Team-Working in UK Public Sector Health – Is there a solution?

Team-Working in UK Public Sector Health – Is there a solution?

22 Jul 2024

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This informal CPD article ‘Team-Working in UK Public Sector Health – Is there a solution?’ was provided by Dr Jacqueline Haughton, Medical Director at Healthcare Skills International, an approved education centre delivering a range of externally validated competence-based qualifications to the medical profession and healthcare industry.

In healthcare teamworking, factors such as personality clashes, poor team dynamics and psychological safety adversely influence patient outcomes and negatively impact co-workers (Rosen et al 2018). They are mitigated and positively modified by good organisational leadership (Lawther 2023), and good clinical team-working is the bell-weather of a healthcare organisation’s culture and leadership success.

What is a team?

A team is a group of individuals working independently or together to achieve a common goal. We know that teamworking in healthcare is essential to protect patients and achieves good clinical outcomes (Mazzocco et al, 2009) and it grew organically from traditional care models during the 20th century.

In recent years, the influence of healthcare management has become less clinician-based (Kirkpatrick, 2021) and the workload of clinical teams has increased significantly (Bailey and West 2021), creating the systems we currently work in. Traditionally, in ‘good’ hospital teams, senior doctors would lead and make executive decisions, reaching a consensus with their junior medical team and the nurse in charge. The core medical team was stable and cohesive: members knew each other well and worked together extensively, learning, practicing and anticipating each other’s response as their level of expertise and experience grew.

Other important team members included the consultant’s secretary and others responsible for services required during a patient’s time in hospital or after discharge. There was recognition that theatre sisters, outpatient staff, laboratory based specialties such as pathology and biochemistry, radiologists, allied healthcare professionals and many others were key to successful patient outcomes. There was mutual respect and understanding of roles, and acceptance that ultimate responsibility lay with the senior doctor in charge, who therefore had the ‘casting vote’.

How teamworking has changed in the UK public health sector

So, when did that high-functioning, top down model of teamworking change? And was it ‘good’ change or ‘bad’?

‘Top down’ medicine used to work well before the complexity of healthcare escalated. Back in the day, the patient’s response to attempted shared decision-making would most likely be “whatever you think’s best, doctor”. It was a time when consultants would typically be in their mid to late 40s at the time of appointment, which meant that junior medical team members were also clinically mature. Consultant patronage was key to career advancement, and this was one of the glues that underpinned a safe and stable system. Generally, public perception was that nurses were angels, doctors were saints, and unholy behaviour didn’t happen (although, of course, it did, and was usually quietly resolved). Being on call as a team, being in theatre as a team, and continuity of care for patients were never an issue, and we simply never questioned it – it happened automatically as it was best for patients. The system wasn’t ‘good’ or ‘bad’ – it’s just the way it was.

With increasingly complex healthcare associated with an ageing population and medical innovation, this model proved unsustainable. The European Working Time Directive (implemented for junior doctors in full in 2009) also eroded the pillars on which the clinical hierarchy was built - patronage for promotion, unlimited availability of junior medical staff, with competence and dedication securing patronage. Societal acceptance of paternalism in medicine also declined (Montomery v. Lanarkshire Health board 2015), while the blurring of healthcare roles and the introduction of new ones (DHSC Media Team 2023), staff shortages (Mallorie 2024, Statista 2024), financial constraints (NHS Confederation 2024i), increasing complexity of care and workload (NHS England 2024), threat of litigation (NHS Resolution 2022) and changing political priorities (NHS Confederation 2024ii) gained momentum and made the landscape more complex. 

So, ‘change’ wasn’t ‘good’ or ‘bad’ – it was inevitable. Fast forward to 2024, and in many hospitals consultant secretarial services are provided by a pool, ward rounds have peripatetic juniors with consultants the sole “clinical constant" (BMA 2020), nurses work from hand-over notes (NICE 2018), and it’s pot-luck as to whether or not theatre lists have familiar supporting team members. Coordinating acute patient care can be like conducting an orchestra of unrehearsed musicians with unknown competence and variable experience who come together on the eve of performance – time is short, the team is frustrated, relationships are difficult (Lawther 2023), outcome likely suboptimal, and with the conductor ultimately accountable, burn out and disengagement are common.

