Multidisciplinary Team Working toolkit

Introduction

Welcome to this introductory guide which aims to support practices exploring how to develop their clinical teams and create a way of working that is better able to meet their population needs for both urgent and routine primary care. This guide is intended for general practice and primary care teams who are thinking about introducing new clinicians into their multidisciplinary team and need some help and support. It is aimed at supporting GPs in clinical supervisor roles. Whilst this guide has been applied to an England context, many of the principles and ideas can be applied across the UK.

Expanding practice teams brings the opportunity to embed new skills into primary care, widens the range of services offered by general practice and works towards resolving some of the challenges currently faced in primary care. We know that general practice across the UK is facing change, with significant GP workforce shortages. This has been impacted by several factors, including fewer doctors choosing general practice, problems retaining newly qualified GPs and middle-aged GPs retiring early. ^1,2,3,4

This coupled with changing population demographics in the UK, an ageing population and the shift of care from secondary into primary care; has led to an increase in primary care workload. In 2016 the Nuffield Trust expert seminar identified significant potential in all areas of NHS service for workforce change, but particularly in primary and community services.⁵

RCGP will be publishing a workforce roadmap in 2019 as part of the Fit for the Future: a vision for general practice.

References

1. Primary care Workforce Commission. The future of primary care: creating teams for tomorrow. The Roland Commission 2015.
2. Royal College of General Practitioners. Patient safety implications of general practice workload, 2015.
3. Smith J, Holder H NE, Maybin J, Parker H, Rosen R, et al. Securing the future of general practice: New models of primary care. London: King's Fund and Nuffield Trust. 2013
4. Nuffield Trust Policy Briefing. Health and social care priorities for the Government: 2015–2020. 2015
5. Imison C, Castle-Clarke S and Watson R (2016) Reshaping the workforce to deliver the care patients need. Research Report. Nuffield Trust.

Demand and capacity

Assessment and management of demand

Some questions you can ask:

• What are the current and future staffing issues you are facing? 
• What is your demand like?
• What are the gaps in your demand and capacity? 

Knowing the level and characteristics of the demand on your practice, enables you to design any effective interventions and evaluate their impact. 

The World Health Organisation paper Determining skill mix in the health workforce: guidelines for managers and health professionals suggests we start with four approaches: 

1. Evaluate the need for changing your team
2. Map autonomy and flexibility and identifying the opportunities and barriers for change
3. Assess resource availability and plan for change
4. Identifying appropriate approach to skill mix and make the change happen

Demand and capacity

The West of England Academic Health Science Network 'Measuring demand in General Practice' report in 2015 made the following recommendations:

• Actively measure demand and trying to fully understand the extent of demand. Rather than trying to fit demand around existing capacity. 
• Find a common tool both for measuring demand and measuring performance against that demand. This allows Practices to evaluate the changes they are making. 
• Avoid making continuous operational change because of a desire to meet increasing levels of patient expectations in their ongoing quest to deliver more immediate services to a greater volume of patients 
• Using telephony services to measure telephone volume data was a reasonable proxy measure for demand. Phone systems should be able to provide you with call volumes, volume patterns, waiting times and abandonment rates. 

Most clinical IT systems provide workload information. Such as consultation rates filtered by age and gender, and broken down by face-to-face consultations, telephone calls, e-consults and home visits.

Determining optimal skill mix

Determining your own team’s skill mix

Having ‘the right staff, with the right skills, in the right place at the right time’ and is a complex process that requires careful planning and support.  Leadership that involves everyone, including patients, and approaches to change management that look at the full picture and are open to all possible approaches can really help.  

What can I do to determine the skill mix of the current team in place?

The World Health Organisation (2000) guidance for determining skill mix in the health workforce emphasised that skill mix is not just a technical exercise. It is a method of organisational change which requires careful planning, communication, implementation and evaluation if it is to achieve its objectives and main approaches to this are included in the Main approaches to determining skills mix (PDF).

