5 reasons why health providers don’t trust each other

Trust is an essential ingredient of effective healthcare delivery. It’s important for interprofessional as well as inter-organisational collaboration.

A 2018 literature review concluded that collaboration leads to more job satisfaction, improved morale and a better working atmosphere. Unfortunately, health providers don’t always trust each other. The authors of the review found 5 sources of distrust:

  1. Doubting the other’s motivation in providing care and the perceived benefit for him/her
  2. Feeling threatened by the other’s involvement and being afraid of losing some territory
  3. A difference in philosophies and scope of practice
  4. Negative images of the profession
  5. Lack of confidence in the other’s skills and lack of awareness of the other’s role in patient care.

Other ingredients of effective collaboration include adequate communication, respect, mutual acquaintanceship, equal power-distribution, shared goals, congruent philosophies and values, consensus, patient-centeredness and environmental factors.

The authors did not explore the level of importance of each factor but I am putting my money on trust as the secret ingredient. If we continue to distrust each other, collaboration will remain a challenge. The question is, how to change this?

Human interoperability

Health professionals often complain about software and IT. It doesn’t always do what we want it to do. It slows us down, makes us do extra work.

A common problem is lack of interoperability. Computer systems are not talking to each other, a bit like Microsoft and Apple many years ago. Patients have also noticed that important information is not always available, which leads to inconvenience, delays and sometimes more tests.

At the same time GPs are unhappy that the hospital doesn’t provide essential info, for example when a patient has passed away, and hospital staff complain that referral letters don’t contain important triage information. Etc etc.

This raises the question, how ‘interoperable’ are health professionals? Do we know how we can best facilitate transfers and improve clinical handovers? What information do our colleagues need and when? How often do we meet to sort out issues in a collegial way?

It’s good to see there are passionate people working on these issues – but they need help. Computer systems are a reflection of the silos we work in. First fix human interoperability and our IT systems will follow.

5 ingredients for effective collaboration

Collaboration can be very rewarding. It is often talked about but not easy to achieve, and it doesn’t always make the top of the priority list.

Although it’s not the solution to everything, effective collaboration can be a source of satisfaction and has the potential to make work, and life, more fun. Of course, collaboration does not mean that we have to agree on everything.

I’d like to share some thoughts on the ‘ingredients’ of successful collaboration:

#1: Letting go of control

No one is as smart as all of us, said Ken Blanchard. It’s ok to not have all the answers. In collaborative cultures outcomes are largely dependent on organic group processes. It is important to empower others and trust in the wisdom of the group and diversity of thought.

#2: Celebrating diversity

Interesting things happen when people bring different backgrounds, disciplines, skills and ideas to the table. We need to be open to a dialogue that celebrates differences. This is not always easy as our tendency is to engage with like-minded people.

Diversity improves decision-making as it stimulates critical evaluation and prevents groupthink. Diversity also means accepting that we can have differences of opinion.

#3: Aiming for mutual benefit

In collaborative cultures mutually beneficial solutions become more important than winning and personal gain. We need to attend to the needs of all parties and not just our own.

Consensus improves the quality of decision-making through genuinly addressing individual concerns. Asking questions and finding out what outcome the other party needs is key to finding common ground for agreement.

#4: Formulating shared values or goals

Often we want to jump to the ‘how’ without having explored the ‘why’. Universal values are motivating! They answer the why question and are the reason we get out of bed in the morning. Providing excellent care to our patients is an example of a universal value/goal most of us share.

#5: Building relationships

If we focus on outcomes without investing in relationships, there is a good chance that we will fail. Building trust and relationships are key components of effective collaboration. This is never a once-off tick-box exercise but should be an ongoing activity.

This post was originally published on BridgeBuilders.

Integrated health services, what do you mean?

It has been described as the holy grail of healthcare: the patient at the centre and the care team working seamlessly together, no matter where the team members are located, what tribe they belong to or who the paymaster is.

Integration has been talked about for many years. The fact that it’s high on the current political agenda means that there’s still a lot to wish for. Although we have high quality healthcare services, our patients tell us that their journey through the system is everything but smooth. Most health professionals are painfully aware of the shortcomings in the the system.

What is integration?

So what do we mean when we talk about integration? Co-location of health professionals? Team meetings between doctors, nurses and allied health professionals? Hospital departments talking to each other? Communication between GPs and specialists? Working across sectors? Packaging preventative and curative services? Patient participation? One electronic health record? A shared management and funding system?

Integrating health services means different things to different people. For that reason the WHO proposes the following definition:

“Integrated service delivery is the organisation and management of health services so that people get the care they need, when they need it, in ways that are user-friendly, achieve the desired results and provide value for money.

Integration is a means to an end, not an end in itself. Sharing resources may provide cost savings but, says the WHO, integration is not a cure for inadequate resources. Obviously, integrating services doesn’t automatically result in better quality. It’s also worthwhile noting that co-locating services does not equal integration.

There is a difference between integration from a consumer point of view, which often implies seamless access to services, and professional integration, which is achieved through mixing skills and better collaboration. These two types of integration don’t necessarily go hand in hand.

So it is useful to ask: what problem are we trying to solve? Are we trying to improve the patient journey through the health system? Do we want to support health professionals to deliver better care? Or is the main driver government concerns about costs?

How to achieve it?

One thing is certain: we must fight fragmentation. This is challenging as we are seeing a wave of commercially driven, disruptive services appearing in the healthcare sector. These solutions may be attractive to consumers because they are convenient, but they usually don’t contribute to a better or more integrated health system.

Unfortunately the evidence around integration is limited, but the authors of this MJA article are suggesting a way forward. They have looked at international health reform initiatives improving integration between community and acute care delivery, and they found that the following 10 governance elements are essential to support integration:

  1. Joint planning. Governance arrangements included formal agreements such as memoranda of understanding
  2. Integrated information communication technologies
  3. Effective change management, requiring a shared vision
  4. Shared clinical priorities, including the use of multidisciplinary clinician networks, a team-based approach and pathways across the continuum to optimise care
  5. Aligning incentives to support the clinical integration strategy, includes pooling multiple funding streams and creating equitable incentive structures
  6. Providing care across organisations for a geographical population, required a form of enrolment, maximised patient accessibility and minimised duplication
  7. Use of data as a measurement tool across the continuum for quality improvement and redesign. This requires agreement to share relevant data
  8. Professional development supporting joint working, allowed alignment of differing cultures and agreement on clinical guidelines
  9. An identified need for consumer/patient engagement, achieved by encouraging community participation at multiple governance levels
  10. The need for adequate resources to support innovation to allow adaptation of evidence into care delivery.

Major paradigm shift

The first thing we need is a shared vision. A major paradigm shift towards more integration requires motivated and engaged stakeholders and champions, a shared sense of purpose and a culture of trust. This should be established before embarking on a new journey. We must avoid making the same mistakes that have caused so much havoc in projects like the PCEHR.

It will be a challenge to get health professionals to focus more on coordination instead of daily care delivery. An essential step here is to increase capacity. The last thing we need is an overloaded primary care sector such as in the UK. The RACGP is suggesting an overhaul of primary care funding to faciliate integration and coordination. Similar changes will be required to free up hospital doctors to e.g. discuss patient cases with primary care providers.

The big question is: who will take the lead? It is likely that a lot of  work will happen at a local level and primary health networks could play a crucial role here. A shared agenda, clear goals and genuine stakeholder involvement are keys to success.