When things go wrong, we talk of communication failure as the commonest cause - as though it's a human failing we can overcome if we work at it - whereas the real solutions lie in good leadership and cross-professional teamworking (West et al, 2015). Without addressing the lack of good organisational leadership at all levels of the service, dysfunctional teamworking at the coalface will continue (Saeed et al 2015).

Co-ordinating acute patient care

Teamworking today and beyond

In recent years, when senior clinicians have complained of instability and functional decline in the teams they belong to (BMA 2020), difficulty building a cohesive group due to system-wide barriers, and increasing workloads, little attention has been paid. When it impacts their working relationships (Team reviews retrospective, 2021), and eventually patient care and outcomes, early retirement or the involvement of the General Medical Council may result (GMC 2024).

The General Medical Council has the helicopter view of this, and increasingly sees that leadership and system failure in healthcare organisations are at the heart of the fitness to practice referrals for many doctors. So ‘hats off’ to them for seeking to apply an evidence-based approach to this – to dig deeper about why doctors might fail. In research published recently and commissioned by the General Medical Council, more than 70 healthcare professionals were questioned from across the United Kingdom (Crampton et al 2023) to better understand the barriers and enablers to effective teamworking.

The findings were not surprising to those with experience at the coal face: good organisational structure, a manageable workload, a favourable workplace environment, well-balanced and competent individuals, and good leadership are all important to successful and sustainable clinical teams. A leadership which is understanding and approachable as well as an inclusive, and positive organisational culture are key to team stability. There also needs to be sufficient time for teams to meet regularly, form cohesive relationships and communicate effectively. Clearly defined roles, respect for members and specialisms, continuity and support for those in newer roles are also key to good team-working.

When we consider what drives bad team-working - sustained high service demand and work pressures (Lawther 2023, Massey 2024), a lack of respect, appreciation or understanding of different roles, and equality, diversity and inclusion issues – many of us recognise the factors present in our own team-working in a healthcare system under pressure.

The research found that team members often felt unable to speak out and communicate effectively with other team members. Hierarchy, generational differences, seniority, and role type also had an impact on this and how individuals felt they fitted into their team. Power imbalance was another important factor, with some team members not realising the weight of accountability on the medically qualified, and some medically qualified being not recognising their abuse of the authority gradient.

Conclusion

Teamwork thrives in a supportive organisational context where policies, reward structures and the culture aligns with the expected values and behaviours of individual team members (Rosen, et al., 2018; Lyubovnikova, et al., 2015). A supportive team culture is one of the most important elements positively affecting workplace wellbeing (Anderson, et al., 2021).

Recent research clearly identifies that the need for good leadership needs to be addressed across the entire organisation (Vize R 2022). The data is clear: when staff feel able to discuss challenges, support each other and learn from mistakes, they contribute and take ownership of the delivery of safe patient care (Rosen, et al., 2018). We look forward to an environment where there will be the appetite and ambition to achieve good team-working in in UK public sector health. [1280 wds]

We hope this article was helpful. For more information from HC Skills International Ltd, please visit their CPD Member Directory page. Alternatively, you can go to the CPD Industry Hubs for more articles, courses and events relevant to your Continuing Professional Development requirements.


References

Anderson N et al. (2021) Facilitators, barriers and opportunities in workplace wellbeing: A national survey of emergency department staff. International Emergency Nursing, 57, 1-8

Bailey S and West M (2021) Naming the issue: chronic excessive workload in the NHS: https://www.kingsfund.org.uk/insight-and-analysis/blogs/naming-issue-chronic-excessive-workload-nhs#:~:text=The%20Health%20and%20Social%20Care,for%20people%20in%20their%20communities.

