Take a multiskilled approach to collaboration

In modern healthcare – whether frontline clinical environments or management circles – teams seem to be the accepted mechanism by which work is done.

The culture within the NHS clearly has team work at its heart with 90 per cent of employees stating that they work in teams.

‘Our healthcare providers must encourage and develop a new way of working that encourages team work’

Much work has been done to understand teams and maximise their effectiveness in relation to patient care and as a consequence there is a clearer understanding of why team working is important in the complex world of health.

A move from considering teams in isolation as single entities to a consideration of the system as a network of teams, with both interdependence on each other and a need to collaborate, is required to keep pace with the challenges posed by a modern patient in a modern world.

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Uniprofessionalism

Given the way healthcare is currently commissioned in the UK, this requires a multitude of providers to be involved in the care of individual patients – with the potential for duplication and inefficiencies. 

The example of teams of nurses working for the Buurtzorg organisation in the Netherlands shows us that this does not have to be the case.

Here the nurses form a uniprofessional team, with shared leadership and a shared objective of delivering a complete care experience for patients in the community. The team members have cultivated stability and embedded learning and support within their programme.

‘Team stability and clear boundaries for long term condition management translates into quality’

The result is, as predicted, innovation and the creation of a culture of care involving multiskilled people to provide for all the needs of their patients rather than relying on shorter discrete visits from professionals with single skills.

This has had dramatic effects resulting in high levels of job satisfaction and financial efficiencies as fewer total hours of care are required and it has been met with higher levels of patient satisfaction, patient empowerment and better clinical outcomes.

Team stability and working with clear boundaries in the management of long term conditions is suggested as a key attribute that translates into quality. However, it is suggested that task interdependence may have a detrimental effect despite the Buurtzorg experience.

‘Liquid’ healthcare

Should we be surprised by this? As discussed above, modern healthcare throws more challenges our way. In his recent paper, Alan Bleakley introduces the concept of “liquid” healthcare.

He focuses on the notion that if teams are to be effective and their output is to result in quality, they cannot exist as stable entities – they must be dynamic and adapt more easily to cross-team working.

Individuals must be able to switch between teams seamlessly and transfer knowledge as required.

He predicts a change in direction and a “new wave” of theory about teams so that we not only contemplate how work is done by individual teams, but also how teams interact with each other and how those interactions translate into quality patient care.

He introduces the concept of “knotworking” (a play on “networking”) to describe how professionals “come together to tie and untie individual threads of their work” and do so, one imagines, to deliver bespoke care to patients without having to create new isolated teams to provide separate aspects of care.

‘The public must be at the heart of transformation’

One can see some congruence with the Buurtzorg model in terms of outcome, but the theoretical model appears to be different.

In the Buurtzorg team, stability creates the environment to ensure effective team processes which, in turn, leads to quality outputs as predicted by Hollenbeck – perhaps in our “liquid” world professionals must be able to transfer the “knotworking” principles to process as well as task.

Focusing on the UK situation, and bearing in mind the workforce challenges described earlier, Bleakley’s theories begin to make perfect sense. The challenge is not to do more of the same; we can’t just recruit more staff and create more, albeit, effective teams working in isolation to tackle individual problems based on areas of specialty, however broad.

Our healthcare providers must encourage and develop a new way of working that encourages teams to work together, to share knowledge and to use delegated leadership to increase the quality of care our patients receive.

The autonomy created by the Buurtzorg model means that the power in relation to decision making is retained within the team, another of Hollenbeck’s key team features. One can see quite easily that decision making within a stable team may be a more straightforward process. However, this creates a difficulty when considering the more “liquid” model and could be perceived as a weakness.

Future challenge

Historically in healthcare teams, authority is held by those with perceived (or actual) higher status and in a clinical context by doctors.

Uniprofessional teams do provide a solution but they cannot be universally applied to all scenarios. The challenge therefore for our teams of the future is to ensure that there are clear processes by which decisions are made and that shared leadership becomes commonplace ensuring team autonomy whether the team is stable or not.

‘All team members can sign up to a way of working that focuses on quality patient care regardless of status and role’

Perhaps Bleakley’s “new wave” of theories will help here or perhaps as health provision changes in the UK we will see the emergence of organisations governed with psychological contracts as at Virginia Mason Medical Center in the US.

Its “compact” shows us that all members of a team can sign up to a way of working that focuses on the key predictors of quality patient care irrespective of their status, role or how long they have been a team member.

This type of thinking is beginning to develop in the UK but the drivers for this change do differ. Hull CCG is using these concepts to deliver its future vision of collaborative healthcare, Hull 2020.

In the city there is significant deprivation, poor health outcomes and a system filled with duplication of effort. The CCG is still in its infancy but, given the challenges and the context of diminishing resources, has published a vision for a way of working that encompasses much of what has been discussed here.

Single system in Hull

Hull 2020 describes a future healthcare environment where all public sector services work together as a “single system”.

In addition, the vision is clear that the public must be at the heart of this transformation, with the key goal of designing services around the patients that receive the service rather than the providers of those services.

Partnership working is not new in the city – some individual services already involve multiple providers. What is new is that the philosophy of partnership working will be applied to all services.

Furthermore, the desire is to create a single highly skilled workforce that can adapt to the needs of patients and that the individuals within the workforce can switch seamlessly between teams where required.

There are a number of workstreams already identified – an example of which is the “frailty and isolation” workstream.

This focuses on elderly patients as the Buurtzorg model does and is interestingly led by the Humberside Fire and Rescue Service, not health.

Its objective is to coordinate the existing teams working in this field to provide a more efficient, safer and patient centred entity.

There will be focus on patient education, communication between teams of professionals, cross-sector unity and collaboration, sharing professional skills and a desire to improve what is on offer.

Humberside Fire and Rescue, Hull CCG, Hull City Council, Humber Foundation Trust, Hull and East Yorkshire Hospitals Trust and community provider City Healthcare Partnerships are developing an education and public awareness campaign and have delivered the Older People’s Week event using local media outlets to raise awareness of situations in which elderly people become more vulnerable.

‘We envisage wider use of multiskilled teams in the delivery of care to the people of Hull’

Community hubs are being developed within the city to coordinate the services and there is joint working to provide a combined winter strategy aimed at elderly patients living alone to take steps to prevent deterioration and hospital admission. One example is of their work is the Cold Alarm service. In cold homes the risk of respiratory disease and vascular disease including myocardial infarction increases.

Elderly patients who live alone are having cold alarms installed in their property and when the temperature falls below 16 degrees centigrade an alarm is triggered.

The response will come from a variety of sources – social services, community nurses or the fire service – which will visit and employ measures to increase the ambient temperature within the home.

Various other work streams are being developed such as a falls “pick up” service, making use of the fire service in addition to the ambulance service to attend and assess patients. 

It is early days but as confidence increases, and our experience of cross-sector working develops, we envisage wider use of multiskilled teams in the delivery of care to the people of Hull.

This builds on the evidence for effective team working as described earlier, but recognises the liquidity of the environment using the patient as the starting block and moulding teams around patient with inter-team versatility.

Dr Mike Holmes is associate medical director at Hull CCG