Conflict and collectivism: the challenges of working across boundaries in health care

In addition to improving patient care, the aim of integrated care – and of the proposals set out in the NHS five year forward view – is for health care organisations to work more effectively across boundaries. Intellectually this idea makes good sense and is attractive and persuasive, but in practice it is not just difficult to achieve – it requires us to confront possibly our greatest flaw as a species.

That flaw is the human impulse (even instinct) to categorise others, on the basis of the flimsiest of differences, into members of 'in-groups' and 'out-groups' and to discriminate in favour of other 'in-group' members or against 'out-group' members.

Early studies of these powerful inter-group processes, in what have become known as the Robber's Cave experiments, demonstrated the fundamental nature of human inter-group prejudice and the potential for associated hostility. 

In other research children quickly learnt to be profoundly prejudiced simply on the basis of eye colour. And we can see how inter-group prejudice condemns mergers and acquisitions to limited success or outright failure.

In health care organisations, staff engagement is built by encouraging a sense of distinctive organisational identity, and developing compelling strategic narratives and shared values – precisely to create a strong ‘in-group’ identification. This approach makes it difficult to build cross-organisational co-operation, supportiveness and shared identity in the short or medium term, attractive though the idea might be, because of all the work that has been done to build pride in our existing organisations.

Successful integration requires leaders to find ways of blurring boundaries between pre-existing organisations by emphasising the benefits of the larger grouping (as will be the challenge for Manchester with its new mandate to manage a combined health and social care budget).

But inter-group bias will ensure that integration will not always be easy. People working in health care organisations will inevitably resist the kinds of organisational transformations that NHS leaders are proposing, unless they believe that these changes are for the long term and will not be abandoned, and that they will make a powerful, positive difference to patient care. People also have to be reassured that change will help them do their jobs better and maintain their key working relationships.

What then are the solutions? The first is establishing and promoting an overarching shared vision across newly merged organisations or across health and social care divides. From the perspective of health care staff, this vision must relate to improving the delivery of high-quality and compassionate care. It also means continually identifying, communicating and valuing progress towards achieving shared goals (with outcomes particularly focused on patient care, rather than on less inspiring outcomes such as productivity, cost effectiveness and efficiency).

Second, it is vital that there is frequent and sustained contact between key individuals and groups from the merging organisations. Cross-boundary relationships often spawn conflict because of clashes of values, working methods, identities, territories and inter-group prejudice. The issues need to be identified and resolved quickly, transparently and creatively in the best interests of patient care and all those involved. Cross organisational trust is built through authenticity, openness, fairness and commitment in the process of conflict resolution.

Third, the different organisations that come together or that seek to work collaboratively must build an approach of mutual altruism, mutual concern, unselfishness and an eagerness to work tirelessly at developing cross-organisational or cross-boundary relationships that are characterised by a strong sense of mutual support, belonging, appreciation and trust.

We understand much about inter-group relations; how they affect our ability to work together to solve shared problems (think of the difficulty of nations working together to deal with climate change), and how pervasive this fundamental human tendency is. If we are to be effective in creating the organisational forms and processes needed to meet the health and social care needs of our communities, we have to recognise the problems that will confront us. Good ideas on paper are one thing; the realities of human behaviour are quite another and we can and must adapt our good ideas to take account of this.

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Comments

#543407 Pearl Baker
Care/Independent Mental Health Advocate and Advisor
Independent

There is no mention of the Voluntary Sector who play an important part crossing boundaries of both Health and Social Care.

Advocates could hold the 'key' to the success of 'Integration' our role is often to challenge both health and social deficiencies generally due their failure to identify what agencies should be involved with their shared clients. The agencies involved would not necessarily be the same for each client group. I would like to give an example. A mentally ill individuals has become made homeless by the state! why! because he could not complete 45 pages of question to retain his welfare benefits, or too ill to attend an interview for 'fit for work' the latest piece of legislation to effect the mentally ill most, particularly is you are unsupported. The question how could this happen, when they receive medication for their illness. This has been identified by me as a 'gap' in the system, brought about poor observation by HEALTH, who should have a mechanism in place to ALERT Social Services. We have an underclass within the 'integrated' system of health and social care, and it is getting worse. The Advocates like myself are 'picking' up the pieces of system that is far from 'integrated' until you understand and care enough to address the issues i am afraid 'integration' will be in name only.

