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Breaking down our habitual silos in primary care

Collaboration is an often used word in healthcare and conjures up happy images of us healthcare professionals working jointly with our colleagues within practices, but also across healthcare settings as a joint endeavour to improve the care we deliver our patients.

The reality is probably greyer. However, working as a ‘coal face’ GP, through my involvement with Gloucestershire Clinical Commissioning Group (CCG), the Sign up to Safety campaign (SU2S) and working for the West of England AHSN, the concept of collaboration is a ‘no brainier’.

How else do health systems provide safer patient care across multiple settings and between many different professions? In addition ‘the patient’ is rapidly becoming a more informed and sophisticated service user, who, through the Internet has access to limitless information which is equalising the traditional power differential between professional and patient. In my view this is to be welcomed, but does pose challenges.

For one, more doctor training is about tasks and science and less about people. At times there can seem to be so many ‘sharp edges’ between us professionals where we focus on our differences and this can hinder collaboration which perhaps does require more oblique interactions. This is nothing new as the 1787 painting ‘Doctors differ and their patients die’ testifies. When I think back to medical school, perhaps I would have got more out of studying Dale Carnegie’s ‘How to win friends and influence people’ rather than rote learning Krebs Citric Acid Cycle.

For me collaboration is a mind-set as much as a collection of behaviors and for which the front line is not well trained in. It is about finding common solutions to our shared challenges and using the strengths of patients, carers and professionals across settings to improve the safety of care we deliver.

In my opinion the current system of competition and fragmentation in our local system can, at times, feel like a zero sum game. Different payment mechanisms for different care settings and professions are incongruent with collaborative healthcare. It can allow us to agree to disagree and encourages unwarranted variation which can then affect the quality of healthcare we deliver. An aligned, patient outcome focused payment system, as proposed by Michael Porter in his paper on ‘What is Value in Healthcare’,  would certainly provide an enabler in the quest for a safety culture based on collaboration. In practice the new Accountable Care Organisation’s proposed in the Five Year Forward View should facilitate collaboration.

Our current management of sepsis across the system provides a useful example. If a patient has suspected sepsis then a one hour care regime (called the Sepsis 6 care bundle) is instigated as soon as that person arrives in the hospital. However, the admission of many older people can involve an element of sepsis and these people might remain in the community for many hours before being seen for lack of GP visit prioritisation and coordinated ambulance response. From a patient safety and commissioning point of view a collaborative approach between care settings and professions would allow for a more joined up and timely response that would improve patient morbidity and mortality.

When I’m back on the coal face, I can see why collaboration is sometimes hard. I often only think about the patient I am seeing in front of me and in the setting in which I am seeing them. The Sign up to Safety campaign and my wider roles have helped me to reflect on the aggregation of all the single decisions I make and to see the consequences of those in terms of patient safety not just on the single patient but also on the whole population.

Our practice has the same ups and downs as all practices and there can be a tension between, on the one hand, everyone agreeing to disagree and doing things differently and ‘group think’ where people don’t adequately think things through in their quest to agree. It is important to hear all views and concerns, but it is equally important to start with a problem solving and collaborative mind set, and then to all agree to implement in the same way. My work for the Gloucestershire Clinical Commissioning Group has made me acutely aware of how, across the system, we can all work in silos and thus see patient care only from our unique perspective. How we communicate with each other is vitally important in overcoming this tendency.

From my perspective collaboration is about moving away from individual ways of working and developing effective teams particularly on the front line. Some of the dysfunction that can arise in teams is due to an absence of trust which can lead people to conceal their weaknesses and mistakes from each other whilst hesitating to provide constructive feedback. There is a fear of conflict and this can create an environment where politics and personal attacks thrive, and waste time and energy.

For me collaboration is more about the journey than a destination. Through the experience gained via my various roles and also our practice’s involvement with Sign up to Safety I have noticed that when we are working collaboratively as a team, we do 5 things well:

  1. We have a team mission with planning and goal setting which allows colleagues to gain clarity around the reasons for needing to change.
  2. Team roles are clarified so colleagues understand what is expected of them and where their accountability lies.
  3. Our team has a collaborative operating process, which, at its heart has effective teamwork
  4. We are aware of our teams’ interpersonal relationships and we actively encourage team members to engage with and support each other with open communication and a willingness to share information.
  5. We are also aware of our inter-team relationships and our impact of our work on other teams across the health system.

‘Signing up to Safety’ has given us a much needed impetus to think differently about safety. I would urge all GP surgeries to actively consider how they might better influence their health system to be more collaborative, as this would help turn our attention away from organisational silos and towards the most important people, our shared patients.

This blog post was first published on the Sign up to Safety website on 11 April 2016.


Posted on May 10, 2016 by Dr Hein Le Roux, GP & Primary Care Lead for Patient Safety for the West of England AHSN

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