Nelson et al. classified skill-mix in general practice as:

• the range of competencies possessed by an individual healthcare worker
• the ratio of senior to junior staff within a role
• the mix of different types of staff in a team/healthcare setting.

Changing the skill mix in primary care. How do I do it?

Once you have identified the skill mix that your current team have, by adding this to the demand you face from patients that you have evaluated in the “Assessment and management of demand” section you can then determine if: 

• Your team members are all working at the top of their potential
• If you have the right mix of skill to cope with the demand from your unique population of patients.

If you identify gaps in your skills mix, or gaps in individual roles within the team, you then have the choice to alter the skill mix of the team. Skill-mix changes have been classified into three broad role modifications: 

• enhancement (for example, extension of a primary care practice nurse’s role without need for supervision); 
• delegation (for example, a GP transferring tasks to a physician associate under supervision); and finally 
• innovation (for example, a physiotherapist leading musculoskeletal clinics that provide a new/enhanced service in primary care).

Can we move workload to a more appropriate clinician?

A simple way to measure potential task substitution is using the alternative professional questionnaire for GP consultations (PDF) with your GPs for one week.

Systematic approaches to matching competences and skills required to job roles and training needs have been developed and deployed in England.  

Examples of these are:

• Calderdale Framework¹
• Skills for Health’s ‘Six Steps Methodology to Integrated Workforce Planning'
  

Other examples in the UK are described in the Nuffield Trust's 'Reshaping the workforce to deliver the care patients need' report.

Guide to introducing skill mix

Extend skills and knowledge to improve service efficiency and outcomes. Could tasks be allocated from one group of professionals to another? For example, practice pharmacists could perform repeat prescribing rather than GPs. Home visits performed by GPs can be done by Advanced Nurse Practitioners or primary care paramedics.

The primary care workforce commission (2015) recommend practices should:

• Analyse their clinical caseload in order to decide on the skills that will meet the needs of their population.
• Agree clear pathways and referral criteria for what each clinician will see and do, and ensure people fully understand their new roles and evaluate these together over time.  

To get ideas for what staff roles may work effectively in your practice, it may help to talk to other practices, your primary care network, CCG or local Federation and ask what worked for them, particularly for new staff roles that you may be unfamiliar with. They may be able to guide you to local support and resources as well as work collaboratively. 

There are opportunities for different staff to manage:

• minor illness
• musculoskeletal problems
• patients in the management of their long-term physical and mental conditions
• develop care plans
• medicines optimisation and reconciliation from hospital discharge letters and correspondence

An alternative to employing new staff can be to extend the skills of current staff. This can lead to more responsive care as well as a deeper appreciation of each team member’s skills. 

Reference:

1. Smith R, Duffy J. Developing a competent and flexible workforce using the Calderdale Framework. International Journal of Therapy and Rehabilitation 2010;17:254-62.

Workforce design

Workforce redesign

In 2016 the Nuffield Trust identified 10 important lessons for organisations seeking to redesign their workforce.

• Be realistic about the time and capacity needed to support change
• Create a receptive culture for change
• Support transformation with a strong communication and change management strategy
• Build roles on a detailed understanding of the work, staff skills and patient needs
• Invest in the team, not just the role
• Ensure robust triage mechanisms
• Develop and invest in a training capability
• Build sustainability for new and extended roles
• Evaluate change
• Adopt a systematic approach to workforce development and change
• Complex / continuity

Skills for Care provides a practical guide to workforce planning to take you through the whole workforce planning process using a practical analyse-plan-do-review method.

The principles of workforce redesign include:

• Take a whole system view of organisational change
• Recognise the different ways people, organisations and partnerships respond to change
• Nurture champions, innovators and leaders; encourage and support organisational learning
• Engage and empower people in the process; acknowledge value and utilise their experience
• The different ways that people learn should influence how change is introduced and the workforce supported
• Encourage and utilise the understanding of values, behaviours and practice to shape innovation
• Engage with your patient participation group and your community to understand its cultures and strengths; work with the community to develop inclusive and creative workforce planning.

