Teamworking is fundamental to the future of general practice. Practices are coming together at scale in primary care networks and new roles are being introduced, creating multidisciplinary and multi-agency teams. Making these teams function effectively is a complex task. The King’s Fund has a long history of supporting and developing teams working in across health and care systems, and more recently we have been working with general practices and primary care networks as they develop team-based models of care.
This guide brings together insights from our research, policy analysis and leadership practice. The need for collaboration and communication underpins much of the guide and we provide further reading and case studies to support each section. You will already be doing some of the things we talk about, and some of what we’ve included may seem obvious. Some of the sections will be more relevant to you than others, but if you are a GP, practice manager or other professional working in primary care, or you are supporting practices, we hope you can use this guide to help you think how you will go about creating and sustaining effective teams within general practice.
What are the fundamentals of effective teams?
Professor Michael West’s research on team-based working in health care suggests that care outcomes, innovation and staff retention can all be enhanced, and staff sickness, absence, stress and injury reduced, by making sure the following three features are present in your teams.
A small number of meaningful objectives
A set of compelling objectives that your team members share responsibility – and accountability – for achieving, helps to create a sense of shared purpose, trust and collective achievement.
Clear roles and responsibilities among team members
Team members need to be clear about what activities need to be undertaken and who is responsible for completing them, so that nothing slips through the gaps. This is especially important when teams are forming, but roles and responsibilities may shift as your team matures and you get to know each other’s strengths. These roles and responsibilities should be revisited regularly to ensure that expectations about how things would work are indeed how they are working.
Reflect on how the team is working together
All teams benefit from taking time out to reflect on how they are working together and how they might improve. You might want to do this in the form of team time-outs, away days or regular huddles, covering both technical aspects of work, and how people are feeling. This time will be wasted, however, if people don’t feel able contribute freely, regardless of their role or position in the management hierarchy. So it’s important to think about how you will create a safe environment for your colleagues to speak up.
Which roles should you recruit?
There is evidence that introducing new roles into general practice could both bridge the workforce gaps that exist and supplement, rather than replace, the role of the GP. GPs, who manage uncertain diagnoses and risk and offer holistic care to patients with increasingly complex morbidities, will need to be at the heart of these teams.
NHS England is investing significant new resources in general practice through a new contract, providing funding for specific new roles: pharmacists, physiotherapists, physician associates, paramedics and community link workers. The recruitment of these new roles, which will be part funded through the network contract, relies as much on national availability as on need, though there is good evidence for the effectiveness of all of them.
In England, and in other countries, roles including occupational therapists, psychologists, mental health nurses, health coaches and dieticians also play an important role in primary care. You could choose to employ these professionals in your practice, share them across networks of practices or subcontract them from other organisations.
The two examples below might help you think about other roles that might be useful a multidisciplinary team.
Collaborative care at the Advancing Integrated Mental Health Solutions Center, Seattle, United States
The collaborative care provided by this organisation is designed to manage common mental health conditions in a primary care setting. Trained primary care clinicians and behavioural health professionals provide evidence-based medication or psychosocial treatments, supported by regular psychiatric case consultations and treatment adjustment. Patients are supported by a primary care physician, a full-time behavioural health care manager and a psychiatric consultant.
The behavioural health care manager typically oversees 100–150 patients. They support the primary care physician by co-ordinating treatment, providing proactive follow-up of treatment response, alerting the primary care physician when the patient is not improving, supporting medication management and facilitating communication with the psychiatric consultant about treatment changes.
They also offer brief counselling, a form of counselling that involves using evidence-based techniques such as motivational interviewing, behavioural activation and problem-solving treatment. The psychiatric consultant does not usually see the patient, except in rare circumstances, and does not prescribe medications, but is available to the behavioural health care manager and the primary care physician for ad-hoc consultation as needed.
Health coaching at Iora Health, Boston, United States
Iora Health’s model uses a significant number of non-medical staff to serve its diverse list of 40,000 patients across 29 practices and 11 states. It focuses on providing patients with the required emotional and practical support to engage with their health and adopt health-promoting behaviours. Iora Health’s clinics are typically staffed by two to three GPs, a clinical team manager (usually a nurse), a social worker and six to nine health coaches. The whole team works with the patient to set health goals, while the health coach actively supports the patient to achieve those goals. Daily morning ‘huddles’ enable staff to discuss patients they are concerned about, therefore enabling proactive, holistic care provision before a situation escalates.
