Team effort pays off

Service improvement is more achievable when it involves whole practices and makes the most of every individual’s knowledge, according to a research project on the treatment of back pain.

Back pain is a condition where GPs feel particularly frustrated because clinical guidelines and evidence don’t seem to fit with everyday practice and patient needs, says Dr Charles Campion-Smith, who led the clinical part of the study.

Nine practices in Dorset and Wiltshire have been involved in the Bournemouth University project, funded by the Health Foundation, to see how inter-professional teams can learn and work together using a continuous quality improvement approach.

The project offered bursaries to enable practices to release staff to attend eight facilitated workshops, which introduced improvement tools, such as flowcharts, to help them understand existing processes, and provided expert advice in areas like communication and self-care. 

To maintain the push towards change, coaches visited participating practices in between workshops. This meant all staff, not just a minority, were actively involved and learning from events could be effectively shared with colleagues.

Ongoing evaluation aims to ensure change is sustained through continued team working and raised professional confidence as well as specific initiatives. Qualitative research findings cover personal, clinical and functional outcomes such as referrals to secondary care, patient satisfaction, time off work and people’s feelings about the impact of back pain on their lives.

The project has produced learning on three levels:

• specific to back pain
• improvements through teams taking control and redesigning services
• inter-professional learning from and about each other.

“We didn’t want this to be a one-off project, so it was important it produced transferable lessons, not just topic-specific learning,” says Charles.

So what does he feel have been the key lessons learned?

• Primary care is very complex, with room for change and improvement at every stage. Until you have the whole team on board you will get it wrong because no one person understands the whole process. Continuous improvement is about understanding how the bits fit together before you can make changes.

• A key message from patients was ‘stop trying to cure us and start listening to us’. This was very liberating for the professionals involved. As an individual tackling problems can be frustrating, but as a team you can take action to change systems of care to meet patient needs, like providing better information on back pain and different access routes to help, such as referral to physiotherapy. 

• It’s important to listen to patients from the outset. There’s a tendency to make assumptions based on a medical model of care. Patient representatives were on the project steering group and their personal stories helped practices see the need for the change from a patient perspective. The workshops encouraged teams of practice managers, patients, other practice staff, GPs and nurses to work together, but also gathered groups of patients and admin staff, for instance, to ensure their views were heard. “In a mixed team, you can find that people with the answers, like receptionists, don’t speak up because they feel disempowered by clinicians,” says Charles.

• Any approach to service improvement must take into account the competing demands on people’s time and attention. “During the project we had major changes in local infrastructure and personnel – you need a model that can adapt and work in the real, messy world,” says Charles.

• It is important each practice designs its own changes from the bottom up, drawing on a depth of local knowledge perhaps not previously exploited. For instance, a practice in an area of low literacy chose to offer information in a more graphic way.

• Commitment by key people is vital. Having practice managers who saw the project as part of the whole team’s development and GPs who saw their practice as a learning organisation empowered everyone else to maintain their efforts to sustain change and produce research-level evidence.

Find out more about the Learning to improve the management of back pain in the community project (LIMBIC) at www.limbic.org.uk.

The IHM’s MHSC diploma covers team effectiveness.