Guides to specific issues 1. This issues guide is linked to the vignette Sometimes talking is so hard.

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1 Guides to specific issues 1 This issues guide is linked to the vignette Sometimes talking is so hard. Successful teamwork is critical to creating an environment for sustainable change in health care. Depending on your stage of team development/evolution, you may need to set aside protected time in a team workshop to discuss these issues. Things to consider The principles of teamwork and teambuilding are straight forward, but the devil is in the detail, and in developing trust in team relationships. Questions to ask when considering teams for PMHC are: Team identity? Who are the members of the team and do they have a common purpose? In PMHC team members may have been drawn from different disciplines and may not have worked closely together e.g. psychiatrists, GP s, primary mental health coordinators. Team members roles and responsibilities? Are the members of the team clear about their roles? If previously the GP has been responsible for all aspects of the patient s PMHC, what should their new role be now that there are additional team members such as counsellors or clinical psychologists? Role perception? Defining each team member s perception of their role is as important as identifying the actual role that they play. There is little point in allocating counselling to a practice nurse in a team if their perception is that they are solely responsible for monitoring and follow up. Leadership? Teams do not function well without good leadership. Leadership in PMHC is difficult because a new discipline has been created, and there is little experience in effective

2 Guides to specific issues 2 leadership by either individuals or teams. It is important that leadership is allocated to the person who can most effectively take forward the team objectives, no matter what their disciplinary background. Communication? Many problems in effective teamwork are due to poor communication or miscommunication. Teams cannot communicate well if team members do not know each other. Creating protected time for team members to communicate effectively with each other is challenging in primary care and must be specifically created. Philosophies of care? PMHC is being developed by professionals from a number of different backgrounds. Primary care and secondary care traditionally have different philosophies of care, as do professionals from nursing, medical and psychological therapy backgrounds. These different philosophies of care must be discussed and consensus reached on a common philosophy, if the team is to work effectively. Conflict? Conflict is inevitable in teams and protocols and contingency plans should be developed to enable conflict resolution. Protected time is necessary for effective conflict resolution. The operation of the team? Linked to the philosophy of the team is the way that team has been designed. Many teams have been created as a response to workforce shortage or fiscal constraint. In this situation team members may be substituted or delegated for each other e.g. nurses for doctors, counsellors for psychologists. The opportunities for team effectiveness in this situation are very different than if there is a deliberate strategy to enhance team effectiveness by combining the skill sets of different team members.

3 Guides to specific issues 3 Stability? The health sector in recent years has been characterised by rapid and constant change. Developing and sustaining effective teamwork in this environment is difficult. The more challenging teamwork feels in a rapidly changing environment the more it should prioritised.

4 Guides to specific issues 4 Sometimes talking is so hard (click here to go back to guide) Rory feels like he s telling his story for the fifteenth time, this time to the kindly psychiatric registrar, following on from the Emergency Department registrar and the admitting nurse, and the ambulance crew, and before that all the people who sort of listened and sort of didn t. Yes at the time he had meant to kill himself and the rope was round his neck and if Mahlia hadn t come in and found him, well who knows Six weeks previously Rory had started to fall apart after his girlfriend of four years had left him, his boss had threatened him with dismissal if his work didn t improve and his drinking had become problematic, particularly at weekends. His flatmates had escorted him to the local GP, when a skin infection had begun to spread the length of his arm. The GP asks questions about Rory s mental state after prompting from the accompanying flatmates and makes a working diagnosis of depression, with associated adjustment and alcohol use problems. (There is no suicidal ideation on direct questioning by the GP). With his low income Rory qualifies for free psychological support from the local primary mental health initiative (PMHI) and he is referred to the local mental health coordinator. The GP also prescribes antidepressants and arranges to see him again in a week. The GP has not met the mental health coordinator face to face, but has heard good reports of the way the scheme is working from the other doctors in the practice. An appointment is made for Rory for the beginning of the next week, and he attends, accompanied again by one of his flatmates. The PMHI coordinator has a past mental health nursing background, and at the interview notes that Rory has been feeling more depressed and occasionally thought he would be better off out of it. There is no definite suicidal ideation, and she refers Rory to one of the five counsellors with whom the PHO has a contract. The counsellor has a particular interest in alcohol problems. Rory attends the first meeting with the counsellor five days later. The counsellor finds him withdrawn and argumentative and is concerned that he is expressing definite thoughts of self-harm. She feels that he is not a primary care

5 Guides to specific issues 5 referral and says he should go back to his GP. She also phones the mental health coordinator. The coordinator phones the practice, and leaves a message for the GP, who is away on annual leave. She speaks to the duty doctor who suggests that the coordinator contact the crisis intervention team, as routine referrals for psychiatric assessment usually take between four and eight weeks. The coordinator attempts to contact the crisis team, who say that the referral must come from the GP, and that in the meantime counselling might help. Rory fails to keep his appointment with the GP, but his flatmate phones the PMHI coordinator to say she is worried about him. The mental health coordinator felt disappointed at the previous response from the duty GP at the practice and leaves a message with the Practice Manager to say that Rory still has problems. Rory s GP receives the message and attempts to ring Rory. Failing to do so, the GP contacts the crisis team. The crisis team request that Rory is seen before they will accept the referral. Rory has been alone in the flat for three days since Mahlia and the others went away for the party down South. Questions to consider 1. Who is the Primary Mental Health Care Team? 2. Who has responsibility for care at each stage of the story? 3. How might communication and teamwork have been improved?