Some other key information that will help you plan includes:

• Staff overview: for how many staff members you employ, the roles they fill and absence rates
• Recruitment and retention: for turnover and retention issues
• Workforce demographics: for age, gender, ethnicity and nationality
• Pay: for annual and hourly pay rates (you can compare your pay rates against others locally, regionally and nationally). The practice accountant may be able to help you benchmark your staff costs
• Qualifications and training: to see how qualified and well trained your workforce are and to help with training plans
• The workload demand and demographics: Comparing your population projections and any new housing and care home developments in your area. This is particularly helpful in looking ahead and future proofing your business.

New clinical roles

Over the next five years in England, there will be some new roles created within primary care but also several existing roles will begin to work in new ways:

• Network Clinical Director
• Clinical pharmacists
• Social prescribers (also known as Link Workers)
• First contact physiotherapists
• Primary care paramedics
• Physicians associates

Given these are emerging roles, it is important to for practices to set clear expectations of the functions that they would like the person to carry out. There are opportunities to exchange ideas or materials such as template job descriptions through forums locally and nationally.

It is vital to help the whole team to understand any new role that has been allocated. This helps to ensure appropriate work is assigned to the new role and so that other team members can explain the role to patients and families. This is also a good opportunity to explore boundaries of the work a new role will handle and the words they would use to describe their unique skills.

These new team members will need to be supported to develop the specific skills needed to work within primary care. This may be through:

• Encouraging individuals to network with others, perhaps in terms of supporting exchange or in seeking professional support and training from others in the community
• Developing a clinical peer network can help to expand the range of functions, teach additional skills, sometimes shortcut innovation by swapping tools and templates

Resources have been produced by several organisations which explain in more detail the roles and responsibilities that the expanded primary care team may have and develop.

• PCN handbook (PDF file)
• RCGP position statement on multidisciplinary team working

Professional bodies:

• The Chartered Society of Physiotherapy
• The College of Paramedics
• The Health and Care Professions Council 
• Health care assistants: Royal college of Nursing
• Advanced Nurse practitioners 
• Pharmacists 
• Physician Associates 
• Social workers 
• Occupational therapists 
• Mental Health Support Workers

The role of the GP in expanding skill mix team and supervision

Those team members who have not worked in general practice before would, as part of an induction programme, require training in several areas including:

• use of the clinical computer systems
• Quality and Outcomes Framework (QOF)
• clinical coding
• clinical and information governance
• safeguarding adults and children

GPs can expect to become more involved with supervision of the expanding primary care team and will need to review the systems and processes in place within the practice setting to support the skill mix. 

GPs need management and leadership skills to supervise an effective team of nurse practitioners, paramedics, pharmacists, nurses, medical students and HCAs. In addition to seeing patients, updating medication and dealing with routine enquiries.

Not only will supervision by GPs be important but mentoring and coaching skills will become increasingly needed as we work to inspire, educate and nurture those working in the wider team within general practice.

Teamworking

When starting to think about how you approach team building and team development it may be helpful to think about this in two ways:

• What do practice leaders need to do to foster a sense of team? For example, through team meetings and protected time for development
• How do we make sure that there are opportunities for career progression and development for all new practice team staff?

The style of leadership that best suits each multidisciplinary team will vary. The NHS Leadership Academy has developed a leadership model that has prompts to help leaders in a traditional organisation or network. The Leadership Centre has produced a guide on system change through Leadership. 

You can approach your local at scale providers, for example, federations, acute hospital trusts to support you with finding solutions for these questions.

Where to start

• Does the team have a clear purpose?
• Does the existing team understand what any newly introduced roles will do, their roles and responsibilities?
• How do you build a high performing team with shared responsibilities for patient care?
• How to ensure members working across multiple practices/primary care networks feel a sense of belonging?
• What impact can you expect from the introduction of new roles and the wider team?
  
