Improving the quality and safety of care has, in recent years, been a key driver for the use of interprofessional teamwork, as the need for effective collaboration and communication is seen as central for achieving such gains. Arguably, the focus on delivering a quality service is linked with the rise of many of the other developments, such as the patient-centred movement and consumerisation (see below) as well as the emergence of a number of quality improvement initiatives (see Chapter 3). Encouragingly, a small number of studies have indicated that interprofessional teamwork can contribute to improved quality in the following areas: reducing patient complaints, increasing patient satisfaction, and reducing stress and burnout among professions (e.g. Beckman et al., 1994; Wofford et al., 2004). However, at present, the rigour and quantity of this research are still rather limited.

In relation to safety, concerns can be traced back to Ivan Illich’s (1977) seminal book entitled Limits to Medicine in which he argued that the medicalisation of society caused more harm than good; and often rendered many people, in effect, lifelong patients. Through the use of a range of health statistics, Illich demonstrated the extent of post-operative side effects and drug-induced illness, which he termed iatrogenic – physician-induced – disease.

The publication in 2000 of the Institute of Medicine’s (IoM) report, To Err is Human, re-ignited both public and professional interest in safety and the reduction of errors (Kohn et al., 2000). Based on data from US medical record studies dating back to 1984, it was found that there were between 44000 and 98000 adverse events reported each year. The IoM report went on to state that in order to identify error, each team member needed to know their own responsibilities, as well as those of their members. Recommendations to prevent error included that health and social care organisations should begin to implement patient-safety programmes that trained professionals to work effectively together in teams.

Since the publication of this report, a range of patient-safety initiatives (e.g. checklists) have been developed to improve the quality of team communication and interprofessional relations (e.g. Awad et al., 2005; Haynes et al., 2009) (also see Chapter 6). In addition, a number of organisations promoting interprofessional teamwork and patient safety have been established such as the UK National Patient Safety Agency, the US Institute for Healthcare Improvement, the Australian Patient Safety Foundation and the World Health Organization’s World Alliance for Patient Safety. A range of interprofessional patient-safety initiatives has also emerged from these organisations. For example, the Canadian Patient Safety Institute (2008) recently published its interprofessional competencies aimed at enhancing collaborative knowledge, skills and behaviours related to safety.

Despite improvements in quality and safety, Wachter (2004) has argued that error-reporting systems have had little impact, and scant progress had been made in improving professionals’ accountability. Indeed, a recent national survey of medical residents’ perceptions of intra- and interprofessional conflict and error undertaken by Baldwin and Daugherty (2008) found that of the 523 residents who reported conflict with at least one other professional, 36% reported that it was linked to a ‘serious medical error’. Of the 187 reporting conflict with two or more other professionals, the serious medical error rate was 51%. A recent qualitative study provides further information on how professionals perceive error (Box 2.1), and suggests that a better understanding of these perceptions may be helpful in designing systems to improve patient safety.

Patient-centred care

According to Jewson (1976) in his paper on the ‘disappearance of the sick man’, care in the 1700s was patient-centred. Physicians, he argued, at that time were very responsive to the needs of their usually rich patrons. However, towards the end of that century, this relationship altered. The production of medical knowledge was assumed by medical investigators. This changed the practice of medicine from being negotiated between physician and patient to a consensus of opinion imposed from the growing community of publicly funded medical researchers.

The modern notion of ‘patient-centred care’ was introduced into the health literature in the mid-1950s by Balint (1955, 1956), who compared it to ‘illness-centred medicine’ (Brown, 1999). The concept emerged from the paradigm of holism, which suggests that people need to be seen in their bio-psychosocial entirety (Henbest and Stewart, 1989), and focuses the attention of health care providers on patients’ individual identities (Armstrong, 1982; Lewin et al., 2001; Beach et al., 2006). The main features of patient-centredness include health and social care providers sharing control of consultations, decisions about interventions or the management of the health problems with their patients, and a focus in consultations on the patient as a person, rather than solely on the disease (Lewin et al., 2001). This may involve shared decision-making to develop a treatment plan, listening to patients’ experience of illness and forming a patient-doctor relationship based on empathy and care.