BMA (2020) Consultant workforce shortages and solutions: Now and in the future:   https://www.bma.org.uk/media/3429/bma-consultant-workforce-shortages-and-solutions-oct-2020.pdf

Crampton P, Kehoe A, Ellawala A and Karunaratne D (2023) Teamworking: Understanding barriers and enablers to supportive teams in UK health systems: https://www.gmc-uk.org/-/media/documents/teamworking---understanding-barriers-and-enablers-to-supportive-teams-in-uk-health-systems-106637377.pdf

DHSC Media Team (2023) Physician and Anaesthesia Associate roles in the NHS – fact sheet:   https://healthmedia.blog.gov.uk/2023/11/03/physician-and-anaesthesia-associate-roles-in-the-nhs-fact-sheet/

General Medical Council (2024) Power imbalances and hierarchy prevent doctors from working effectively in teams GMC research shows:  https://www.gmc-uk.org/professional-standards/professional-standards-for-doctors/maintaining-personal-and-professional-boundaries/maintaining-personal-and-professional-boundaries

Kirkpatrick I, (2021) Unfinished business: The development of medical management roles in UK NHS:   https://www.fmlm.ac.uk/news-opinion/unfinished-business-the-development-of-medical-management-roles-in-the-uk-nhs

Lawther I, (2023) Overcoming dysfunctional relationships: Suggestions for GP trainers: https://madeinheene.hee.nhs.uk/Portals/6/Trainers/Educators%20Conference/2023%20Handouts/Iain%20Lawther%20-%20Overcoming%20Dysfunctional%20Relationships%20-%20March%202023.pdf?ver=2023-03-09-104426-080

Lyubovnikova J, West MA, Dawson JF & Carter MR (2015) 24-Karat or fool’s gold? Consequences of real team and co-acting group membership in healthcare organizations. European Journal of Work and Organizational Psychology, 24(6), 929-950

Mallorie, S (2024): https://www.kingsfund.org.uk/insight-and-analysis/blogs/staff-shortages-behind-headlines

Massey, C (2024): https://www.nhsemployers.org/articles/factors-contribute-effective-teamworking-doctors

Mazzocco, K. et al. (2009). Surgical team behaviors and patient outcomes. American Journal of Surgery, 197, 678-685

Montomery v Lanarkshire Health board (2015): https://www.supremecourt.uk/cases/docs/uksc-2013-0136-judgment.pdf

NHS Confederation (2024i) https://www.nhsconfed.org/publications/state-nhs-finances-202425#:~:text=We%20have%20been%20warning%20of,that%20hasn't%20been%20delivered

NHS Confederation (2024ii): https://www.nhsconfed.org/publications/building-health-nation-priorities-new-government

NHS England (2024):    https://www.england.nhs.uk/future-of-human-resources-and-organisational-development/the-future-of-nhs-human-resources-and-organisational-development-report/evolving-to-meet-a-changing-world/#:~:text=There%20is%20a%20rising%20demand,more%20individuals%20managing%20multiple%20conditions

NHS Resolution (2022):   https://resolution.nhs.uk/2022/07/20/nhs-resolution-continues-to-drive-down-litigation-annual-report-and-accounts-published-for-2021-22/

NICE (2018) Chapter 32 Structured patient handovers:  https://www.nice.org.uk/guidance/ng94/evidence/32.structured-patient-handovers-pdf-172397464671

Rosen, M. A. et al. (2018). Teamwork in Healthcare: Key Discoveries Enabling Safer, High-Quality Care. American Psychological Association, 73(4), 433-450

Saeed S.A. et al (2015). Role of leadership in narrowing the gap between science and practice: improving treatment outcomes at the systems level. Psychiatric quarterly, 86, 311 – 323

Statista (2024):   https://www.statista.com/topics/9575/nhs-staff-shortage/#:~:text=Key%20figures%20of%20the%20NHS%20staff%20shortage&text=As%20of%20the%20first%20quarter,yet%20much%20less%20among%20doctors.

Team reviews retrospective (2021):  https://resolution.nhs.uk/resources/team-reviews-retrospective/

Vise R (2022) Ockenden report exposes failurea in leadership, teamwork and listening to patients:  https://www.bmj.com/content/376/bmj.o860

West M, Armit K, Eckert R, West T, Lee A (2015) Leadership in healthcare: A summary of the evidence base: https://www.fmlm.ac.uk/sites/default/files/content/resources/attachments/Leadership%20in%20Health%20Care%20%20-%20A%20Summary%20of%20the%20Evidence%20Base_WEB.pdf

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For more information from HC Skills International Ltd, please visit their CPD Member Directory page. Alternatively please visit the CPD Industry Hubs for more CPD articles, courses and events relevant to your Continuing Professional Development requirements.

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