Tag Archives: Cat Roberts

Integration and true collaboration to develop primary care

Cat Roberts is Clinical Lead GP involved in developing and delivering primary care services within an acute trust, including a GP-led frailty service

You can read Cat’s first post: Challenging the norm: GPs as innovators here.

I vividly remember one of my first consultations as a general practice registrar. The patient had a list of complex problems and I did not have the skillset to deal with the multitude of issues or her expectations. The consultation became strained, and as she pressed me for answers and solutions I became more defensive. The defensiveness manifested itself in the use of medical jargon, hiding behind guidelines and explaining resource limitations.  This was a subconscious attempt to assert authority and establish a clear balance of power. It ended rather comically with me leaving the room as I was fearful she never would.  My supervisor emerged from his room, looked over the top of his glasses and inquired:
“Is everything OK?”
“I don’t know how to make her leave my room…”
“Why is she still there?”
“Because I haven’t helped her.”
I perceived she wanted an answer, and whilst trying to find an answer I had stopped listening.  All empathy and rapport had left the room. I returned to the room with some new questions which were able to facilitate meaningful conversation.

These are all symptoms of a floundering relationship and a dynamic that makes sharing management a challenge.


Why did that all go wrong?
Is it possible that this dynamic exists on a larger scale with our colleagues in secondary care, community care and social care? With limited resources and time we may become defensive and confrontational towards one another; too quick to assign blame, judging each other’s skillset and capacity. Do we subconsciously imply a balance of power in the wording of a discharge letter, when referring a patient to a bed manager, or in our tone in a referral form?  Are we creating boundaries, relinquishing responsibility, being fearful of blame? Are we angered by perceived unfair allocation of time and resources? These are all symptoms of a floundering relationship and a dynamic that makes sharing management a challenge.

Tell me about yourself
One of the six principles of our Integrated Frailty Service is Culture and Education. We host joint educational events on topics relevant to frailty and multi-disciplinary team members frequently present. GPs run sessions on managing uncertainty and other strategies that are intrinsic to consultations in primary care. Hospital clinicians present the latest evidence based practice, reawakening our love of clinical medicine and allowing us to cast our net of differential diagnoses wider. These sessions are attended by both clinicians and non-clinicians so we request that anyone attending avoids jargon and tailors content appropriately. Rapport between clinical directorates and across providers is restored, stories are exchanged and challenges are viewed from all perspectives. Myths and misunderstandings surface and are addressed and a true empathy of each other’s skills and constraints develops. This principle, despite being impossible to quantify in data and Key Performance Indicators, has the most tangible benefit and has the biggest impact on patient care.

Both camps are fearful of change, repercussions, impact on patient care and sustainability.


Maybe we both want to achieve the same thing?
Another core principle of our service is Integration. This broad term refers in part to practical challenges such as shared electronic records, imbedding the service within the directorates of the Trust and helping align community services to best respond to patient needs. It also underpins another vital relationship needing bolstering – that of the clinician and the non-clinical manager. Sometimes frustration, exasperation and being overwhelmed by a problem can manifest as apathy, indifference and a reluctance to engage with any system improvement drives. Both camps are fearful of change, repercussions, impact on patient care and sustainability. Perceptions are sometimes tainted by behaviours and the balance of power fluxes between clinicians and managers. The result can be systems which are fragmented, dysfunctional and hinder clinical care and positive patient experiences. The potential gains in true collaboration and understanding result in seamless transitions of care for patients – with experts in clinical care optimising their time and skills, and experts in strategy and operations facilitating this change.

The consultation no longer feels overwhelming or hopeless.  We may have reached a middle ground in terms of mutual understanding and empathy. The complex problems still exist but the management is starting to feel shared.

Read Cat’s last blog: Challenging the norm: GP as innovators

Challenging the norm: GP as innovators

Cat Roberts is Clinical Lead GP involved in developing and delivering primary care services within an acute trust, including a GP-led frailty service

Following a few years of basking in the ‘delicious ambiguity of general practice we returned to the hospital wards to try to fully understand patient care pathways. Any doctor studying for membership exams will describe how the second learning cycle is so much more meaningful when digested with a wealth of clinical experience – the same is true of returning to secondary care having worked in primary care. We were stepping from a land of hypothesis into a land of diagnosis, from a world where uncertainty is used as a tool to a world where much is done to eliminate ambiguity.

The aspiration was to create a service for frail older patients. The pilot funding had been secured and we had a year in which to create a service of value. Would there be a role for GPs to work alongside gerontologists to create a Frailty Unit for these patients, focussing on key generalist principles – a holistic Comprehensive Geriatric Assessment, avoidance of over-medicalisation and aligning primary care, community services, social services and voluntary sector to facilitate this pathway?

We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.

The challenges that presented themselves were not clinical, in fact the familiarity of vague symptoms sets and unusual health beliefs in patients provided an anchor in a strange land. The challenges were operational, practical and political. We needed to learn another language – ‘management’ in order to communicate our understanding and to understand the ideas, concerns and expectations of managers.  In working with healthcare managers, we had to develop a new version of a shared management plan and understand each other’s agendas to improve concordance and collaboration. This was a GP consultation on a larger scale, held in an unfamiliar language, with different cultural backgrounds and with intrusive time constraint

In order to design a service for frail older patients you need to ask some fairly controversial and challenging questions of all providers, including familiar questions such as:

  • When is discharge safe?
  • When is it safe to stop a medication?
  • What if I miss something by not investigating?

However, some of the most useful questions include those not routinely asked such as:

  • When is admission safe?
  • When is it safe to start a medication?
  • What am I hoping to achieve in investigating?

Pressures, processes and clinician behaviour often means these questions do not have time to be asked, let alone answered.  And can you ask these questions unless you fully understand the alternatives?  GPs have all trained in secondary care however not all secondary care clinicians have had the opportunity to spend time in primary care – it is challenging to place trust in a system that you don’t fully understand, especially if your perception has been altered by examples of when that system has not worked well for your patients.

GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions.

So, our focus and first step was to start to develop mutual understanding with our secondary care colleagues, because those questions can only be asked and truly shared when they are perceived as a shared challenge. To start to gently challenge systems and behaviours was a fragile and privileged journey that required small tentative steps and open and constructive dialogue.

Over the course of a few blogs we would like to take you on this journey with us, to share our experiences, to explain the organic evolution of our service principles and structure, to reaffirm the notion that clinician-led service design and development can work, to celebrate in our successes and ask for your guidance with our challenges. GPs will always be scholars – they are puzzle solvers, they delight in ambiguity and they will always seek to liberate themselves from conventions and assumptions. These skills are not confined to clinical medicine.