Primary Health Care Team

Professionalism has contributed a great deal to modern health care, but it may also inhibit team working. An ageing population with complex clinical and social needs, rapid developments in our ability to deliver more care outside hospitals and major new Government-led policy initiatives, make the understanding and removal of such ‘inhibitions’ in the field of primary healthcare an urgent priority.¹

The Primary Health Care Team (PHCT) is responsible for the delivery of primary healthcare. In recent years there have been organisational changes not only affecting which professional groups might be considered part of the team but also the working relationships between these professional groups. These organisational changes have developed in parallel to changes in the demand for healthcare resulting from demographic changes and technological advances. The nature of illness and disease within this relatively short time has hardly changed at all.

It is now no longer adequate to define the PHCT merely by listing those professionals who might, by common consensus, be considered members of this team. It is perhaps more useful to consider the background to changes affecting the PHCT, important factors driving change, the principles of good team work and finally a new and much broader concept of what constitutes the PHCT.

From the early years of the National Health Service in the 1940s general practitioners (GPs) worked from their own homes. Other professionals were few in number and were often linked with hospitals rather than the doctor's surgery. GPs began their role as 'gatekeepers' to secondary healthcare as well as managing many health problems within primary healthcare.

With changes in the complexity of work and the formation of larger partnerships, purpose built premises were developed and it became commonplace for such buildings to accommodate a much wider range of health professionals. The concept of a PHCT emerged from this and the premises often became a focus for team working.

Doctors have been a core profession within the PHCT and central to the development of primary healthcare, but the process of change continues and an even wider range of professionals are now being integrated into ever larger buildings with a wider range of services being offered within primary healthcare premises. This can include many community based services which have overlapping interests and responsibilities to those of the more traditional PHCT. The PHCT might therefore be considered to incorporate a much wider range of activities and professional groups. This might include:

• The traditional PHCT, for example:
  • GP partners
  • GP assistants and other salaried doctors
  • GP registrars; pre-registration house physicians (medical students)
  • Practice nurses
  • Practice managers
  • Receptionists
  • Community nurses
  • Midwives
  • Health visitors
  • Nurse practitioners:
    • Diagnose and initiate treatment
    • Patient satisfaction is high
    • Consultations are longer by 3-4min
    • More tests are done^2,3
• Selected secondary care services, for example:
  • Hospital consultants
  • Diagnostic imaging
  • Operating services
• Allied health professionals, for example:
  • Physiotherapy
  • Dietetics
  • Podiatry
  • Pharmacy
  • Counselling⁴
• Complimentary therapists, for example:
  • Acupuncture
  • Homoeopathy
• Social services, for example:
  • Social workers
  • Social care workers
• Health promotion, for example:
  • Gymnasiums
  • Education
• Others beyond the surgery:
  • NHS direct
  • NHS walk-in services
  • Nurse-led personal medical services
  • Community pharmacists
  • Health education officers
  • Community physicians

This is not an exhaustive list.

There are many factors driving changes which affect the PHCT. These changes affect:

• Which professional groups are part of the PHCT.
• Which professional groups work alongside the PHCT.
• The working relationship between these different professional groups.

These changes are driven by a mixture of political, economic, social, professional and health related factors. A few of these have been selected to exemplify the diverse and profound nature of such changes:

• Economic factors (including the current banking crisis) will have a big impact on the development of healthcare premises. The development of healthcare premises affects the PHCT because:
  • About 60% of primary healthcare premises are still owned by GPs Many existing premises are too small or unfit for purpose and growing numbers of new GPs need to be accommodated.
  • There is a trend away from smaller traditional doctor-owned premises to much larger buildings owned and developed by private companies and NHS Local Improvement Finance Trust (LIFT) schemes.
  • There is a developing trend towards a much wider range of services within enlarged premises.The introduction of additional services is helping to fund new surgeries and this trend is likely to continue for both political and economic reasons.
  • This presents a massive challenge to successful teamwork.
• There are political pressures to:
  • Increase the range of services available in primary care and for these to be commissioned by GPs through practice based commissioning.
  • Reduce the cost of treatments.
  • Provide more treatments closer to where patients live.
• 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 prescribing⁵ and triage.
• The growing number of ageing patients will bring:
  • More chronic illness (managed largely in primary care).
  • A greater demand for healthcare generally (managed largely in primary care).

The Forum on Teamworking in Primary Healthcare was convened as a result of a joint initiative between the Royal Pharmaceutical Society, the British Medical Association, the Royal College of Nursing, the National Pharmaceutical Association and the Royal College of General Practitioners.¹ The Forum was supported by an even wider group of representatives from other professions and The Patients Association. The remit of the Forum was: ‘to examine the practical aspects of teamworking in primary healthcare and to bring forward proposals by which the national organisations representing primary healthcare professionals can support and promote this concept’.¹The recommendations are outlined briefly 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 health 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.

A combination of factors have come together to promote a new concept of the PHCT. In summary:

• The PHCT is no longer a narrow list of professional titles and job descriptions.
• A broad list of professional groups and stakeholders are now encouraged to come together and define individual and common purpose. This should include patients and carers. The PHCT should define and agree the objectives and principles of teamworking.
• The development of new and larger practices poses a challenge to the members of the PHCT to initiate effective teamworking.
• The success of new and bigger practices depends on successful teamworking and is one of the emerging challenges for primary healthcare.