Collaboration and teamwork ..Collaboration and teamwork ..

Peter MilburnPeter MilburnNov 2008Nov 2008

Questions and issues for Questions and issues for discussion……..discussion……..

Is the consideration of collaborative practice necessary at all??Is the consideration of collaborative practice necessary at all?? Could you recognise effective collaboration if you met it!!Could you recognise effective collaboration if you met it!! Is ‘it’ a learnt skill?Is ‘it’ a learnt skill? Are there factors that might hinder or facilitate effective collaborative Are there factors that might hinder or facilitate effective collaborative

practice within a healthcare team or organisation?practice within a healthcare team or organisation?

A definition …………………..A definition …………………..

‘‘Effective collaboration in the modern health and social care sector is Effective collaboration in the modern health and social care sector is about everyone appreciating there position and being clear about about everyone appreciating there position and being clear about where the ‘book stops’ (if things get ‘sticky’) and doing as they are told where the ‘book stops’ (if things get ‘sticky’) and doing as they are told without question?without question?

The n MRCGP……..The n MRCGP……..

Curriculum Statements: Curriculum Statements:

Coordinating care with other professionals in primary care and with Coordinating care with other professionals in primary care and with other specialtiesother specialties

Understanding the importance of excellent communication with Understanding the importance of excellent communication with patients and staff and skill in effective teamworkpatients and staff and skill in effective teamwork

‘‘being a GP requires the ability to be an being a GP requires the ability to be an effective team player’effective team player’ Understand methods and models of brining about effective teamworkUnderstand methods and models of brining about effective teamwork

(n MRCGP 2007)(n MRCGP 2007)

Similar statements appear in the curriculum of every Health and Social Similar statements appear in the curriculum of every Health and Social Care Practitioner Care Practitioner

– – the majority of H&SC practitioners are now taught on the majority of H&SC practitioners are now taught on ‘interprofessional programmes’‘interprofessional programmes’

Policy statements …….Policy statements …….

The NHS Plan (2000)The NHS Plan (2000) “social services and the NHS will come “social services and the NHS will come together with new agreements to pool resources …. prevent together with new agreements to pool resources …. prevent patients/clients … falling in the cracks between ..”patients/clients … falling in the cracks between ..”

Every Child Matters (2003) Every Child Matters (2003) “addressing poor integration of “addressing poor integration of services” services”

Modernising Medical Careers 2003 ‘Reform had been long overdue and was driven by the need for care based in more effective teamwork, a multi-disciplinary approach and more flexible training pathways tailored to meet service and personal development needs’.

Our Health, our Care, our Say (2006)Our Health, our Care, our Say (2006) “integrated “integrated approaches … innovative models of joined-up support within approaches … innovative models of joined-up support within communities”communities”

Secondly, UK society is changing ….Secondly, UK society is changing ….

- The breakdown of the post-war social democratic - The breakdown of the post-war social democratic consensusconsensus

- Increase in personal wealth and autonomy- Increase in personal wealth and autonomy- Growth in the availability of material goods - Growth in the availability of material goods - Dissolution of social hierarchies – (elders and betters)- Dissolution of social hierarchies – (elders and betters)- Society has become secular, materialistic, - Society has become secular, materialistic,

individualistic & rights focusedindividualistic & rights focused

How has the NHS changed in response…How has the NHS changed in response…

The NHS of today is ….The NHS of today is ….

– Market-led (payment by results)Market-led (payment by results)– BureaucraticBureaucratic– Quality drivenQuality driven– Standardised (NICE, SCIE)Standardised (NICE, SCIE)– AccountableAccountable– Performance Managed (AfC)Performance Managed (AfC)– Has (or attempting to) break down professional Has (or attempting to) break down professional

boundaries, barriers and restricted practicesboundaries, barriers and restricted practices

The language of Health Care has The language of Health Care has Changed……Changed……

Autonomy Autonomy (not paternalism)(not paternalism) Individual need Individual need (not common good)(not common good) Choice Choice (not sameness)(not sameness) Partnership Partnership (not deference)(not deference) Empowerment Empowerment (not authority)(not authority) Person-centred Person-centred (not professionally-led)(not professionally-led) ConsumerConsumer (not patient) (not patient)

Do you think …………………..Do you think …………………..

– the response appropriate??the response appropriate??

– the response is evidence based??the response is evidence based??

How have the professions responded …How have the professions responded …

How have the professions responded…How have the professions responded…

Positively by:Positively by:

Creating pillars of societyCreating pillars of society Reflect rationality Reflect rationality Adopting practice concerned with core values selflessness / advocacy Adopting practice concerned with core values selflessness / advocacy Managing scares resources effectivelyManaging scares resources effectively Applying rational knowledge efficiently and regardless of personApplying rational knowledge efficiently and regardless of person Having developed and work to written code of ethicsHaving developed and work to written code of ethics

Negatively by:Negatively by:

Creating closed occupational groupCreating closed occupational group Establishing elitists training & selection programmesEstablishing elitists training & selection programmes Formed professional association to exclude othersFormed professional association to exclude others Being political activity to establish recognition and protection of professional workBeing political activity to establish recognition and protection of professional work Put the interest of their profession before the needs of the publicPut the interest of their profession before the needs of the public

adapted from Wilensky (1964) (Schon 1988)adapted from Wilensky (1964) (Schon 1988)

What is it the public want from What is it the public want from professionals….professionals….

