Clicky

Reflections on multi-disciplinary teams working in general practice in Northern Ireland

Peter McNelly is a mental health nurse with over 50 years experience working in the field of mental health in England, New Zealand, Australia and Northern Ireland.

The drive to have other health professionals working with GPs in their practices in Northern Ireland arose as a result of both the Bengoa Report1 and the Health and Wellbeing – Delivering Together Report,2 together with the ever growing workload demands faced by GPs.3 The development of multi-disciplinary teams (MDTs)4 working as part of the primary care team alongside GPs is both new and untested anywhere in the UK.

GP Federations have been established in Northern Ireland5 with two main aims:

  • To support and protect GP Practices.
  • To help deliver the transformation agenda in Health and Social Care.

The creation of the federation model has been led and funded by GPs themselves. There are currently 17 fully incorporated GP Federations covering all areas of Northern Ireland, all of which are owned entirely by GPs.

The creation of the [Northern Irish] federation model has been led and funded by GPs themselves.

GP Federations aim to provide better care for their patients delivered in a more responsive way and closer to home, for patients registered on the lists of practices within the Federation. The focus is on working across the local health and social care community, in collaboration with a wide number of agencies, to design and implement innovative healthcare strategies and ways of delivering high quality care.

GPs remain the primarily responsible medical officer for patients, while MDT professionals play an important complementary role in assisting GPs with their work. Without such an agreement and cooperation, MDT professionals would be unable to work in GP Practices.

Context

In the last five years the number of GPs in Northern Ireland has remained unchanged, despite the workload and patient expectations. The prevalence of poor mental health and social deprivation in Northern Ireland has been well documented, indicating 25% higher increase than other parts of the UK.

MDTs6 seek to address any issues that patients face at an early opportunity, providing access to a range of experts who can provide care, advice and support to GP Practice patients. The MDTs consist of a Social Worker (SW), Social Worker Assistants (SWA), Mental Health Practitioner (MHP), Pharmacists and Physiotherapists. Part of the MDT’s role is to provide timely and appropriate first contract of patients, freeing up GP appointment slots and assisting with GP workload pressures. The General Medical Services (GMS) Contract requires that the GP must see or contact a registered practice patient if the patient so requests, therefore MDT professionals may still not necessarily be the first contact for a patient even if that would have been more appropriate.

The MDTs consist of a Social Worker, Social Worker Assistants, Mental Health Practitioner, Pharmacists and Physiotherapists.

Discussion

An enormous culture shift is required for an MDT Professional working in an NHS Trust who wishes to transfer to work for a GP Federation. GP Practices are small businesses. Whilst the majority of GP practices operate as registered members of their local GP federation there is little or no uniformity in their approach to service delivery, administration processes or practice structure. This is often in stark contrast to the experience of the MDT professional who may have traditionally worked in quite structured programs of care, with uniformed governance standard and approach to service delivery.

SWs and SWAs are currently still employed by the Trusts and not the GP federations, and in some Federations in Northern Ireland the Physiotherapists are still also employed by the Trust, but as members of the MDTs they do work in the various GP Practices within the GP Federations. At times such arrangements appear to add to role confusion. It is essential that all parties involved in the development of GP Federations and MDTs have a clear understanding of the core fundamentals of how MDTs in GP Practice will work in the real world.

MDT members need to be aware that each GP is unique and clinically autonomous, especially in their decision-making. The role and function of a MHP is illustrated by some GPs referring to the MHP as being a CPN, a Counsellor, and/or Therapist, perhaps indicating that the role and function of a MHP in any given surgery remains ambiguous.7 The patients seen by the MHP usually fall within the remit of Common mental health problems, and are Step 1 and 2 in need, as per NICE guidelines.8

It is important that MDT members such as the MHP and physiotherapists do not create caseloads of their own by default, as they can be required to see any of the patients registered with the practice. Given that there are usually many thousands of patients, then just like the GPs these MDT professionals must be available to contact all patients within a reasonable time frame.

The lack of medical personnel in Northern Ireland’s Trusts is also a concern.