There is a growing literature arguing for the adoption of patient-centred care in the delivery of health and social care services (e.g. Stewart, 1995; Amey et al., 2006). The inclusion of the patient in the care process is viewed as important for it allows professionals to tailor their care to respond to the different needs of different individuals. As the UK Nursing and Midwifery Council (2002, section 4.2) stated, ‘patients and clients are equal partners in their care and therefore have the right to be involved in the health care team’s decisions’.

More recently, the notion of patient-centred care has come to embrace a collaborative, team-based approach. The focus has expanded to include all health and social care professionals working together, with the patients at the centre, to improve the quality of the services they deliver (e.g. Dean, 2008).

As Herbert (2005, p. 2) has noted:

Collaborative patient-centred practice is designed to promote the active participation of each discipline in patient care. It enhances patient- and family-centred goals and values, provides mechanisms for continuous communication among care givers, optimises staff participation in clinical decision making within and across disciplines, and fosters respect for disciplinary contributions of all professionals.

Box 2.2 offers an example of how in Canada the adoption of collaborative patient-centred practice has been significant in the past few years.

By including patients as part of the team, this approach assumes they can be given the opportunity to increase their knowledge of care. It also provides opportunities for professionals to increase their knowledge of the patient and their individual health and social care needs. In addition, it has been argued that a patient-centred team approach could act as a method of disease prevention (Dean, 2008) and may also allow the patient to recover in a positive environment (Edwards, 2002).

While efforts to advance patient-centred team practice are laudable, there are a number of challenges. For example, in order for patients and their families to play a successful role in an interprofessional team, it is important that both they and their care providers learn how to work within these contexts. Such learning creates an extra burden for both patients and professionals. Also, one needs to be mindful that imbalances of power exist between patients and professionals – traditionally professionals have controlled health and social care interactions. Indeed, there is little evidence to suggest that any systemic transfer of control from professional to patient has in effect occurred.

Shift towards chronic conditions

In the past 25 years we have experienced a shift from acute to chronic illnesses such as arthritis, hypertension and diabetes. This is linked to shifting demographics – people are living longer, and the burden of complex chronic conditions which occur in later life has grown accordingly (Strong et al., 2005; World Health Organization, 2005). For example, in the UK it has been reported that chronic illness affects six in ten adults, but this burden of illness is particularly severe among older people, affecting two-thirds of those aged over 75 – nearly three million people (Office for National Statistics, 2002). In North America it is estimated that the percentage of people aged 65 years and older will double from the current 13% to approximately 25% in the next 20 years (Medical Advisory Secretariat, 2008). Many low- and middle-income countries face a similar situation. By 2030, for instance, it is anticipated that China’s population of people over the age of 65 years will increase from 7 to 16% (National Bureau of Statistics of China, 2009).

The growth of disease from chronic conditions has meant that the acute care models on which most health systems have been based since World War II are no longer seen as the most appropriate way of delivering services. Health and social care professionals, it has been suggested, need to work together to ensure that they can respond to and manage these chronic (and often complex and longterm) illnesses (World Health Organization, 2005). However, this rise in chronic illness does not necessarily mean that policies recommending more interprofessional teamwork and greater integration of services will be implemented. For example, Cott et al. (2008) undertook a qualitative study which explored the relevance of traditional chronic care uniprofessional models in comparison with interprofessional models, and found no evidence for the widespread use of formal collaborative interprofessional teamwork. Typically, professions working in this context preferred traditional uniprofessional models of care delivery.

Media coverage of teamworking

The media – television, radio, newspapers and the internet – are extremely powerful tools in shaping the way that people perceive the world. The media’s role in affecting health and social care policy and in changing the public’s perceptions of care has been regarded as critical (Otten, 1992; Seale, 2003, 2004). Today, the media often provides reports of adverse care due to poor interprofessional teamwork and collaboration. Recent instances of the media reporting such examples include problematic care delivered to cancer patients in the Netherlands, where limited coordination and communication were reported among oncology teams (Dutch News, 2009); and poor interprofessional interactions between nurses and physicians in the US, where a nurse described being belittled by a physician after paging him during the night for a seemingly non-urgent case (Terkin, 2008).

