT functions. Curricula for personal development and continuing multiprofessional education of these special groups and those in the Core PHCT will hinge on achieving much greater

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PERSONAL CARE AND TEAMWORK 99

clarity of purpose, structure and responsibilities. A Royal College of General Practitioners working party is addressing the essential content of general medical practice. The working party will report in 1995 and it is hoped that other professional groups will respond constructively from their own perspectives. The Core PHCT needs to be properly recognised for its proven past achievement and its future potential in a changing world.

Acknowledgements

The ideas in this paper have grown out of close collaboration with many colleagues from several countries. In particular I am grateful to the members of the RCGP Working Party on the Essential Content of General Practice and to two Welsh Working Parties. Mrs. P. Moore provided secretarial assistance.

References

BELFIIN, R. M. (1981) Management Teams: why They Succeed or Fail (Oxford, Heinemann). BOWLING, A. & STILWELL, B. (eds) (1988) The Nurse in Family Practice. Practice Nurses and Nurse Practitioners

HERMAN, J. (1994) Polarities in Medicine, British Journal of General Practice, 44, pp. 543-544. HOPKINS, P. (1973) The time factor, in: BALINT, E. & NORRELL, J. S. (eds.) Six Minutes for the Patient,

HJORTDAHL, P. & BORCHGREVINK, C. (1991) Continuity of care: influence of general practitioners knowledge

JOINT WORKING PARTY OF THE WELSH COUNCIL OF THE RCGP AND THE WELSH GMSC (1994) Patient care

MACKICHAN, N. D. (1967) The GP and the Primary Health Cure Team (London, Pitman Medical). MARSH, G. N. & KAIM-CAUDLE, P. (1976) Team Care in General Practice (London, Croom Helm.). MARSH, G. N. (1991) Efficient Care in General Practice (Oxford, Oxford University Press). P)VRETVEIT, J. (1 993) Co-ordinating Community Cure (Buckingham, Open University Press). PHILLIPS, D. R. (1986) The demand for and utilisation of health services, in: PACIONE, M. (ed.) Medical

PRITCHARD, P. M. M. (1978) Manual of Primary Health Care. Its Nature and Organisation (Oxford, Oxford

PRITCHARD, P. & PRITCHARD, J. (1994) Teamwork and Shared Care: A Practice Workbook, 2nd ed (Oxford,

ROYAL COLLEGE OF GENERAL PRACTITIONERS (1 972) The Future General Practitioner: Learning and Teaching

SPITZER, W. D. (1974) The Burlington randomised trial of the nurse practitioner, New England Journal of

STARFIELD, B. (1994) Is primary care essential? Lancet, 344, pp. 1129-1 133. STOTT, N. C. H. (1983) Primary Health Care: Bridging the Gap between Theory and Practice (Springer Verlag). STOTT, N. C. H. (1993) When something is good, more of the same is not always better, British Journal of

in Primary Health Care (London, Saitari Press).

pp. 142-1 53. (London, Tavistock).

about their patients on use of resources, British Medical Journal, 303, pp. 1181-1 184.

and the general practitioner, British Medical Journal, 309, pp. 1144-1 147.

Geography. ~ ~ O ~ T K S S and Prospect (London, Croom Helm).

University Press).

Oxford University Press).

(London, BMJ)

Medicine, 290, pp. 251-6.

General Practice, 43, pp. 254-58.

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/24/

14Fo

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nly.