The number and duration of appointments for professionals in MDTs, especially MHPs, is often a moot point. The lack of uniformity and the fluid and unorganised role of MDT professionals in primary care practice can lead to unresolved tensions, especially regarding appointment duration and the number of slots assigned.

In this context, time management becomes an important issue. How many times a MDT professional must attempt to contact a patient without any response can become debatable. GPs are seeking 15 minute routine appointment slots.9 It is not uncommon for GPs, if they are aware beforehand that the appointment is for mental health, to book a double slot i.e. 20 minutes for the appointment, reflecting GPs’ experience that the patient with mental health concerns generally requires more time for the consultation than those with physical health concerns.

The continued workload for GPs is also reflected in did not attend (DNA) rates. In primary care the percentage of DNAs is small in comparison to the rates of DNAs in NHS Trusts, thereby adding to the continued flow of demand on the GP, MHP and physiotherapist time each and every day. The use of Thebigword translation services provider and face to face interpreters is another workload consideration for GPs and members of the MDT.

The lack of medical personnel in Northern Ireland’s Trusts is also a concern, and particularly in trusts’ adult and children mental health teams. With the acceptance criteria bar moving forever upwards for a GP referral to be accepted, with GPs then being required to manage patients who in the past would have at least been seen as an Out Patient, many of whom would have had ongoing input and therapeutic support from the various mental health teams. The revolving door phenomenon appears to have resurfaced, and been moved from trust mental health teams to GPs in primary care.

The revolving door phenomenon appears to have resurfaced, and been moved from trust mental health teams to GPs in primary care.

The way MHPs have patients booked into their appointment slots has a major impact on two objectives of MDTs working in general practice. The primary findings from three practices show that if the objectives of making first contact and reducing the workload of GPs are important, then triage by reception staff play a significant role. One practice had a 50/50 split of appointment slots being filled by reception staff, and the remained mostly by the GP after they themselves had a consultation with the patient.

Another practice recorded a 90/10 split, with most appointment slots for the MHP being filled by reception staff after triaging patient calls, and the other 10% by GPs and occasionally by other MDT colleagues. First contact and reduced GP workload objectives were better achieved by the practice with the 90/10 split.

The function and role of the MHP is brought into focus with the disparity between practices, and how Practices and GPs use the MHP resource. It might suit some practices to use the MHP in a manner that does not aim at first contact or reduced workload objectives, but such a consideration with its inherent flaw of a caseload, should be discussed and agreed by all  parties in the first instance.

My personal experience of working in two of the five GP Federations in Northern Ireland suggests that the level of staff burnout is already high, especially with MHPs. GPs themselves look for a little variety and less isolation in their day to day work within the practice, so a balance that is cost effective will also be required for the MDT Professionals working alongside their GP colleagues in order to help avoid isolation and burn out.

My personal experience …. suggests that the level of staff burnout is already high.

How MDT members in the GP Practices interact with each other is quite ambiguous. MDT meetings are not what most trust health professionals would recognise as a typical MDT meeting. When they do occur they are usually monthly, and are a practice / business meeting rather than a clinical meeting, again reflecting the great differences between trust and primary care work, and how the professionals in primary care work in isolation be they GPs, SW, MHP, Physiotherapist or Pharmacist.

MDT professionals working in GP Practices are managed by a Team Leader, one for each of the professional disciplines in the MDT, and staff receive professional supervision according to their profession. However when working in GP Practices the day to day, week to week management issues for some MDT members such as the MHP, some Physiotherapists and Pharmacists are undertaken by the PM.

Tasks and duties are also frequently delegated by the various GPs within a practice, and this again brings into focus the role and function of a MHP in Practice. This makes any similarity of how the MHP should practice virtually impossible, given the many different opinions on these issues.

The involvement of MDT members in Quality and Outcome Framework Targets (QOF) needs exploration, as GPs and PMs have a view on the involvement or otherwise of MDT Professionals in QOF, as do the MDT Professionals themselves.