The British Medical Association set out what some of these new roles (clinical pharmacists, community link workers, musculoskeletal first-contact physiotherapists, primary care paramedics and physician associates) can do, and the benefits they can bring to patients, the practice and the wider NHS when they join a primary care team. Further information and guidance on employing various health care professionals in general practice is available, for example, for [pharmacists](http://www.doncasterlmc.co.uk/Guide for GPs employing pharmacy staff.pdf).
Managers, administrators, data analysts, care navigators, prescribing clerks and receptionists will be needed to underpin effective teams and will need to be integrated into your teamworking model.
How can you make the best use of new roles?
There is no magic formula for the ‘right’ team structure in general practice. In fact, the research shows that creating a multidisciplinary team appears to be as important as the composition of the team. Evidence shows that in any team, the mix of professions and practitioners must be able to respond to the needs of the population concerned, while still being small enough to allow members to know each other.
You should have a clear understanding of the needs of your patient population and map the skills and knowledge of existing team members against those needs. This will help you to identify gaps, which can be overcome in a range of ways.
It is unlikely that ‘bolting on’ new professionals to your practice without re-thinking workflow will be effective. To make sure new roles become embedded in your team, you could take the following steps:
describe the different tasks currently undertaken by team members and any new tasks required
identify which skills are required to complete those tasks and any groupings of tasks that are important to keep together
identify the skills, strengths and interests of all current team members
involve the team (and patients if possible) in redesigning ways of working to match tasks to people, with the aim of providing best patient care and enabling personal and team development
carry out small-scale tests to experiment with new ways of working, before committing to full implementation.
Integrating the right mix of administrators, patient navigators, receptionists, data analysts and managers will also enable your team to function effectively.
Some practices have adopted several ‘microteams’ within a practice to bring together a smaller group of professionals to manage a designated number of the patients within the practice. This is particularly common in US models of care. Each of these smaller teams typically consist of one or more GPs, a nurse, a medical or health care assistant and an administrative assistant and manages all the acute and chronic care needs of their particular group of patients. These small teams are supported by a wider range of professionals in the practice, such as pharmacists, mental health specialists and midwives who work as part of an extended primary care team. The principle behind the use of a ‘core’ team is to make it easier for patients to develop ongoing relationships with their health care team and for that team to move to a more proactive model of care. Working with the same care team every day also helps build trust between clinical staff.
‘Microteams’ at Nuka System of Care, Southcentral Foundation, Alaska
This model uses microteams, typically with a GP, a nurse case manager, an administrator and a certified medical assistant. The nurse case manager handles routine health issues and triage; the administrator schedules appointments and communicates regularly with patients; and the medical assistant greets patients and carries out routine monitoring tasks. The GP handles only the most complex duties, particularly diagnosis. Each core team is responsible for around 1,400 patients and each group of six teams is supported by an integrated care team, which includes a dietician, a pharmacist, behavioural health consultants and midwives. The teams sit together, going to the patients in clinic rooms rather than the patients being brought to them. This allows them to make informal handoffs to other professionals, often acting opportunistically, and make personal introductions to other professionals, which builds trust and confidence.
Whichever method is used, including all staff in workflow redesign using data to demonstrate how team process changes can improve patient care will help get staff buy-in to the model that is chosen. You will also need to make it clear when recruiting that these are roles that will be working as a part of a team rather than as individual professionals.
How can teams communicate effectively?
The importance of communication within teams cannot be understated. With new team members, changing roles, restructured teams and re-designed physical spaces, thinking about how teams communicate will be the most important element for leaders to consider. Google’s two-year research project into teams found that the highest-performing teams had one thing in common: psychological safety – the belief that you can speak up or make mistakes without retribution. People become more creative, resilient and motivated when they feel safe. This can build over time if leaders work with their teams to encourage and develop this type of communication but needs to be nourished and respected as it can also be easily lost.