#543415 Terry
Member of the public

What about leaders being good role models, telling staff what is expected, supporting them to achieve and with all being under no illusions of the sanctions that will be enforced if not met. We are talking of peoples lives and well being here not simply how to run a convenience store.
There is far too much 'wishy washy' comment that backs off when it comes to taking real and difficult decisions. There is no place for 'catagorising people' or other theories, simply show positive results in actual improved patient care and that is often basic stuff.
A simple matter of how little health and social care know about each other just shows just how far behind we are.

#543426 Theresa Eynon
GP and County Councillor on Health Scrutiny Cttee
Leicestershire County Council

"What then are the solutions? The first is establishing and promoting an overarching shared vision across newly merged organisations or across health and social care divides."
Having been a Clinical Translation Fellow tasked to translate the BGS "Silver Book" Acute Guidelines for the Elderly, I have lived experience of the difficulties described by Michael West. I used to describe my job as "politics for clinicians". Getting people to share a vision, let alone work together to achieve it is no mean feat.
Like Pearl Baker, I am concerned that even the Kings Fund is missing the role of the voluntary sector. There is some recognition that measuring patient outcomes is more likely to inspire health and social care staff to work together to a common goal. The reality behind the scenes is a Leadership Programme for chief executives et al.
Campaigning charities, advocates, individuals like Julie Bailey and the occasional maverick politician are providing real leadership in the field of Patient Safety. They are, it seems, not invited.
At a recent EMAHSN Patient Safety Collaborative we heard some strong messages about the systemic barriers to health improvement. One of these is a fear of hearing the truth in case it exposes a service to political criticism.
Prof Robert Dingwall pointed out that learning lessons from poor care and 'accountability' are not on the same linguistic page.
I did ask the EMAHSN if it had a role in explaining this to the political class. I am told it does not.
Having got myself elected to improve my local NHS, I will continue to do my best to provide some leadership - on a shoestring and without the benefit of a Kings Fund Leadership course.

#543428 Umesh Prabhu
Medical Director
Wrightington Wigan and Leigh FT

With good value based leaders who share same values across the boundaries anything is possible but with poor leaders with no common values everything is difficult.

NHS, Social care and others who have a stake in this collective leadership must appoint value based leaders who uphold the values of our NHS and must appoint leaders who put patients at the heart and also look after staff well and inspire them to do their best for patients with excellent governance. In Wrightington, Wigan and Leigh FT we have defined our values, appointed value based leaders and removed those leaders who do not fit in with our values and by having robust staff and patient engagement we have transformed the Trust. Today (compared to 2008) 450 more patients survive, all 24 quality measurements have improved, got 24 awards, got 220 patient safety champions and our staff feedback has improved from bottom 20% to top 4th in the country and patients who recommend our Trust has also gone up/ Of course, we are not perfect and there are still many challenges.

Our aim is to work with our CCG, community Trust, Mental health Trust and Social care services to transform our Healthcare and reduce hospital admissions and shrink the hospital and to invest in the community so that all our patients get the best and safe care as close as possible.

Of course we got to do this without compromising patient safety and quality of care. It needs value based leaders from all sides to come together and do what is right for our patients and work with our staff.

#543430 Tim Delaney
Head of Pharmacy
Tallaght Hospital

When we reconfigured our clinical pharmacy service along medical specialty lines instead of geographically by ward, we achieved greatly improved outcomes as measured by medication error reduction and Medication Appropriateness Index. We also found that the acceptance rate for pharmacists' suggestions about care went from 67.5% to 98%.

Whilst we did not explore the reason for this change in the study, we surmise that increased acceptance of suggestions was a result of acculturation. The pharmacists by aligning themselves to the work practices of the medical teams became part of the in-group. Informal interviews with the pharmacists identified that they themselves felt more part of the team and more accepted. They also mentioned gaining new insights into how doctors worked that made them adjust their own approach. On a practical level greater familiarity with the doctors' routine throughout the day led to new work systems evolving to fit communications in with work patterns. Pharmacists reported a much greater level of face to face communications rather than relying on pagers or chart notes.

Collaborative working is the logical outcome of seeing work as a process. It is challenging in hospitals because of the existence of multiple subunit cultures including professional culture, team culture and ward/department culture. Professional leaders must find ways to accommodate their people within teams and yet retain elements of the professional culture. This requires humility and patience.

Our paper on collaborative pharmaceutical care was published in BMJ Quality &Safety 2014 July;23(7):574-583

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