Patient Perspective - (2008) Volume 16, Issue 3
Lay co-opted member of The Academy of Medical Royal Colleges and President of The National Association of Patient Participation Groups
In this short article I explore, from a patient perspective, some aspects of team working in primary care, aspects that are not often discussed in professional literature. I emphasise that this is not a criticism of the principles of team working. Patients and the public are aware that different professionals have different skills that are appropriate for different aspects of their patients’ health. For example any patient who has had a varicose ulcer or wound to be dressed knows very well that the practice or district nurse is the person to deal with. Similarly, many patients with long-term conditions learn which professional to consult. However, there are some specific concerns about continuity of care, accountability and patient confidentiality.
The team approach
The Royal College of General Practitioners (RCGP) argues that the current infrastructure of general practice is well placed to deliver the services that the public want,1 and this includes continuity of care and provision of a wide range of services in the community. However, the RCGP states that this will require changes in how practices are organised and it recommends that the basis of effective andefficient health care in the NHS must be primary healthcare teams responsible for defined and registered groups of patients. Such a system, it is argued, should enable both continuity of care for patients as well as co-ordination of services. How clinicians should work in teams is increasingly part of both the undergraduate and postgraduate education syllabus for doctors, as well as other healthcare professionals. Furthermore, the General Medical Council (GMC) states that in order to communicate effectively doctors need to make sure that patients are informed about how information is shared within teams and among those who will be providing care.2 The wider use of the skills of healthcare professionals other than doctors has for some time been encouraged. In some situations, these professionals may carry out the tasks that were previously routinely done by doctors and this allows for wider patient choice.
Continuity of care
Recent patient surveys continue to show that patients want and value continuity of care from their general practitioner (GP).3 But there is a potential conflict for the patient between continuity of care provided by a named GP and continuity of care provided by a team of healthcare professionals. Part of this conflict may be due to an information deficit. Not all patients know or understand that care is given by the practice team that has access to their records. Consider the case of the seriously ill patient, being cared for at home and who has been told by the GP to request a home visit as required. A request is made for the GP for a home visit to discuss the patient’s medication as a matter of urgency, the reason for the request and basic demographic details are given to the receptionist. After further questioning, the receptionist informs the patient that the triage nurse will get in touch shortly. The triage nurse questions further, and includes questions about bringing the patient to the surgery; she states that she will need to discuss this with the doctor, who phones back, agrees that the visit was essential and quite appropriate, and subsequently leaves his mobile number. The receptionist and the triage nurse were only doing their jobs. But if continuity of care is provided by the practice, all staff need to know which patients may be requesting home visits. In the example given, the practice failed to provide easy continuity of care by appearing not to know the patient’s circumstances or the severity of the situation. The patient and the supporting family were distressed and frustrated.
Accountability and working in teams
Teams need a leader and someone who ultimately takes responsibility. In the situation of a patient with cancer living at home, domiciliary care may require the involvement of several members of the healthcare team, including GP, dietician, Macmillan nurse and district nurse. When a patient was informed that a multiprofessional teamwould be looking after him, he asked who the team leader was. In this situation the patient was not dissatisfied with the care received nor did hewish tomake acomplaint. It was a logical question based on the premise that all teams must have a leader. However, it seemed to have been a challenging question for the staff concerned and one that had not previously been raised by patients. From the patient perspective, while it is important to be informed that there is available a team of people with different skills to help with their care, it is equally important to be informed who is the person co-ordinating this care and who takes ultimate responsibility. The larger the team involved, the more important this becomes. While different team members may have specific responsibility for particular areas of work,4 the ultimate responsibility in primary care is surely the role of the GP.
Confidentiality and teams
Good team working requires good communication between team members. The content of the communications will involve sharing information about patients. This is very obvious to healthcare professionals but may not be realised or understood by all patients. Thus patients need to be informed and agree that information relevant to the particular episode of care will need to be shared with staff delivering that care. This is particularly important if identifiable information is to be shared with anyone employed by another agency or organisation.5 While doctors are accountable to the GMC, all staff members receiving personal information in order to support or provide care are bound by a legal duty of confidence whether or not they have contractual or professional obligations to protect confidentiality.
Many breaches of confidentiality are unintentional. Nevertheless, such disclosures can cause great distress to patients and they are avoidable. Maintaining confidentiality when working in teams in primary care requires well-trained staff. All staff should be trained about the importance of confidentiality to the patient. They should be alerted to situations where breaches most commonly occur, such as in waiting areas and at the reception desk. But they should also be alerted to the problem of the ‘chattering classes’, particularly in smaller communities where confidential information is let slip in social situations, for example at the supermarket or in the post office.
In this short paper, some challenges in team working in primary care are discussed. Continuity of care does not need to be provided by only one person. It can be provided for patients in a system involving several healthcare professionals. However, patients need to be informed about the extent of the team, their role in the care of the patient,what information is available to the different team members, and who is ultimately responsible. This is not difficult. It simply means working with the patient as a partner and treating patients with respect.
