THE BARRIERS TO EFFECTIVE TEAMWORKING

There have been several authors who have identified barriers to successful interprofessional working. Mackay, Soothill and Webb (1995) offer their thoughts on the barriers. They describe the perceived and ascribed occupational status, occupational knowledge and the perceived importance of that knowledge for health care as being significant barriers along with a fear or distrust of the perspectives of other occupational groups. The relationship of different professions will be discussed later as the ‘tribal’ nature of professions is explained but the context within which many professionals work has a significant affect on their teamworking ability. The turbulent nature of this context

will now be described by looking at working relationships prior to and since the inception of the NHS in 1948.

2.3.1 Organisation and re-organisation in the NHS

Between 1870 and 1948 consultants and nurses developed a stable pattern of working in healthcare which according to Gamarnikow (1978) replicated the paternalistic relations of the Victorian family. The nurses adopted many similar organisational features to doctors such as graded hierarchy, strong professional ethics and similar licensing of practitioner arrangements.

The NHS since its inception in 1948 was never carefully designed and, in the aftermath of the Second World War, a political deal was struck with the doctors that put hospitals under the control of the local councils (Klein 1989 in Ackroyd 1995). The political influence on the NHS continued and their administration was soon changed so that hospitals were run by hospital boards and health authorities. However the organisational structures established in hospitals at this time were unusual as they lacked direct management and Ackroyd (1995) states that

”It was a puzzle how such organisations worked at all, never mind effectively”

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Yet they did function well. The basis of efficient working in hospitals at this time was put down to co-operation of different professional groups within what Davies and Francis (1976) described as a triple hierarchy made up of bureaucratic, professional, and political elements. Klein 1989 in Ackroyd (1995) describes this relationship between nurses and doctors as being like a “producer’s co-operative”. Since the producers of hospital treatment (the doctors and nurses) effectively co-ordinated and directed the organisations in which they worked.

In short the NHS functioned on good will between the consultants and nurses with the consultants making the clinical decisions and the nurses providing hospital care and organisation, practical care for patients and managing personnel and materials. They also managed the co-operation of other health workers (Ackroyd 1995). Although they

had been subjected to several re-organisations the staff continued to provide the services to the best of their ability.

Throughout the 50’s 60’s and 70’s the NHS delivered an enviable level of service to many people. But there were changes emerging in the users of the service and the running costs could not be contained by local political control. The public became more demanding and therefore doctors responded with new and more elaborate treatments. As costs spiralled the health service required subsidising by the state not just for clinical services but administrative services too. This was at the time, in the 1970’s, of the OPEC crisis when oil prices increased substantially and money became scarce.

A new form of administration was introduced into hospitals in the 70’s and early 80’s that put a tier of administrators between the government and local structures. This upset the autonomy of the clinical hierarchy that had survived in hospitals for many years and is likely to have had a significant effect on staff. For example rather than having a member of the clinical staff e.g. matron determining what services or equipment should be offered to patients based upon need, this was done by an administrator. Hence there was a shift in power and status which destabilised service provision. The budgetary and political control for services shifted more towards central government. Ackroyd describes the organisation of the hospital system for the period up to the end of the 1970’s as being

“...characterised as that [period] of its greatest success..”

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Ackroyd (1995) describes the problems that existed at the end of this period. He states that firstly hospitals were increasingly subject to administrative direction from central government. Secondly there was an increasing cadre of administrators developing accountancy-based limits on expenditure to curb costs. Thirdly costs were spiralling out of control and the service was having difficulty providing the range of new and traditional medical treatments. Finally the general public were becoming increasingly unhappy about the services being provided for them and wanted to have a say in how they were run.

The response to these problems was another re-organisation and the introduction of general management from the Griffiths reforms (1983). According to Donaldson and Gray (1998) the effect of this on the hospital service was that senior managers were appointed as heads of each hospital and health authority and they became responsible for all aspects of its performance. Gradually doctors were drawn in to management by being able to control clinical budgets and head up clinical directorates, the sub-units of clinical services based around specialities. The emphasis of accountability for managers at this time was on financial duties and meeting workload targets. The quality of care was a stated aim of the service but in reality the responsibility for this was at a clinical rather than managerial level.

The development of centrally direct management gradually changed the function of the administration in hospitals and as Ackroyd (1995) notes this was focussed towards the control of costs with the administration

“..far from being simply supportive of the activities of health professionals, now involves the exertion of control over them..”