  • How will you monitor patient safety and quality of care?
  • What indicators might you choose?
  • What will be the impact on prescribing activity, A&E attendances & admissions and, first outpatient referrals?
• How to use technology and digital tools to improve team working and delivering care?
• How will you actively manage the change process?

Communication

• How do patients see the new roles integrating into the team? Do they have any concerns and how will you address these concerns?
• How will you make sure that patients are signposted to the most appropriate member of the team?
• How will you communicate effectively as a team? What support tools might you use?

Person-centred Care and Continuity

• How do you transition from a more single GP approach to care to team based care?
• What will the impact be on continuity and coordination of care?
• How do you promote self-care in the new way of working?

Learning and Support

• How do you build an effective learning platform to span the needs of the team and support integrated working with other healthcare professionals outside of your organisation?
• How will indemnity work?
• How will the new roles be supervised and who will review their training needs?

Example roles

1. Paramedic home visiting model in Wokingham
2. Expansion of clinical pharmacy
3. Improving access to general practice
4. Advanced clinical practitioners
5. Kings Fund: Innovative Models of General Practice (new roles in general practice (pg 49)
6. Physicians associates in general practice - NHS case study
7. Releasing two GP sessions a week for more appropriate appointments
8. Musculoskeletal (MSK) First Contact Practitioners
9. First Contact Physiotherapy posts in general practice:

• First contact physiotherapy posts in general practice
• Improving Access with physiotherapy

Summary of Top Tips

1. Don’t be afraid to ask other professionals about their roles and professional backgrounds – if we don’t understand each other, it’s harder to work well together.
2. Encourage your team to share insights into how the other services work – and make sure someone finds out any details no one is sure of.
3. Don’t assume that others will have been kept up to speed with changes within your organisation – be proactive in checking that they understand new initiatives and structures.
4. Incorporate some ‘socialising’ into multi-disciplinary team meetings. This helps to develop that vital personal connection. It will improve the effectiveness of working relationships.

Resources

1. It is well worth reading Becky Malby’s managing demand blogs to consider some ideas about potential ways of reducing demand other than by using skill mix:

• Primary Care - reducing demand in practice - Part 1
• Primary Care - reducing demand – Part 2

2. Other useful ideas come from the Wessex primary care report 2017 from the Academic Health Services network:

3. National Data England - GP data shows numbers and details of GPs, Nurses, Direct Patient Care and Admin/Non-Clinical staff working in General Practice in England, along with information on their practices, staff, patients, and the services they provide:

• General Practice Workforce, Final 30 September 2018, Experimental statistics
• General Practice Workforce Interactive dashboard

4. The Wessex Primary Care Project provides workforce planning tools in their 2017 report:

• A Lifeline for Patients and General Practice: new ways for Primary Care in Wessex

5. Royal Pharmaceutical Society:

• General practice based pharmacist
• A guide for GPs considering employing a practice pharmacist
• Professional indemnity requirements
• Working in Urgent & Emergency Care - a guide
• Working in GP Practices - a guide
• Pharmacists in GP Practices
• Primary Care Networks and Clinical Pharmacists
• Primary Care Networks and Community Pharmacists
• Polypharmacy: Getting our medicines right
• Medicines optimisation hub
• Multidisciplinary Teams (MDT) in General Practice: Making MDT work for Wales

6. Royal College of Physicians

• Physicians associates in general practice

7. The Bradford Effective Multidisciplinary Teams Development Tool, which includes sections on defining clarity of purpose.

