Primary care in the UK changed enormously over the 25-year period up to 2010.¹ The roles and demands on the primary healthcare team (PHCT) have increased and will continue to increase in a primary care-led National Health Service. Membership of the PHCT has broadened. Teams dominated by general practitioners have given way to multi-professional teams including nursing and many other professionals. New nursing roles such as nurse practitioners and clinical nurse specialists are blurring traditional boundaries and old roles are being extended. The roles of practice managers and reception staff are also being continuously modified and extended.²

Members of the primary healthcare team

The PHCT might therefore be considered to incorporate a much wider range of activities and professional groups, including:

• The traditional PHCT - for example:
  • Practice manager.
  • Doctors: GP partners, GP assistants and other salaried doctors, GP registrars.
  • Nurses: practice nurses, nurse practitioners, community nurses; appropriately trained and supported nurses can produce high-quality care and achieve as good health outcomes for patients.³
  • Support staff: receptionists, secretaries, clerical staff.
  • Midwives.
  • Health visitors.
• Primary care premises may also be used for selected secondary care services, e.g. hospital consultant clinics, diagnostic imaging, operating services.
• Allied health professionals may also work closely with the PHCT, e.g. physiotherapy, dietetics, podiatry, pharmacy, counselling⁴ (see separate article Counselling in Primary Care), complimentary therapists (e.g. acupuncture, homoeopathy) and social services.

Changes affecting the primary healthcare team

Changes for the PHCT include:

• Ageing population: more chronic illness (managed largely in primary care) and a greater demand for healthcare generally (managed largely in primary care).
• Increasing healthcare roles, e.g. primary care clinics and minor surgery in primary care.
• Expectations and demands on the PHCT have also increased. See separate articles Patient Satisfaction - Assessing and Achieving, Patient Groups and Expert Patients.
• Increased monitoring of primary care (see separate article Monitoring the NHS - Local Involvement Networks (LINks)).
• Records: see separate articles Records, Computers and Electronic Health Record, Data Security and Caldicott Guardianship and Paperless General Practice.
• Economic factors continue to have a big impact on the development of healthcare premises. There is a developing trend towards a much wider range of services within enlarged premises. This also presents a massive challenge to successful teamwork.
• There is a continuing trend to increase the range of services available in primary care and for these to be commissioned by GPs through practice-based commissioning.
• The development of new and extended professional roles will affect how different members of the PHCT work together. For example:
  • The development of healthcare assistants (often from existing reception staff).
  • The extended role of pharmacists in medicines' management and minor illness.
  • The development of nurse prescribing and triage.⁵

The principles of good team development

The development of new and larger practices has provided a challenge of effective teamworking within the PHCT to initiate effective teamworking.

• Practice-based interprofessional collaboration is important in improving healthcare processes and outcomes.⁶ Practice meetings should be regular, structured, relevant and inclusive of everyone's views.
• It is vital that the practice should have a regularly updated, agreed and evaluated development plan as well as each individual having a personal development plan.
• Opportunity should be ensured for regular training and updates for all clinical and support staff, both within the practice and with similar professionals from other practices.
• Audit and feedback can be effective in improving professional practice.⁷
• Keeping up-to-date and maintaining good practice are now formally monitored with audit, prescribing analysis, personal development plans, appraisal and revalidation.
• Educational meetings can improve professional practice and healthcare outcomes for the patients.⁸
• Educational outreach visits (e.g. by pharmacists, secondary care professionals) can also improve healthcare outcomes.⁹
• Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates, based on current evidence. However the effects of 'in-house' second opinion and other intermediate primary care-based alternatives to outpatient referral appear promising.¹⁰

The Forum on Teamworking in Primary Healthcare in 2000 provided recommendations for establishing a successful PHCT. The team should:

• Recognise and include the patient, carer, or their representative, as an essential member of the primary healthcare team at individual patient-centred team level or at practice level.
• Establish a common agreed purpose (share understanding of teamworking).
• Agree set objectives and monitor progress towards them.
• Agree teamworking conditions, including a process for resolving conflict.
• Ensure that each team member understands and acknowledges the skills and knowledge of team colleagues (and regularly reaffirms).
• Pay particular attention to the importance of communication between its members, including the patient.
• Take active steps to ensure that the practice population understands and accepts the way in which the team works within the community.
• Select the leader of the team for his or her leadership skills (rather than on the basis of status, hierarchy or availability) and include in the membership of the team all the relevant professions serving a practice population.
• Promote teamwork across healthcare and social care.
• Evaluate all its teamworking initiatives on the basis of sound evidence.
• Ensure that the sharing of patient information within the team is in accordance with current legal and professional requirements.
• Take active steps to facilitate inter-professional collaboration and understanding through joint conferences, education and training initiatives.
• Be aware of other measures involving national organisations, educational measures, research and general guidance which impact on teamworking.

Document references

1. Charlton R; General practice. Clin Med. 2010 Dec;10(6):600-4. [abstract]
2. Arksey H, Snape C, Watt I; Roles and expectations of a primary care team. J Interprof Care. 2007 Mar;21(2):217-9.
3. Laurant M, Reeves D, Hermens R, et al; Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001271. [abstract]
4. Bower P, Rowland N, Mellor C, et al; Effectiveness and cost effectiveness of counselling in primary care. Cochrane Database Syst Rev. 2002;(1):CD001025. [abstract]
5. Picton C, Granby T; Maintaining and developing competencies in nurse prescribing. Br J Community Nurs. 2002 Feb;7(2):90-3. [abstract]
6. Zwarenstein M, Goldman J, Reeves S; Interprofessional collaboration: effects of practice-based interventions on Cochrane Database Syst Rev. 2009 Jul 8;(3):CD000072. [abstract]
7. Jamtvedt G, Young JM, Kristoffersen DT, et al; Audit and feedback: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2003;(3):CD000259. [abstract]
8. Forsetlund L, Bjorndal A, Rashidian A, et al; Continuing education meetings and workshops: effects on professional practice and Cochrane Database Syst Rev. 2009 Apr 15;(2):CD003030. [abstract]
9. O'Brien MA, Rogers S, Jamtvedt G, et al; Educational outreach visits: effects on professional practice and health care Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000409. [abstract]
10. Akbari A, Mayhew A, Al-Alawi MA, et al; Interventions to improve outpatient referrals from primary care to secondary Cochrane Database Syst Rev. 2008 Oct 8;(4):CD005471. [abstract]

Internet and further reading

• Improving quality in primary care, Dept of Health, Oct 2009
• Suter E, Oelke ND, Adair CE, et al; Ten key principles for successful health systems integration. Healthc Q. 2009 Oct;13 Spec No:16-23. [abstract]
• Good Medical Practice, General Medical Council
• Teamworking guide for primary healthcare; Health Development Agency, NICE (2003)