Well-publicised failures of interprofessional collaboration have been at the centre of many health and social care inquiries over the past 25 years, such as the Cleveland child abuse inquiry (Butler-Sloss, 1988) and the Victoria Climbié inquiry (Laming, 2003) in the UK. Furthermore, Kennedy’s (2001) report on the death of babies undergoing heart surgery, also in the UK, found that while surgeons considered themselves as effective team players, this contrasted with the perceptions of their colleagues, from other professions, who saw their approach to teamwork in more problematic terms. Similarly, the Justice St Claire report in Canada found that in the cases of the multiple sentinel events and incidents at the children’s hospital cardiac operating room (OR), nurses reported concerns about a surgeon’s practice were largely ignored as they were perceived as not capable judges of surgical performance (Sinclair, 2000). Indeed, OR nurses’ comments on surgeons’ practice were deemed to be inappropriate as they were outside their scope of practice. Such extreme cases may be rare, and usually linked to systemic failures in which poor interprofessional teamwork contributed in part to the problem, not its entirety.

Rising consumerism within health care

Today patients are (or have the potential to be) more informed about the nature of their health conditions and their care than previously. They and their families can access a wide range of sources – the media, patient organisations, pressure groups and professional organisations – which can provide them with insights into the nature of their illness and their health and care services. Access to a wide range of health care information through the internet (through both specialised care sites and more general information sites such as Wikipedia) has further contributed to the growth in patient awareness of health and social care issues, although the quality of this information is very variable (Eysenbach et al., 2002). Patients are also increasingly encouraged to participate in care through government initiatives such as expert patient programmes (e.g. UK Expert Patients Programme, 2009).

Increasing patient awareness, empowerment and responsibility can be linked to the notion of consumerism in health and social care, as several authors have discussed in relation to the growing centrality of consumerism and patient choice within UK health policies (Newman and Vidler, 2006; Greener, 2009). Changing relationships between consumers and providers may have impacts on interprofessional teamworking. For example, consumers and their carers are being drawn increasingly together in different care teams through programmes such as lay selfmanagement and policy initiatives such as collaborative patient-centred practice (see Box 2.2).

While such developments have appeared to shift attention towards the patient and their family, one needs to consider the actual nature of a patients’ role within health and social care teams. As we noted above, the balance of power between patients and professionals has traditionally favoured the latter. It is still unclear how consumerism may have affected these historical imbalances. Arguably, professionals still hold the dominant position in managing care due to their control of, or central role in, many aspects of this process.

Rising costs of care

Every year the cost of providing health and social care services rises. In some years, expenditure rises slowly, in others, for example, the past decade or so, more rapidly (Ginsburg, 2004). These budgetary increases in cost of care have been an important element in various governments’ interest in interprofessional teamwork. Reorganising services to provide a more coordinated, collaborative, teamoriented approach has been seen as a way of reducing duplication, improving efficiency and effectiveness as well as helping to contain costs (Ingram and Desombre, 1999; McPherson et al., 2001).

Pressures from governments to decrease patient lengths of stay as a way to contain rises in the cost of care within acute inpatient institutions are widespread (e.g. Rice, 1992; Ikegami and Campbell, 2004; Bodenheimer, 2005). With such decreases in inpatient length of stay, the need for effective interprofessional teamwork becomes more pressing. Communication between professionals becomes increasingly important; as patients enter and exit the inpatient care setting more quickly and professionals have less time to communicate with one another. Advances in information technology or IT (see below) have the capacity to help with communication especially when more than one team is involved in patient care. For example, electronic medical record systems allow each team member to have quick access to up-to-date patient information and are being implemented rapidly into health systems in a range of settings, although evidence regarding efficiency gains remains weak (Poissant et al., 2005).

