Understanding the Barriers to Multiprofessional ... - EMAP

CLINICAL

FOCUS

Understanding the barriers to

multiprofessional collaboration

Biggs, S. (1997) User voice,

interprofessionalism and

postmodernity. Journal of

Interprofessional Care;

11: 2, 195¨C204.

Department of Health (2000) The NHS

Plan. A Plan for Investment. A Plan for

Reform. London: DoH.

Department of Health (1998) A First

Class Service: Quality in the New NHS.

London: DoH.

Department of Health (1997) The New

NHS: Modern, Dependable.

London: DoH.

Glendinning, C. et al (2001) Primary

Care Groups: Progress in Partnerships.

British Medical Journal; 323:

7303, 28¨C31.

Home Department (2003) Report of an

Inquiry by Lord Laming on Victoria

Climbi¨¦.

Norwich: HMSO.

victoria-climbie-.uk/

finreport/finreport.htm

Hugman, R. (1991) Power in the

Caring Professions. London: Macmillan.

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The NHS is the largest organisation in Europe. It has more

than a million employees and is recognised by the World

Health Organization as one of the best health services in

the world (Department of Health, 2000). The Health Act

1999 imposes a duty on all NHS organisations to work in

partnership (Glendinning et al, 2001). Yet recommendations from Lord Laming¡¯s report on the Victoria Climbi¨¦

Inquiry (Home Department, 2003) stress the need to

improve interprofessional collaboration and there is a

great deal of evidence to suggest that barriers to interprofessional working partnerships still exist.

Professional groups

Everyone in the NHS shares a common goal ¨C the wellbeing and health of patients. However, this goal becomes

a singular ideal within each discipline, based on the ¡®cure

or care¡¯ aim of that discipline and the role of the professionals within it. It is this strong identity of professional

groups that has led to rigid distinctions between them

(Biggs, 1997). These distinctions are then compounded

by a further combination of factors.

Communication between groups

Effective communication between professional groups is

the linchpin of successful collaboration. Traditionally

within the NHS this communication has relied on written

formats ¨C referral forms, feedback forms, case notes, care

plans, letters, faxes and message books. However, while

quality record-keeping and evidence-based policies and

procedures are necessary, they can result in ¡®inactive collaboration¡¯, with each professional group having a rigid

and singular input into patient care.

Purtilo and Haddad (1996) stress that verbal communication is essential to the patient and health professional

relationship. Meetings can be a solution. Regular meetings of a multiprofessional team linked by a common

care pathway help to enforce verbal communication and

to activate that team¡¯s collaboration. Effective integration

depends on a one-door (single referral) entry into a

multiprofessional team that has agreed objectives,

priorities and operational procedures (Leathard, 1994;

Ovretveit et al, 1997).

Professional identity and patient power

Hugman (1991) seeks to find possible solutions for the

future of interprofessional collaboration based on an

analysis of the idea of power within health care.

Leathard, in turn, describes the rivalry between professional groups ¡®as a form of social Darwinism of occupations¡¯ (Leathard, 1994). Power struggles within society,

for example the power of seniors (experienced) over

juniors (inexperienced), are a barrier to interprofessional

working. New developments in health care such as the

generic skill-mixing approach, and a drive towards true

patient-centred care ¨C using patient power to govern the

priorities of interprofessional teams ¨C may be the way to

overcome these barriers.

Differences in philosophies of care

Professional groups are known to have differing moral

and ethical philosophies of care. The paternalistic

approach of the cure-oriented medic versus the public

health and social advocate stance of the health visitor

are examples. If real power were given to patients in the

form of an expert patient board responsible for the governance of an interprofessional care pathway group, then

true autonomy might exist. But autonomy, as an identified ethical principle of individualised, patient-centred

care, is itself challenged within health care professional

groups (Woodward, 1998).

Finances and resource allocation

Professionals have markedly different pay scales according to their professional group and their role within it.

Resource allocation can be a source of conflict. There is

the issue of funding for staff. Seeing monies being used

to employ staff from one group to provide a service normally provided by another can cause resentment. Staff

shortages can also damage interaction as groups withdraw in an attempt to limit demands made upon them.

In addition there is the fear that multiprofessional collaboration is designed to reduce costs. Leathard (1994)

cites McGrath¡¯s suggestion that one of the advantages of

interprofessional working is ¡®more efficient use of staff¡¯.

Ovretveit et al (1997) discuss ¡®ownership of resources¡¯ ¨C

the concept of a multiprofessional team taking full

responsibility for resource allocation according to patient

need and its own service responsibilities.

NT 2 March 2004 Vol 100 No 9

Alamy

REFERENCES

AUTHOR Gloria Daly, BA, BSc, RGN, is clinical practice

development nurse, Barnet Primary Care Trust.

ABSTRACT Daly, G. (2004) Understanding the barriers

to multiprofessional collaboration. Nursing Times; 100:

9, 78¨C79.

Multiprofessional collaboration is key to delivering quality patient care. Many developments in health care such

as supplementary prescribing or the single assessment

process rely on the premise that such collaboration

already exists. This article focuses on barriers to interprofessional collaboration and explores whether ¡®new

ways of working¡¯ in health care can survive in an environment with a long history of independent disciplines.

