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Primary care in the UK changed enormously over the past two decades. The roles and demands on the primary healthcare team (PHCT) have increased and will continue to increase in a theoretically primary care-led NHS. Membership of the PHCT has broadened. Teams traditionally dominated by general practitioners have given way to multi-professional teams including nursing and many other professionals. New nursing roles such as nurse practitioners and clinical nurse specialists have changed traditional boundaries and many roles, including those of practice managers and administrative staff, are being continuously modified and expanded.The traditional PHCT is therefore in a process of change and looks as if it will undergo more drastic change in the near future.
Members of the primary healthcare team
The PHCT might therefore be considered to incorporate a much wider range of activities and professional groups, including:
- The traditional PHCT - for example:
- Practice manager.
- Doctors: GP partners, GP assistants and other salaried doctors, GP registrars.
- Nurses: traditionally practice nurses and community nurses (now including nurse practitioners and palliative care and other specialist nurses).
- Support staff: receptionists, secretaries, clerical staff.
- Health visitors.
- Primary care premises may also be used for selected secondary care services - eg, hospital consultant clinics, diagnostic imaging, operating services.
- Allied health professionals may also work closely with the PHCT- eg, physiotherapists, dieticians, podiatrists, pharmacists, counsellors, complementary therapists and social workers.
Roles are changing and expanding. There is evidence for some of these changes. A Cochrane review suggested that high-quality care and good health outcomes achieved for patients by doctors can also be achieved by appropriately trained and supported nurses. However, it advises these results be used with caution due to study methodologies and uncertainties about outcomes.Another Cochrane review found counselling in primary care to be associated with better short-term outcomes and good patient satisfaction rates, although there was no long-term benefit.
Changes affecting the primary healthcare team
Changes for the PHCT include:
- Ageing population: more chronic illness (managed largely in primary care) and a greater demand for healthcare generally (managed largely in primary care).
- Increasing healthcare roles - eg, primary care clinics and minor surgery in primary care.
- Increased expectations and demands on the PHCT: see separate Patient Satisfaction - Assessing and Achieving, Patient Groups and Expert Patients articles.
- Increased monitoring of primary care: see separate Monitoring the NHS article.
- Records and changes in IT systems: see separate articles Electronic Patient Records, Data Security and Caldicott Guardianship and Paperless General Practice?.
- Economic factors continue to have a big impact on the development of healthcare premises. There is a developing trend towards a much wider range of services within enlarged premises. This also presents a massive challenge to successful teamwork.
- Increasing numbers of part-time salaried or sessional doctors making up the GP workforce.
- There is a continuing trend to increase the range of services available in primary care and for these to be commissioned by clinical commissioning groups (CCGs). Increasingly, complex conditions are being managed in the community.
- The development of new and extended professional roles will affect how different members of the PHCT work together. For example:
- The development of healthcare assistants (often from existing reception staff).
- The extended role of pharmacists in medicines' management and minor illness.
- The development of nurse prescribing and triage.
The principles of good team development
The development of new and larger practices has provided a challenge within the PHCT to expand effective teamworking.
- Practice-based interprofessional collaboration is important in improving healthcare processes and outcomes and there have been some studies into how this could be improved. Practice meetings should be regular, structured, relevant and inclusive of everyone's views.
- Each practice should have a regularly updated, agreed and evaluated development plan as well as each individual having a personal development plan.
- Opportunity should be ensured for regular training and updates for all clinical and support staff, both within the practice and with similar professionals from other practices.
- Audit and feedback have been shown in successive Cochrane reviews to result in small but potentially important improvements in professional practice.
- Keeping up to date and maintaining good practice are now formally monitored with prescribing analysis and audit, personal development plans, GP appraisals and revalidation and through the Care Quality Commission (CQC) inspections.
- Educational meetings can improve professional practice and healthcare outcomes for the patients.
- Educational outreach visits (eg, by pharmacists, secondary care professionals) can also improve healthcare outcomes.
- Active local educational interventions involving secondary care specialists and structured referral sheets are the only interventions shown to impact on referral rates, based on current evidence. However, the effects of 'in-house' second opinion and other intermediate primary care-based alternatives to outpatient referral appear promising.
The Forum on Teamworking in Primary Healthcare in 2000 provided recommendations for establishing a successful PHCT. Many of these tenets are still relevant, although the concept of the primary health care team has widened and changed. The recommendations at the time were that the team should:
- Recognise and include the patient, carer, or their representative, as an essential member of the PCHT at individual patient-centred team level or at practice level.
- Establish a common agreed purpose (share understanding of teamworking).
- Agree set objectives and monitor progress towards them.
- Agree teamworking conditions, including a process for resolving conflict.
- Ensure that each team member understands and acknowledges the skills and knowledge of team colleagues (and regularly reaffirms).