The professional backgrounds MHPs are recruited from appears to be a significant factor in the way they practice.10 Unlike GPs who have a medical background and training to provide care from cradle to the grave, MHPs in GP Federations in Northern Ireland may come from a background of Social Work, Mental Health Nursing, Occupational Therapy or Psychology. Such diverse professional training, coupled with an individual’s experience in the field of mental health, fosters wide-ranging differences in how each MHP sees their role and how they practice.

Such diverse professional training …. fosters wide-ranging differences in how each MHP sees their role and how they practice.

Lack of uniformity in the ability of MHPs to practice in a predetermined and predictable way is an issue that requires consideration, both by the GP federations and individual GP practices.

Agreement in principle of the exact role and function that MDT professionals are to play in GP Practices should be agreed by all parties beforehand, but also with acknowledgement that as with most new systems some changes may be required on review. However the role and function of the Physiotherapists needs much less clarification than those of some other MDT members.

The inclusion of some of these MDT professional groups working in the primary care setting within Northern Ireland is likely to be assessed by individual GPs and PMs as being less helpful in meeting their perceived needs.11 A broadly similar endeavour with primary care networks (PCNs) in England has many of the same issues.12 The objectives and functions of MDTs being attached to GPs should become clearer by reviewing current experience and knowledge of GPs and MDT professionals who are working with this new model in Northern Ireland.

Again, anecdotally, the outcomes for many patients as a result of the input from MDT professionals has been very positive, and has gone some way to reduce the duration of patients’ ongoing physical, mental and social difficulties.

Recommendations

My experience suggests that the deployment of MHPs and physiotherapists as members of multidisciplinary teams working in GP practices in Northern Ireland can reduce GP’s workloads. This is demonstrated by the number of appointment slots such professionals can free up by being the first contact for patients. This view is supported by GPs themselves.

The deployment of MHPs and physiotherapists as members of multidisciplinary teams working in GP practices in Northern Ireland can reduce GP’s workloads.

The process of triage by reception staff is important in placing the patient with mental health, physical or social care issues with the most appropriate professional at the right time, and also in meeting the objective of first contact. The involvement of MDT Professionals in addition to the GP has the potential to enhance the care to patients registered with the GP Practice, in part due to the experience and knowledge and time available to these MDT professionals.

All MDT members require adequate recognition and support to address the issues of personal and professional isolation, inclusiveness, deskilling and burnout. To this working in one GP Practice only would both aid inclusiveness, and is a better use of the current limited MDT staff resource.

A fundamental review of the MDT’s role, especially that of the MHP, should be undertaken before new GP Federations become live in Northern Ireland. Full time allocation of each MDT professional per 10,000 practice patients must also be looked into.

References

  1. Systems, Not Structures-Changing Health and Social Care. Bengoa Report, 2016.
  2. Department of Health. Health and Wellbeing 2026 – Delivering Together. 2017
  3. Department of Health. Review of GP-Led Primary Care Services in Norther Ireland. March 2016
  4. Department of Health. Regional Launch of Primary Care Multi-Disciplinary Team.
  5. Health and Social Care Board. GP Federations 2016
  6. Royal College of General Practitioner’s. Multi-disciplinary teams. An expanded team. 2019.
  7. Kilmartin S. How our mental health nurse reduced GP workload and cut prescription costs. Pulse Journal October 2018
  8. Common mental health problems: identification and pathways to care. NICE Clinical guideline, May 2011
  9. M.Thompson-F.Walter. Increases in general practice workload in England. The Lancet, April 2016
  10. Kamal Sidhu. Hiring a mental health practitioner. Pulse Journal. 2021
  11. Pulse PCN roundtable: The Additional Roles Reimbursement Scheme. Pulse Journal 30 September 2021.
  12. Primary care networks two years on. PCN Network NHS Confederation, August 2021

 

Featured image by Takahiro Sakamoto at Unsplash     

Leave a Reply

This site uses Akismet to reduce spam. Learn how your comment data is processed.

Previous Story

Episode 052: Exploring why emergency admission risk prediction software increased admissions in Wales

Next Story

Into the liminal zone – an opioid experience

Latest from Opinion