A framework to support team-based models of primary care within the Australian health care system

Interprofessional education and learning (IPEL) is recognised internationally as a building block to help primary care professionals work more effectively in team-based care.7,9,11-15 IPEL initiatives enable acquisition of knowledge and skills and have been well received. Limited evidence exists that IPEL can enhance practice, improve service delivery and make positive impacts on care. IPEL still suffers from lack of definitional clarity; variable content, duration, and professional participation; and variable evaluative studies.11

The recent release of core sets of IPEL competencies16 in the United States and Canada will add rigour and clarity to IPEL.

Nine key ingredients of successful IPEL initiatives include: recognising that one size does not fit all; adequate and dedicated resourcing; curricula development across universities and the community; introduction at the right time; creation of collaborative learning environments; modification of structures to support collaboration; embedding IPEL in the system; making a case for IPEL based on the evidence; and interprofessional participants engaging the community.7

Evidence from experience with primary care groups and primary care trusts in the United Kingdom, primary health organisations in New Zealand and family health teams and family health networks in Canada strongly suggests that regional-level primary care organisational structures, policies and systems can enable and support team-based models of primary care through financial, governance and institutional support mechanisms.17-19 However, it is also known that funding, organisational and regulatory arrangements need to align to support such organisational structures.12

We have chosen to describe two of the most current and relevant practice support systems within primary care that demonstrate the interrelatedness of health system innovations within care delivery, workforce systems, records management, and payment systems.

Outcomes of implementing team-based models are also influenced by the type and level of team leadership (particularly collaborative or distributed leadership styles); team composition, including skill mix, knowledge and experience; the extent to which members have shared objectives, communicate, make decisions jointly, support innovation and review working progress; the extent to which funding arrangements reward teamwork; and to what degree regulatory mechanisms support, value or reward teamwork.10

There is wide recognition that interventions fail or succeed depending on the appropriateness or validity of the theory or assumption on which they are based. Multiple theoretical perspectives (eg, sociological, organisational, systems) exist about interprofessional working relationships that can inform support for team-based models of care. We discuss here the potential of an organisational (ie, relational coordination) and a system (ie, complex adaptive system) theoretical framework that may provide a way forward to use the evidence base to develop, implement and evaluate team-based models of primary care.

For over a decade, primary care has been described as a complex adaptive system (CAS).25 “Complex” implies diversity; “adaptive” suggests capacity to change and ability to learn from experience; “system” recognises that primary care is comprised of a set of multiple interconnected or interdependent agents acting with common purpose with dynamic environments. More recently within the public health setting, the term “fifth wave”26 has been used to rebalance and reorient our mindsets, our models and our learning processes in response to challenges facing public health. A CAS requires facilitative leadership, high-quality relationships, and feedback in reciprocal interactions to increase the capacity for collective, creative problem solving. A CAS can provide a framework for sharing common sets of concepts and principles, common language and a common approach that facilitates team-based approaches among primary care professionals.

Based on the argument that coordination is the management of task interdependence, and is therefore fundamentally relational,27 we need to understand the importance of relationships in coordinating team-based work. According to the theory of relational coordination, coordination that occurs through frequent, timely and problem-solving communication supported by shared goals, shared knowledge and mutual respect will better achieve the desired outcomes. The “relational coordination” lens can provide a theoretical framework for team-based models of primary care.

There is also wide recognition that interventions may fail or succeed when implementation or the “how to” has not had sufficient attention. This is often a frustration of the change agents involved (who may be health professionals, service managers, or a range of other “key players”). A multitude of factors can influence (enable or constrain) the capacity of the system to support team-based models of primary care. At the individual level these can include role delineation, skill sets, competencies, and personality attributes. At the organisational level these can include culture, structure, leadership, contractual arrangements and time frame. At the systems level these can include, for example, policy context, sector policy know-how, workforce pressures and funding pressures. To build the capacity of the system to support team-based models of primary care, a capacity-building lens focusing on three operational capacity-building dimensions is required: individual-level workforce skills and competencies; organisational-level leadership and interactions; and system-level infrastructure — to provide a transparent and systematic approach to ensuring key ingredients of successful team-based models are implemented as intended.

Preparing and supporting the primary care workforce to work in team-based models requires adequate and dedicated infrastructure and resourcing. An existing framework that articulates the type and level of infrastructure and resources required is the WHO framework for action on interprofessional education and collaborative practice.28 The WHO framework identifies three mechanisms that can provide a framework to ensure that the multifaceted and multidimensional resources that support team-based models of primary care are implemented as intended:

• institutional support mechanisms — eg, governance models, structural protocols, shared operating resources, personal policies and supportive management practices;

• working culture mechanisms — eg, communication strategies, conflict resolution policies and shared decision-making processes; and

• environmental mechanisms — eg, built environment, facilities and space design.

Policymakers, professionals and communities face challenges in sustaining worthwhile innovations, especially in primary care. Internationally and within Australia, multiple reviews of factors that promote or constrain sustainability of interventions within the system have been conducted. Endeavours to expand knowledge about sustainability have been labelled “sustainability science”,29 which is underpinned by the concept of “ecosystem”. This recognises that the organisation and interaction of the components of the system are as important as the system itself. Gruen and colleagues conducted a systematic review of conceptual frameworks and empirical studies about sustainability29 and developed a unifying model based on the “ecosystem” lens. The model proposes that sustainability of interventions within systems is influenced by the interaction and alignment between three key components: the health concerns of the population, the intervention elements, and the drivers (positive and negative) of the intervention. It can be used to determine the potential sustainability of interventions designed to support team-based models of primary care.

There is clearly a lack of evidence regarding the implementation and impact of team-based models of primary care to inform what works, for whom and in what circumstances. A review of incentives for primary health care team service provision10 recommended, on the basis of limited evaluative evidence, that a key priority was to develop teamwork-focused evaluative tools and indicator sets. The review also suggested that investment was required in reviewing existing (international and Australian) teamwork-related, evidence-based, evaluative inventories, tools and methods for use in the Australian setting, as well as in developing and piloting a set of process and summative teamwork-evaluation indicators (at patient, provider, organisational, and systems levels) for use in the Australian setting. Since then, a systematic review of instruments used to assess teamwork has been conducted28 that further emphasises recommendations supporting team-based service provision.10 Another review of instruments to measure teamwork30 found that very few existing measures demonstrated psychometric properties recommended for use, and that there was inconsistency in conceptualisations of teamwork. A key recommendation was that more research be undertaken to aid in developing and refining measures of teamwork for reliable use by researchers and practitioners or managers. Overall, there is a need for an integrated evaluation strategy focusing on interprofessional, organisational, and practice support strategies for team-based models of primary care.