8. Technology Enabled Care Services, which provides research and evidence on TECS and the impact it had on patient outcomes and cost-effectiveness

• NHS England, Strategic planning resources for commissioners

9. The King's Fund

• How to build effective teams in general practice

10. Skills for Health

• Core Capabilities Framework for Advanced Clinical Practice (Nurses) Working in General Practice / Primary Care in England

Data

National data that is available:

• The RCGP Research surveillance centre RSC is building a general practice 'workload observatory' - aiming to provide a picture of the workload and complexity of cases that we increasingly see in general practice. The RSC can provide weekly reports to most UK practices on workload.  If your practice wants to find out more – please visit the RCGP Research and Surveillance Centre. 
• In England, NHS Digital publishes appointment information on a monthly basis, covering the previous 12 months. It includes historic appointments, numbers seen by GPs and appointment mode, such as face-to-face, home visits, telephone and video.
• NHS Digital has new data on General Practice Workforce for England.  
• You can find data on your CCG and practice workforce on the General Practice Workforce Interactive dashboard. Select your CCG, find your practice on the map and then right click and select drill down option. 

Microskills for interprofessional communication

All Allied Health Professions (AHPs) and clinical supervisors have different training and experience. This can make it difficult for the supervisee and supervisor to share information efficiently and effectively. Particularly if both are doing clinics and have patients waiting. It is important to have information signposted and presented in a structured format.

How to Present a Patient Case: The Signpost Method

Watch the University of Calgary video on the Signpost Method of case presentation. This is a simple way for AHPs to present to their sessional clinical supervisor:

'This is a [age] year old male/female who has had [symptoms] for [unit of time] and I am concerned about possible [issues]. I am not sure what is wrong with the patient? Or I am not sure what treatment to give? Or I am unsure what tests I should consider?'

As a supervisor you could say

'Can you give a brief summary of the case and signpost me to the specific issues you are concerned about?'

SBAR

Particularly for communication over the phone to hospital

SBAR communication tool – situation, background ...

Quality, Service Improvement and Redesign Tools: SBAR communication tool –

• situation
• background
• assessment
• recommendation

RSVP: Reason - Story - Vital Signs - Plan

This tool is to enable you to communicate information effectively about deteriorating patients to another and has been used extensively in the Wessex region since 2009.^6.7

International

A useful tool from Australia is the Ossie Guide to Clinical Handover.

They use another handover tool: ISBAR which adds identification (I) to the SBAR model in 2.

Glossary of terms

• Accreditation: Formal recognition that a health care organisation or provider is fit to carry out specific activities or processes in a reliable way. 
• Advanced nurse practitioner (ANP) 
• Agenda for Change: System used by the NHS to structure staff pay, whereby individual posts are allocated to bands that correspond to pay scales. 
• Calderdale Framework: A systematic method for reviewing staff skill mix, developing new roles and identifying new ways of working in order to ensure safe, effective care. 
• Care Certificate: A set of standards that health and social care workers agree to adhere to in their daily working life
• Care Quality Commission (CQC): Independent regulatory body that monitors and inspects health and social care services in England to ensure they are safe and of sufficient quality. 
• Commissioning for Quality and Innovation (CQUIN): Framework that encourages care providers in England to achieve goals specific to their local area by linking the amount of total funding they receive to their ability to achieve those goals.
• General Medical Council: The regulator of the medical profession, responsible for setting standards in the practice of medicine, overseeing medical training and providing professional protection for doctors. 
• Health and Care Professions Council (HCPC): Independent, UK-wide regulatory body responsible for setting and maintaining standards of professional training, performance and conduct of health care professions. 
• Health Education England (HEE): Department of Health-sponsored public organisation that exists to educate, train and develop the workforce in the health sector. 
• Indemnity: Security or protection against a loss or other financial burden (e.g. professional liability). 
• National Qualifications Framework (NQF): A system that sets out the level at which any professional qualification in the UK can be recognised. This system has now been replaced by the Qualifications and Credit Framework (see entry on this below). 
• Nursing and Midwifery Council (NMC): Independent body that sets standards of education, training, conduct and performance for the nursing and midwifery professions in the UK. 
• Qualifications and Credit Framework (QCF): System for education qualification in England, Northern Ireland and Wales that sets out the level at which any professional qualification in the UK can be recognised. 
• Registration: Process that all health professionals must undergo in order to obtain acknowledgement that they are fit to practice in a given discipline. 
• Regulation: Official oversight of the safety and quality of health care professionals’ work by statutory bodies.