This informal CPD article ‘Team-Working in UK Public Sector Health – Is there a solution?’ was provided by Dr Jacqueline Haughton, Medical Director at Healthcare Skills International, an approved education centre delivering a range of externally validated competence-based qualifications to the medical profession and healthcare industry.
In healthcare teamworking, factors such as personality clashes, poor team dynamics and psychological safety adversely influence patient outcomes and negatively impact co-workers (Rosen et al 2018). They are mitigated and positively modified by good organisational leadership (Lawther 2023), and good clinical team-working is the bell-weather of a healthcare organisation’s culture and leadership success.
What is a team?
A team is a group of individuals working independently or together to achieve a common goal. We know that teamworking in healthcare is essential to protect patients and achieves good clinical outcomes (Mazzocco et al, 2009) and it grew organically from traditional care models during the 20th century.
In recent years, the influence of healthcare management has become less clinician-based (Kirkpatrick, 2021) and the workload of clinical teams has increased significantly (Bailey and West 2021), creating the systems we currently work in. Traditionally, in ‘good’ hospital teams, senior doctors would lead and make executive decisions, reaching a consensus with their junior medical team and the nurse in charge. The core medical team was stable and cohesive: members knew each other well and worked together extensively, learning, practicing and anticipating each other’s response as their level of expertise and experience grew.
Other important team members included the consultant’s secretary and others responsible for services required during a patient’s time in hospital or after discharge. There was recognition that theatre sisters, outpatient staff, laboratory based specialties such as pathology and biochemistry, radiologists, allied healthcare professionals and many others were key to successful patient outcomes. There was mutual respect and understanding of roles, and acceptance that ultimate responsibility lay with the senior doctor in charge, who therefore had the ‘casting vote’.
How teamworking has changed in the UK public health sector
So, when did that high-functioning, top down model of teamworking change? And was it ‘good’ change or ‘bad’?
‘Top down’ medicine used to work well before the complexity of healthcare escalated. Back in the day, the patient’s response to attempted shared decision-making would most likely be “whatever you think’s best, doctor”. It was a time when consultants would typically be in their mid to late 40s at the time of appointment, which meant that junior medical team members were also clinically mature. Consultant patronage was key to career advancement, and this was one of the glues that underpinned a safe and stable system. Generally, public perception was that nurses were angels, doctors were saints, and unholy behaviour didn’t happen (although, of course, it did, and was usually quietly resolved). Being on call as a team, being in theatre as a team, and continuity of care for patients were never an issue, and we simply never questioned it – it happened automatically as it was best for patients. The system wasn’t ‘good’ or ‘bad’ – it’s just the way it was.
With increasingly complex healthcare associated with an ageing population and medical innovation, this model proved unsustainable. The European Working Time Directive (implemented for junior doctors in full in 2009) also eroded the pillars on which the clinical hierarchy was built - patronage for promotion, unlimited availability of junior medical staff, with competence and dedication securing patronage. Societal acceptance of paternalism in medicine also declined (Montomery v. Lanarkshire Health board 2015), while the blurring of healthcare roles and the introduction of new ones (DHSC Media Team 2023), staff shortages (Mallorie 2024, Statista 2024), financial constraints (NHS Confederation 2024i), increasing complexity of care and workload (NHS England 2024), threat of litigation (NHS Resolution 2022) and changing political priorities (NHS Confederation 2024ii) gained momentum and made the landscape more complex.
So, ‘change’ wasn’t ‘good’ or ‘bad’ – it was inevitable. Fast forward to 2024, and in many hospitals consultant secretarial services are provided by a pool, ward rounds have peripatetic juniors with consultants the sole “clinical constant" (BMA 2020), nurses work from hand-over notes (NICE 2018), and it’s pot-luck as to whether or not theatre lists have familiar supporting team members. Coordinating acute patient care can be like conducting an orchestra of unrehearsed musicians with unknown competence and variable experience who come together on the eve of performance – time is short, the team is frustrated, relationships are difficult (Lawther 2023), outcome likely suboptimal, and with the conductor ultimately accountable, burn out and disengagement are common.
When things go wrong, we talk of communication failure as the commonest cause - as though it's a human failing we can overcome if we work at it - whereas the real solutions lie in good leadership and cross-professional teamworking (West et al, 2015). Without addressing the lack of good organisational leadership at all levels of the service, dysfunctional teamworking at the coalface will continue (Saeed et al 2015).