- Pay particular attention to the importance of communication between its members, including the patient.
- Take active steps to ensure that the practice population understands and accepts the way in which the team works within the community.
- Select the leader of the team for his or her leadership skills (rather than on the basis of status, hierarchy or availability) and include in the membership of the team all the relevant professions serving a practice population.
- Promote teamwork across healthcare and social care.
- Evaluate all its teamworking initiatives on the basis of sound evidence.
- Ensure that the sharing of patient information within the team is in accordance with current legal and professional requirements.
- Take active steps to facilitate inter-professional collaboration and understanding through joint conferences, education and training initiatives.
- Be aware of other measures involving national organisations, educational measures, research and general guidance which impact on teamworking.
The future of the primary healthcare team in the UK
Many GPs mourn the days when members of the PHCT were based within their practices and communication was regular, face-to-face and as needed.Teams of community nurses, health visitors and midwives have long since taken up residence in centralised geographically based offices covering wide areas, and communication often relies on faxes and forms.
The NHS England vision for the future suggests boundaries should be further dissolved, with care models centred around the patient.Models include:
- Multispecialty community providers (MCPs): federations of practices incorporating/employing consultants (including physicians, geriatricians, paediatricians and psychiatrists) to work alongside community nurses, therapists, pharmacists, psychologists and social workers, with the idea of shifting many hospital outpatient contacts into the community.
- Primary and acute care systems (PACS): these would allow single organisations to provide NHS list-based GP and hospital services, together with mental health and community care services
- Urgent and emergency care networks.
- Viable smaller hospitals being better used, with different models of staffing, run, for example, by MCPs.
- Specialised teams. Concentration of specialist care in some services.
- Development of community midwifery units.
- Enhanced care within care homes.
A 2015 report by the Primary Care Workforce Commission for Health Education England, called "The future of primary care. Creating teams for tomorrow", makes a large number of recommendations including:
- A multidisciplinary workforce for primary care.
- Federations and networks of practices ("super-practices" or MCPs).
- Better integration of care between practices and pharmacies and with social services and secondary care.
- Wider use of community pharmacies and pharmacy support staff for managing minor illness and optimisation of medication.
- Better use of technology, including communication with colleagues and patients by phone, video, messaging and email. This includes accessing advice from secondary care specialists by email, etc.
- Development of new roles such as physician associates. Wider use of physician associates, healthcare assistants and paramedics.
- Common medical records used by all primary healthcare staff.
Putting all this together, it is clear the PHCT for the future will be changed out of all recognition to the team of twenty years ago.
Further reading and references
Good Medical Practice - 2013; General Medical Council
Suter E, Oelke ND, Adair CE, et al; Ten key principles for successful health systems integration. Healthc Q. 2009 Oct13 Spec No:16-23.
Charlton R; General practice. Clin Med. 2010 Dec10(6):600-4.
Arksey H, Snape C, Watt I; Roles and expectations of a primary care team. J Interprof Care. 2007 Mar21(2):217-9.
Laurant M, Reeves D, Hermens R, et al; Substitution of doctors by nurses in primary care. Cochrane Database Syst Rev. 2005 Apr 18(2):CD001271.
Bower P, Knowles S, Coventry PA, et al; Counselling for mental health and psychosocial problems in primary care. Cochrane Database Syst Rev. 2011 Sep 7(9):CD001025. doi: 10.1002/14651858.CD001025.pub3.
Zwarenstein M, Goldman J, Reeves S; Interprofessional collaboration: effects of practice-based interventions on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2009 Jul 8(3):CD000072.
Ivers N, Jamtvedt G, Flottorp S, et al; Audit and feedback: effects on professional practice and healthcare outcomes. Cochrane Database Syst Rev. 2012 Jun 136:CD000259. doi: 10.1002/14651858.CD000259.pub3.
Forsetlund L, Bjorndal A, Rashidian A, et al; Continuing education meetings and workshops: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2009 Apr 15(2):CD003030.
O'Brien MA, Rogers S, Jamtvedt G, et al; Educational outreach visits: effects on professional practice and health care outcomes. Cochrane Database Syst Rev. 2007 Oct 17(4):CD000409.
Akbari A, Mayhew A, Al-Alawi MA, et al; Interventions to improve outpatient referrals from primary care to secondary care. Cochrane Database Syst Rev. 2008 Oct 8(4):CD005471.
Watton R; The loss of multidisciplinary primary healthcare teams is bad for patient care. BMJ. 2013 Sep 9347:f5450. doi: 10.1136/bmj.f5450.
The NHS Five year forward view; Chapter 3 What will the future look like? New models of care NHS England, October 2014
The future of primary care, Creating teams for tomorrow; Report by the Primary Care Workforce Commission for Health Education England (HEE). February 2015