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.

The Leadership Series – Commissioning Musculo-Skeletal Care

The concept of the Leadership Series is to bring specific senior commissioners together from across the seven CCGs to focus on areas of common challenge, facilitate learning, spread knowledge across the patch and identify further areas to explore collaboratively.

Five Leadership Series meetings have been scheduled to date: three in 2016, covering the topics of ‘Primary Care Demand and Flow’, ‘Commissioning Musculo-skeletal care’ and ‘Commissioning Diabetes Care’, and two of which were held in 2015 on ‘Using Evidence & Evaluation in Commissioning’ (February 2015) and ‘Exploring different approaches to CCG prioritising and de-prioritising strategic initiatives’ (May 2015).

The Musculo Skeletal Care event was held on 19 April with 17 attendees from all seven WEAHSN member CCGs and two UWE researchers.  Feedback from the meeting from delegates was very positive, with a request to meet again in early September, in advance of the CCG business planning timetable.

Feedback after the event included:

“An excellent opportunity to share work in a supportive environment.  I have a far better understanding of what is happening locally and who is involved.” GP Clinical Lead

“Between us we can transform MSK; we need to coordinate much better.” Elective Care Lead

“Very helpful to see what is happening on the patch.  Good to combine clinical perspective with management transformation.” GP & Clinical lead for Planned Care

“We are all grappling with similar issues and it feels a less lonely place now!  There is a collective motivation to embed transformation.”  Service Improvement & Development Manager.

“Useful to collaborate.  We are all trying to do similar things.”  GP Clinical Evidence Fellow

There was also agreement that a musculo-skeletal ‘community of practice’ would be helpful to electronically enable attendees to stay in touch.

The Primary Care Collaborative

In May 2016 we launch our first Primary Care Collaborative. with up to 20 primary care practices from across our seven clinical commissioning groups (CCG) set to join the first cohort. This collaborative will form part of the wider West of England Patient Safety Collaborative.

The initial aim of the Primary Care Collaborative will be to promote a safety culture in the primary care setting through the use of incident reporting, leading to better outcomes for patients. It will also increase awareness amongst practice teams of the patient safety agenda, while promoting an open and honest culture.

Additional benefits for practices will include improving preparation for Care Quality Commission (CQC) inspections and the revalidation and appraisal process for all staff.

Each practice will complete a patient safety culture survey and we will support practices with tools and training in Quality Improvement (QI) methodology, enabling the identification of opportunities to improve patient safety. Practices in the collaborative will come together at four learning and sharing events during 2016/17.

Alison Moon, Transformation & Quality Director for Bristol Clinical Commissioning Group (CCG), says:

“It is really positive working with the AHSN on the primary care programme. There’s a combination of energised joint working, a structured improvement approach and the sharing of best practice and experiences, which gives us a really good chance of achieving our shared objectives on patient safety.”

Contact

For more information on the Primary Care Collaborative, please contact Kevin Hunter at kevin.hunter@weahsn.net.