While some studies have indicated that interprofessional teamwork can help reduce costs (e.g. Zwarenstein et al., 2009), the quality and quantity of this evidence are still rather limited. For example, at the time of writing we could not find a review on cost-effectiveness of using interprofessional teamwork to deliver care. As we go on to note (see Chapter 7), a good deal of the evidence on teamwork rests upon members’ perceptions of their own collaborative performances.

A focus on rural care

Often overshadowed by the complexities of urban care, the needs of rural communities have increasingly come in focus in the past decade (e.g. Australian Institute of Health and Welfare, 2008). This focus is timely given that, for instance, the US Department of Health and Human Services (2003) has estimated that 20 million of a potential 70 million rural Americans have inadequate access to health care. In addition, as the Institute of Medicine (2004a) points out, rural communities represent nearly 20% of the US population and, like urban counterparts, they are rich in cultural diversity. However, delivering care in rural communities, in high, lowand middle-income country settings, presents a number of challenges. Providing coordinated care to large geographically remote areas is particularly difficult, as is recruiting and retaining health and social professionals to work in these regions (Chopra et al., 2008; Grobler et al., 2009).

Interprofessional teamwork in rural communities also faces a number of challenges. Typically, team members need to work across large areas which means opportunities for interactions are restricted. In addition, shortages of professionals based in these regions may mean that they need to work outside of their own professional boundaries to deliver the services of their colleagues who may only visit periodically (Blue and Fitzgerald, 2002). In addition, due to the absence of physicians in many rural settings, physician assistants and nurse practitioners often have an expanded role in providing care (Hooker and McCaig, 2001). While this helps to ensure better access to care, possible tensions with professional role overlap have been reported (e.g. Booth and Hewison, 2002). These elements are examined in more depth in Chapters 4 and 5.

Professional associations

A professional association (sometimes called a professional body or society) is an organisation whose aim is to further the interests of its members. Professional associations such as the UK Royal College of Nursing, the Danish Medical Association and the American Physical Therapy Association are involved in the development and monitoring of professional education programmes, updating skills, regulating entry and maintaining professional standards. They are therefore central in the certification process which allows individual professionals to practice.

As previously noted, professional associations representing the spectrum of the health and social care professions have been calling increasingly for their members to be prepared to work effectively in interprofessional teams. For example, in the UK, the Nursing and Midwifery Council (2002) stated in its Code of Professional Conduct that qualified nurses and midwives:

Are expected to work co-operatively within teams and to respect the skills, expertise and contributions of your colleagues. (section 4.2)

Similar statements can be found in the documents of professional regulatory bodies for other professions, such as physicians (General Medical Council, 2001), occupational therapists (College of Occupational Therapists, 2000) and social workers (International Federation of Social Workers, 2009). In the US, for example, the Accreditation Council for Graduate Medical Education (ACGME) revised the lists of competencies for physicians to include aspects of interprofessional coordination and collaboration (ACGME, 2007).

While professional regulatory bodies have a central role in promoting teamwork in their published documentation, it is unclear how effectively their policy statements are being implemented. As we discuss later in the book, these associations play a role in protecting and advancing their members’ social, economic and political interests. As a result, there seems to be a contradiction in their demands for interprofessional teamwork, on the one hand, and the representation of their members’ profession-specific interests, on the other.

Teamwork funding

Another key driver for the growth of interprofessional teamwork has been the funding provided nationally and regionally by governments across the globe to design, implement and evaluate a range of different interprofessional team-based programmes, courses, initiatives and interventions. In the UK, for example, in the past few years the Department of Health has funded a number of team-based initiatives (see Box 2.3).

Also, as noted in Box 2.2 (see above), Health Canada has provided substantial funding, through its Interprofessional Education for Collaborative Patient-Centred Practice initiative, to establish a wide variety of interprofessional initiatives across the country. In other settings, including Australia, Brazil and South Africa, both public and private funding sources have also supported the development of interprofessional teamwork.