It is important that you pay attention to the quality of communication and ‘dialogue’ within teams. Our work on breakthrough conversations can help support you to move into what we term ‘generative dialogue’. There are also some practical steps you can take to ensure good communication within your teams.
Huddles are short, frequent check-ins to discuss the day’s patients and tasks. It’s natural to be concerned about how introducing more professionals will impact on continuity of care, as too often we hear of patients having to repeat themselves to different health and care professionals. Huddles can help to reduce this by discussing patient-specific issues and clarifying responsibilities. People working this way also report improved work satisfaction, teamwork and practice climate. If you adopt this method, you will need to allow the necessary time and resources for the huddles to take place.
Using digital tools
Digital means of communication, supported by robust IT infrastructure, are critical to teamworking. Each team member will need access to shared patient records and booking systems. There’s good evidence you will also need to think about how digital communication – texting, emailing, video conferencing – could be used to support your team. Effective information-sharing systems are fundamental to the success of teamworking, so that professionals are able to access and share information easily wherever they are, for example, on home visits.
Digital communication at The Mount View Practice, Fleetwood, Lancashire
At this practice, the paramedic practitioner sees patients with minor ailments at the practice in the morning, before going on home visits to see patients who are housebound or who have long-term conditions. These account for the majority of home visits by the practice. The GP carries out home visits for new patients, those who have no diagnosis and occasionally those coming to the end of their lives. Paramedics on home visits can access the patient’s notes remotely and contact the on-call GP by telephone or video call. The digital link allows the GP to see and interact directly with the patient and their family, and the paramedic to get extra advice and support.
Do you need to re-design your physical space?
Changing the physical working environment can help support new teams to function. One option is to bring team members out of their individual practice rooms into a shared working space, which is their default location when they are not seeing a patient.
This is at odds with how many practices currently work, but evidence suggests teams sharing the same working space brings many benefits: improving integration and team cohesion, enabling real-time communication in huddles, and facilitating information sharing between team members. Team members are more likely to be sensitive to one another’s problems and appreciate each other’s roles when they have this sort of contact with each other. For professionals who work remotely or between practices, co-locating on a regular basis in a shared space can really help to improve team cohesion.
Open workspaces at the Nuka System of Care, Southcentral Foundation, Alaska
In its newer facilities, the Southcentral Foundation radically changed the design of its office spaces to promote relationships between employees. Primary care providers (GPs) now sit together in open workspaces with nurse case managers, certified medical assistants, case management support and other care workers. This open environment fosters collaboration among team members. The Foundation has also taken managers and supervisors out of their offices, and they now sit together in open areas with the people they supervise. Communication is made much easier in these types of environments.
Multidisciplinary teams at Healthy Prestatyn Iach, Prestatyn, Wales
Healthy Prestatyn Iach was created by Betsi Cadwaladr University Health Board in April 2016 when several practices in the area closed or were at risk of closure because of difficulties in recruiting GPs. Five multidisciplinary teams composed of GPs, nurse practitioners, occupational therapists, pharmacists and a dedicated co-ordinator care for an allocated group of patients. The teams sit in the same office rather than in separate consulting rooms so they can share support and discuss cases.
Creating shared space isn’t always straightforward. One way you might want to do this is to have all health care professionals sitting together in a shared space, with the former GP offices used as treatment rooms where the patient waits for the professional to see them.
Obviously, co-location isn’t always possible, but focusing on creating lots of opportunities for informal communication through team meetings, team-building activities and technology can help to achieve some of the same benefits of trust and a strong team identity.
Even when co-location is possible, re-designing physical spaces can be met with resistance, even when the current spaces are not optimal, because people are accustomed to particular ways of working. To support individuals who might feel a lack of ownership with shared space or feel they will have less privacy, it’s important to talk about any concerns and explain the benefits of co-location. Ideally, this will be done well in advance of trying to implement any changes, so that your team members can be involved in creating new spaces and ways of working, and you have time to work through any potential implications for their satisfaction and wellbeing.
How can you ensure supportive management and accountability?
Accountability in team-based care can feel complex and difficult. All health care professionals are ultimately accountable to patients and are, in particular, legally accountable to patients for any errors or omissions they make that could cause harm. They are accountable to their professional regulator for standards of practice and to their employers, who must in turn support them to carry out their duties safely and effectively, complying with any codes of practice their profession or organisation has in place.