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In 1990 another NHS reorganisation took place which was to have a significant effect on the staff within it (Working for Patients, Secretary of State for Health 1989). An internal market was created in which responsibilities for purchasing and providing services were separated. This meant that the purchasers of care i.e. health authorities and general practice fund-holders, negotiated with the providers of hospital and community health services i.e. the Trusts, to fund services to meet the needs of local populations. The supposed benefits of this system were to create incentives to increase efficiency and improve quality. Donaldson and Gray (1998) describe some of the effects of this re-organisation. Firstly that purchasers of service would have a choice as to where to buy services so good hospitals would be rewarded by additional income and bad hospitals would flounder. This is likely to have concerned staff in the Trusts who might have had concerns about their job security which could well have de-motivated them and affected moral. The team may have consisted of some weak elements which would have reduced the effectiveness of the team and made a ‘bad’ hospital.

Secondly, hospitals and other providers of service would vie with each other to offer better and more innovative services and thereby win a bigger share of purchasing budgets. Health workers who are essentially there to provide a service to patients might have felt uncomfortable about the notion of competition for a publicly funded service. This puts health workers in competition with other health workers and introduces an atmosphere of rivalry and suspicion that would not be conducive to professions working together for the benefit of the patient.

Thirdly, for the first time, contracts for services were to be struck between purchasers and providers and this would offer a way of making explicit expectations about the quality of services to be delivered. This would put the control of the quality of service with the purchaser and may have lessened the autonomy of the health professional. The cost reducing aims of these reforms could be described as being at odds with the health professional ethos of the patient coming first with other services being organised to support this.

2.3.2 The new NHS

The latest government policy for the NHS, which will effect another reorganisation, is the NHS Plan (DoH 2000). This sets out 10 ‘core principles’ describing them as the common ground between the government and the NHS. Two of the core principles are number six - “The NHS will support and value its staff “and number eight – “The NHS will work together with others to ensure a “seamless service” for patients”. These appear to be worthy goals but will this latest re-organisation support and promote effective teamworking within the NHS or hinder it?

The plan admits that the NHS and social services do not always work effectively together as partners in care, so denying patients access to seamless services that are tailored to their particular need. It sets out new ‘integrated teams’ called rapid response and hospital-at-home teams to provide intermediate care. These new teams will probably need to consist of health professionals who work within the philosophically different medical and social models of care. How will these two, often opposed, views come together for the benefit of patients in intermediate care?

The NHS plan links NHS and social services but this thesis will focus in on issues for NHS staff rather than those for social care.

From the literature presented earlier in this chapter the setting out of a clear team goal is important to the ability of the team to achieve it. The plan requires Trusts to set out annually a prospectus which makes explicit its standards, performance and the views of its patients. This might well have a positive effect on shaping team performance as individuals are able to share the standard set out. They may also feel that they own it and would be motivated towards achieving it.

West and Slater (1996) and Mandy (1996) have made reference to the benefit of having well defined roles in a team. The NHS plan (section 9 p 82) promotes the expansion of roles for a number of healthcare workers including nurses, radiographers, midwives and therapists. This increasing complexity of role and lack of clearly defined role for a professional may have a detrimental effect on the ability of teams to work well together.

Another feature of this new legislation is that there will be extrinsic rewards available to promote teamworking as the plan proposes to reward interdisciplinary working. Local authorities, health authorities, primary care groups and primary care Trusts will receive incentive payments to encourage and reward joint working.

At the moment these are plans and have yet to be put into practice. The NHS plan and other planning and strategy documents will be discussed further in chapter 12 when considering the future of interprofessional working and education.

The effect the NHS plan will have on teamworking is unknown. Yet what is clear is that with the reorganisations of health and social care services since the NHS began in 1948 the ability of teams to work effectively has been severely hampered. As Bruce Tuckman (1965) first described, in his theory of team development, a team goes through the stages of ‘forming’, ‘storming’, ‘norming’ before it starts ‘performing’. Once a team is changed around, such as has been happening in the NHS and social care context this might effect the performance of the team. Paradoxically this surfeit of reorganisations intended to promote interprofessional working may actually be having a detrimental effect upon it.

These changes have been imposed on the professions by the government yet the professions themselves have impeded the development of teamworking too and one often cited inhibiting factor is that of professional tribalism.