Multi-disciplinary team working: building and using the teamMulti-disciplinary team working: building and using theteamMulti-disciplinary team working: building and using the team. Practice Nurse 2008; 35( 12): 42-7 Date received: 6 April 2008 Date accepted for publication: 16 May 2008Primary care is becoming increasingly complex. Recent health and social care reform has focussed on improving the efficiency of theNHS, making services more accessible and reducing inequalities.( n1) It is the Government's wish to shift services closer to people's homes, and it sees prevention and the improved management of long-term conditions as a key priority.( n2, n3) Primary care is seenas the enabler of these reforms, both as a provider and increasingly as a commissioner of services.These changes and the resulting expansion of services now provided in primary care has made it necessary to call on the skills, knowledge and experience of a wide range of clinical and non-clinical staff. The plurality of providers from the public and independent sectors now working within primary care makes team working an increasingly complex task, as does the blurring of the boundaries of the traditional roles of individuals and organisations. The shift from hierarchies to flatter, collaborative, multi-skilled working means that team working skills are becoming a necessity for everyone working in contemporary health and social care organisations, both within primary and secondary care and across the boundaries.'Collaborative teamwork will be a predominant feature of the modern health services'? Given the increasing demands and expectations placed on primary care, it is essential that effective teamwork becomes a reality and is not simply rhetoric.TEAMWORK IN PRIMARY CARETeamwork in primary care is not a new concept. The Dawson Report of 1920 suggested that teamwork was the most productive way of working in primary care.( n5) Even before the NHS was formed, the vision was for family doctors to work in teams. There have been successive policy, legislative and financial incentives to encourage team working over the years (Table 1).Despite permissive legislation and the vision to promote teamwork, there has been a continuous struggle to integrate primary healthcare teams (PCHTs) into fully functional units. This is partly because of barriers between professional groups, but also the result of a lack of real commitment from some individuals and disciplines. Over the years, a lack of co-operation has led to the well documented ineffectiveness of teamwork in primary care, particularly between community nurses, midwives, and GPs and their staff.( n6-n8) Some of this failure has been blamed on management structures, which have been perceived as hierarchical and therefore responsible for impeding the efficient integration of services. With the amalgamation of community services and GP practices within primary care organisations, the potential for team working has improved considerably.There has also been an assumption that the attachment of staff to GP practices, or 'co-location', is synonymous with teamwork. This has too casual an inference for the special relationship on which inter- and intra-professional teamwork needs to be based.WHY IS TEAMWORK IMPORTANT?There are many benefits to teamwork.( n9) Effective teams:• enable improvement opportunities, which cross boundaries• create more responsive services for patients, with better utilisation of resources and more cost-effective service provision• improve problem-solving by using a greater diversity of staff• promote better service redesign• enable more satisfying roles and improve morale.There is a belief that collective input always benefits outcome. It needs to be stated that teamwork is not a panacea for sub-optimal healthcare delivery. Although a group of people working together to achieve a common goal or function can bring huge benefits, there are also times when it makes more sense to work individually, rather than to try to artificially 'weld' individuals together in a 'quasi-team'.( n10) For example, simple task-orientated issues are probably best dealt with by an individual. More complex tasks, which deal with uncertainty, such as strategic planning, benefit from many views. Rarely can an individual effectively tackle such a task in isolation. The team leader will need to decide when a teamwork approach affords greater benefits than an individual approach.WHAT IS TEAMWORK?A simple definition of a team is: 'A small group of people who relate to each other to contribute to a common goal'.( n11) A more encompassing definition, which is used by the Modernisation Agency and the Health Care Team Effectiveness project team, is: 'A group of individuals who work together to produce products or deliver services for which they are mutually accountable. Team members share goals and are mutually held accountable for meeting them; they are interdependent in their accomplishment, and they affect the results through their interactions with one another. Because the team is held collectively accountable, the work of integrating with one another is included among the responsibilities of each member.'( n12)Teamwork, whether in a formal team (eg a permanent team formed to carry out a regular function, such as a community mental health team) or an informal team (eg those brought together to work on a specific task or project) requires individuals to adapt to working in different ways.CREATING A TEAMThe common goal of a sporting team is to win. The best way to create a functional team is to develop a work programme with a common goal, aims and objectives that are clearly understood by all the team members. Teams that are thrown together without this often fail. This is why co-location of staff alone will not build an effective team.In healthcare, there may be several team objectives. Initially however, it is important to identify a common goal; something the team is passionate about and believes it can influence. This could be, for example, a service improvement; such as developing a new care pathway or a workforce redesign, looking at the competencies and skills required to deliver a new service. A useful tool to use for this task is process mapping, which can identify the steps involved in a patient journey. This draws on the day to day experiences of each team member and enables them to contribute, both as individuals and as part of the team.( n13)LEADERSHIPAll teams