The underlying principle for effective management, support and accountability is to create a safe environment where opportunities for professional development and reflecting on practice are inbuilt. Clarity of roles and responsibilities is key, but there also needs to be a focus on effective communication between team members and on the way the physical space is designed to help these conversations. It’s sometimes particularly difficult to ensure good accountability and oversight of staff in new roles that do not fit into established structures, for example, community link workers or roles that spread across different organisations, or physiotherapists or pharmacists working in both general practice and in community or acute trusts. You will need to pay particular attention to how people working in these new roles will be supported and managed. Clinical supervision, appraisals and learning and development opportunities can help you to do this.
Access to clinical supervision is an essential requirement for all health professionals. There are lots of effective models of clinical supervision (including one-to-one, group or peer supervision). The model will vary between GP practices and professions, and should be developed by teams to meet their needs and the requirements of the contract. The scale of primary care networks will offer more opportunities for supervision and for individual professions to meet regularly across the network to discuss issues specific to their profession.
Appraisals are a requirement in the NHS, but there are ways to make them a more productive and positive experience for your staff. Make sure they are focused on a shared understanding of team goals and two-way communication, and concentrate as much on setting goals for the future as on past review.
Gathering feedback from colleagues and patients is a core part of appraisal and revalidation for GPs and nurses. Providing constructive feedback is an important skill for your team to develop and is key to establishing trust and supporting psychological safety.
Learning and development
All team members need to have the skills, knowledge and experience to deliver effective care and treatment. Making sure this is available to a wider range of professionals can feel a daunting task but seeing it as part of a wider approach to shared learning and communication can make this easier. In addition to recruiting the right staff, your practice or primary care networks also needs to make sure that each team member’s learning needs are identified, that team members can access training and that they are given opportunities to develop. Most clinicians need to demonstrate that they have undertaken continuing professional development in order to maintain their registration, but access to learning and development is critical for all team members and should include both planned and unplanned learning.
A frequent recommendation of workforce research and integrated care programme evaluations is the need for cross-professional and cross-organisational training. Clinical commissioning groups often support protected learning time for practices to allow teams to come together and community education provider networks will help to broaden this by providing training placements and learning opportunities for students and staff across a range organisations and sectors.
How can you work across organisations?
While much of the evidence shows that small, stable teams are most effective, we recognise that not all work can be done in such teams. Primary care networks will depend on groups of people who work across different organisations and may not see each other every day working together.
Dr Amy Edmondson from Harvard University calls this ‘teaming’ – creating temporary teams to work together and overcoming what she calls the ‘professional culture clash’. This refers to how individuals see the world in different ways and are products of different training, have different backgrounds and use different language. To create the collaborative mindset required for successful teaming, you will need to make it clear that this is work where you don’t have all the answers, but require everyone to share and value each other’s expertise in order to create a successful team.
It’s important you create psychological safety so people in your team can share ideas without fear. You can support this by demonstrating curiosity rather than always having the answer and directing others. Instead, welcome the diversity of team members’ experience when exploring problems and be willing to learn. Over time, this can help team members to accept that they are dependent on each other, trust each other and share ideas and develop creative solutions together.
The King’s Fund has also looked in detail at the issue of working across organisational and professional boundaries within health and care. We found that having a culture that focuses on protecting professional and organisational identities is a significant barrier to this kind of working, especially when established roles are being reconfigured. Our work suggests that leadership is important here. You can help yourself and others with the emotional transition needed by embracing the principles of collective leadership. This involves being clear about the shared vision across the organisations within your primary care network and continually identifying, communicating and valuing progress towards achieving your improved care aspirations. This can help everyone to take responsibility for the success of the team, rather than just their own job or work area.
This will be supported by the kind of communication and trust-building which all teams need – including opportunities for informal and formal communication, opportunities for shared learning and a physical environment that encourages these.
How should you engage with your patients?