Knowledge:Knowledge: accurate, up-to-date and evidence accurate, up-to-date and evidence basedbased

Skills:Skills: expert clinical and personal skills, open- expert clinical and personal skills, open-minded team playersminded team players

Attitudes:Attitudes: compassionate, respectful, compassionate, respectful, enquiring, fostering independence, honest, enquiring, fostering independence, honest, focusing on possibility not riskfocusing on possibility not risk

Recognition that complex services can only be Recognition that complex services can only be delivered with openness, transparency and delivered with openness, transparency and

COLLABORATIONCOLLABORATION

What are the boundaries to effective What are the boundaries to effective collaborative practice in ‘General Practice’collaborative practice in ‘General Practice’

Suggestions ……….Suggestions ……….

Organisational Barriers:Organisational Barriers:– Organisations have different structures, cultures Organisations have different structures, cultures

and financial arrangements – working across the and financial arrangements – working across the health – social care dividehealth – social care divide

Professional Barriers:Professional Barriers:– Individuals working in Primary Care belong to and Individuals working in Primary Care belong to and

identify with different (professional) groups, each of identify with different (professional) groups, each of which may have differences in knowledge and which may have differences in knowledge and valuesvalues

Personal Inability:Personal Inability:– Differences in personality traits and preferences Differences in personality traits and preferences

may make collaboration difficultmay make collaboration difficult

Models to investigate and facilitate Models to investigate and facilitate collaborative practice ….collaborative practice ….

General systems theoryGeneral systems theory Models of powerModels of power

Social Identity theorySocial Identity theory Contact hypothesisContact hypothesis

Psychodynamic theoryPsychodynamic theory Functional transactional analysis (TA)Functional transactional analysis (TA)

Questions ton ask that may help you Questions ton ask that may help you collaborate more effectively …….collaborate more effectively …….

Who do I need to work with and why?Who do I need to work with and why? What kinds of relationship do we want?What kinds of relationship do we want? How do we expect the relationship to operate?How do we expect the relationship to operate? Is our experience of the relationship satisfactory?Is our experience of the relationship satisfactory? How well do organizational factors support the How well do organizational factors support the

relationship?relationship? How well do people factors support the relationship?How well do people factors support the relationship? Is the relationship delivering the desired outcomes?Is the relationship delivering the desired outcomes?

(Meads and Ashcroft 2005)(Meads and Ashcroft 2005)

How do you know how well you collaborate: How do you know how well you collaborate: The The ‘Taxonomy of collaboration’ ….‘Taxonomy of collaboration’ ….

In your association with others do you …..In your association with others do you …..

Work in Work in isolationisolation Only have Only have encountersencounters other professionals other professionals CommunicationCommunication effectively when necessary effectively when necessary CollaborateCollaborate to make effective decisions to make effective decisions Lead a fully Lead a fully integrated integrated team of professions each team of professions each

being equally responsible for their own being equally responsible for their own effectivenesseffectiveness

(adapted from Bond et al 1985)(adapted from Bond et al 1985)

The excuses…….The excuses……. Conflicting pressures and constraints Conflicting pressures and constraints

– – I’m to busy to be bothered – (I can’t manage myself effectively how on I’m to busy to be bothered – (I can’t manage myself effectively how on earth can I manage others!)earth can I manage others!)

Organisational and professional differencesOrganisational and professional differences– If I collaborate ‘others’ will start to think they can do my job as well as If I collaborate ‘others’ will start to think they can do my job as well as

me!!me!!

Power relationshipsPower relationships– Its natural and important for there to be a social order – how else Its natural and important for there to be a social order – how else

would I justify being paid twice as much!!would I justify being paid twice as much!!

Lack of clarity about purpose and outcomesLack of clarity about purpose and outcomes– My role keeps changing and I am continually being to deliver a My role keeps changing and I am continually being to deliver a

different set of outcomesdifferent set of outcomes(adapted from Charlesworth 2003)(adapted from Charlesworth 2003)

A definition …………………..A definition …………………..

‘‘Effective collaboration in the modern health Effective collaboration in the modern health and social care sector is about everyone and social care sector is about everyone appreciating there position and being clear appreciating there position and being clear about where the ‘book stops’ (if things get about where the ‘book stops’ (if things get ‘sticky’) and doing as they are told without ‘sticky’) and doing as they are told without question?question?

The outcome ……..The outcome ……..

“…“…When the social services came to see me, she When the social services came to see me, she said, “We didn’t realise your mother’s legs were said, “We didn’t realise your mother’s legs were that bad.” I said, “Well, I told you they were when that bad.” I said, “Well, I told you they were when she was in hospital.” When the district nurse she was in hospital.” When the district nurse comes, they say they don’t do legs any longer… comes, they say they don’t do legs any longer… they don’t wash legs, that’s the social services job. they don’t wash legs, that’s the social services job. So they’re arguing in my mother’s house about So they’re arguing in my mother’s house about who’s going to do what.” who’s going to do what.”

(Service user quoted by Charlesworth 2003)(Service user quoted by Charlesworth 2003)

“ “Health is not a product, but a process of interaction within Health is not a product, but a process of interaction within and between individuals and the societies in which they and between individuals and the societies in which they live. live.

The recognition of health and welfare within society as an The recognition of health and welfare within society as an interactive, adaptive process without an end becomes the interactive, adaptive process without an end becomes the only creative basis for strategies, policies and practices. only creative basis for strategies, policies and practices.

In this interactive process, by definition, the ability to In this interactive process, by definition, the ability to collaborate is essentialcollaborate is essential.”.”

(Loxley 1997 p.29)(Loxley 1997 p.29)