KEYWORDS

BOX 1. RECOMMENDATIONS TO ENSURE

MULTIPROFESSIONAL COLLABORATION

¡ñ Regular multiprofessional team meetings to

enforce verbal communication and activate the

team¡¯s collaboration.

¡ñ Single referral entry into a multiprofessional team

that has agreed objectives and operational policies.

¡ñ Health education institutes to develop

multiprofessional preregistration programmes to

encourage newly qualified professionals in

multiprofessional working practices.

¡ñ Removal of the NHS from political agendas and

decentralising of management to improve

multiprofessional communication.

¡ñ Localisation of budgets to improve

multiprofessional care.

Health care education

There is a need to challenge long-held beliefs and ideologies in health care education if we are to foster multiprofessional collaboration (McPherson et al, 2001).

Interprofessional learning

Interprofessional learning is not a new buzzword. The UK

Centre for the Advancement of Interprofessional

Education was founded in 1987 and focuses on how

interprofessional learning fosters respect and overcomes

obstacles to collaborative working. To appreciate each

other¡¯s roles we must develop trust and pride in ourselves as a unified health care provision team.

Breaking down barriers

Segregation of students based on their chosen professional pathway continues to be the norm even though

much research literature challenges this practice.

Segregation continues to foster ¡®professional arrogance¡¯

(Leathard, 1994) and feed the power base of professional hierarchy.

However, within postgraduate education a significant

number of MSc level courses are now fully multiprofessional (Ovretveit, 1997). Health education institutes must

actively develop multiprofessional preregistration programmes to encourage newly qualified professionals in

multiprofessional working practices.

Change in philosophy

In current health care programmes the final hurdle for

students consists of examinations and summative assessments of ability in the key skills and competencies necessary to practice. However, an extensive literature

search revealed no health care programme where examination or summative assessment of the practitioner¡¯s

ability to work multiprofessionally was part of the fitness

to practise rationale. Currently, the philosophy of professional education lies solely in proving your singular

worth to your chosen profession.

NT 2 March 2004 Vol 100 No 9

¡ö

Management

Financial barriers

Leathard (1994) suggests that the most significant barrier to multiprofessional education is financial. Budget

holders are responsible for the education funding of their

own professional group. Underspend in one professional

group¡¯s budget is unlikely to be transferred into another

profession¡¯s budget irrespective of any educational need

to improve patient care. In addition short courses and

study days enhance multiprofessional working (Payne,

2000) and little attention has been paid to the interprofessional networking opportunities these offer.

Politics

Recent government policies for the NHS such as The New

NHS: Modern, Dependable (DoH, 1997) and A First Class

Service: Quality in the New NHS (DoH, 1998) cannot be

delivered without multiprofessional collaboration.

Political agendas

It is not unusual for health care professionals to feel

caught between government drives based on targets

and patient discontent. This has a direct effect on the

patient/professional relationship and alienates professional groups as they disassociate themselves from others where targets and services might be failing.

Removing the NHS from political agendas and decentralising management is seen as a way to improve multiprofessional communication and therefore collaboration.

Clinical governance

If barriers created by power cultures within the NHS are

to be eradicated one of the recent policies that might

facilitate this is clinical governance. However, the white

paper of only a year earlier A First Class Service: Quality

in the New NHS (1998) actively suggests that clinical

governance agendas should be driven by the medical

profession (Kenny, 2002).

¡ö

Multiprofessional collaboration

REFERENCES

Kenny, G. (2002) Interprofessional

working: opportunities and challenges.

Nursing Standard; 17: 6, 33¨C35.

Leathard, A. (1994) Going

Interprofessional: Working Together

for Health and Welfare.

London: Routledge.

McPherson, K. et al (2001) Working

and learning together: Good quality

care depends on it, but how can we

achieve it? Quality in Health Care; 10:

December, 1146¨C1153.

Naidoo, J., Wills, J. (1994) Health

Promotion: Foundations for Practice.

London: Macmillan.

Ovretveit, J. et al (1997)

Interprofessional Working for Health

and Social Care.

Basingstoke: Macmillan.

Payne, M. (2000) Teamwork in

Multiprofessional Care.

Basingstoke: Macmillan.

Purtilo, R., Haddad, A. (1996) Health

Professionals and Patient Interaction.

Philadelphia, PA: WB Saunders.

Whitehead, D. (2001) Collaborative

Practice. Nursing Standard; 15: 20,

33¨C38.

Woodward, V. (1998) Caring, patient

autonomy and the stigma of

paternalism. Journal of Advanced

Nursing; 28: 5, 1046¨C1052.

Budgets and audits

Professional groups often cite rationalisation, limited

resources and centralised budgets as barriers to collaborative practice (Whitehead, 2001). However, Naidoo and

Wills (1994) argue that financial constraints are essential

to collaboration. Increased budgets alone are not sufficient. Localisation of budgets, use of resources for

generic skills acquisition, auditing and improvement of

multiprofessional care as part of budget allocation, and

the broadening of the research arena to include all professional groups would be a step forward.

Conclusion

Modernisation of the NHS and commitment from politicians, educationalists, professionals and patients is overcoming professional barriers (Box 1). As health care

professionals we have never been better placed to

improve patient care through multiprofessional collaboration and working practices. Now is the time to engage

all stakeholders in order to increase the momentum and

to achieve the results. ¡ö

This article has been double-blind

peer-reviewed.

For related articles on this subject

and links to relevant websites see



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