Teamworking models will be most effective if they are co-designed with patients and carers. True engagement – partnership and shared leadership – goes beyond education and consultation efforts to a place where patients co-lead improvement and design initiatives. There are lots of toolkits that can help with this work providing guidance on everything from how to recruit patients to emotionally mapping their experience.
Practices delivering the best team-based care describe patients as members of the team, sharing responsibility for decision-making, expressing their needs and preferences and carrying out their care plans.
For patients and carers who know their GP or believe a GP is the most appropriate person to see, being seen by another member of the team might introduce a source of confusion at an already stressful time. It might not be clear why they are seeing a pharmacist or why a paramedic is doing a home visit rather than a GP. They might have concerns around whether the individual is qualified. It’s vital to engage patients and carers when moving to teamworking so that they can also build trust in the team.
There is good evidence that continuity of care results in better health outcomes and patient satisfaction, and there will be concerns from patients and professionals that teamworking might make continuity more difficult. Continuity in general practice has traditionally been seen as the relationship between an individual GP and the patient; but in other health and care services the relationship is between the team and the patient. It is possible for general practice to shift the relationship too when it is no longer possible or appropriate to have one-to-one continuity. Communication between professionals is therefore vital to a patient having continuity of care with more than one individual. This must also be facilitated by the team structure for example, having consistent microteams that share a patient list allows all members to get to know the patient.
Communication is key – the GP patient survey found that patients’ evaluation of their care was worse if they didn’t get the type of consultation they expected. Crucially, new teams should be made visible: posters and business cards with team members’ names, titles and roles can be really helpful. Being introduced to a new team member by a known health professional and regularly using other team members’ names when talking to patients will help the patient to build trust with new health professionals. Reception staff have a critical role in helping patients to understand and navigate new teams and avoiding inappropriate appointments that could damage trust in new ways of working. They can also be very important in explaining teams and the new ways of teamworking to patients.
How can you manage yourselves effectively?
Moving to new team structures and ways of working inevitably means people will be doing different things when they go to work, and this can change how they interact with each other, and patients. For many people who work in health and care the work they do is intimately tied up with how they see themselves. They like to provide high-quality care and feel valued when they deliver to the public’s and their own standards. Conversations about new ways of working may bring deeply held beliefs that are rarely questioned in day-to-day life to the surface. This may stir up powerful feelings about what is happening, and team members may experience excitement, fear, sadness, optimism, anger or frustration – and perhaps all of these at different times – as they:
encounter uncertainty or ambiguity about how equal team members are, as roles, line management and long-established local and professional hierarchies are reconsidered
move closer to or further away from patients as new arrangements for leadership, supervision and continuity of care are implemented
experience a perceived loss of status or prestige associated with traditional roles, a lack of confidence in taking on new responsibilities or a sense that well-developed competencies will be underused
feel that they are losing autonomy and their ability to determine their own practice.
If there is no space for team members to talk about their experiences, your team might find itself stuck in unhelpful conflicts that may undermine the benefits to patient care you are trying to achieve. Increasing the awareness and ability of teams to deal rationally and collectively with these feelings can be very helpful. Sharing some of the benefits of moving to team-based working with your team can allay some of the feelings.
You can share the burden of stress and reduce the pressures on individuals, reducing levels of burnout. Reflecting together regularly on challenges faced by those in the team has been shown to reduce staff sickness.
Your team can accelerate its learning by sharing knowledge and skills gained from each member’s continued professional development training. This also improves each profession’s multidisciplinary understanding and confidence in their roles.
Members of your team can support one another to work to the best of their abilities, creating a sense of psychological safety, which is shown to increase job satisfaction and sense of fulfilment.
Your team will be able to give more patient-centred care as a result of understanding each other. They will know which professional has the best skillset to manage the patient’s needs at any given time.
Taking regular time out to reflect on how the team is working and incorporating such measures into your team’s routine can help to reduce stress and increase staff enjoyment. This could take the form of:
early discussion between all members about their own and others’ strengths, as well as uncertainties, when the new team forms
continued regular huddles, which provide a safe place for talking, both about patient encounters and relationships in the team. This can provide a feeling of shared responsibility and time to learn from one another.
These are examples of ways to keep talking about how things are going and making adjustments that help all team members to feel valued and valuable as new roles and responsibilities emerge.