Going it alone is no longer always a feasible option for GPs, but there may be an alternative.
With the push for more care to be delivered outside of hospitals and within the community, there is increasing pressure on GPs to have primary responsibility for diagnosis, navigating referrals and treatment. They are the gateway, and sometimes gatekeeper, between specialist services and the community, bearing the burden of orchestrating increasingly complex care.
Despite recognition of the benefits associated with greater interprofessional collaboration between primary care professionals, including GPs, specialists, pharmacists, allied health and mental health services, the understanding of how that can be achieved is limited.
GPs often rely on their professional networks to identify relevant services and practitioners for referral and to provide care. Recognising this gap, the Organisation for Economic Cooperation and Development (OECD) has identified Australia as having one of the least integrated health care systems in the world, which in effect burdens GPs with building bridges between heavily siloed services. Factor in the escalating workload brought about by half of all Australians living with more than one chronic health condition, growing mental health concerns, an ageing population and care models shifting into community, and GPs are facing significant pressure and responsibility.
One as yet largely untapped area of support for GPs lies in the exploration of collective leadership.
Collective leadership is an evidence-based model for creating shared responsibility for leadership among professional teams. In the health care context, this could mean building a team that includes the GP or GP practice, as well as other practitioners and the patient, who take shared responsibility for leading the care process. With an emphasis on collective responsibility for the process of care, this model alleviates the pressure on one individual practitioner, but may also better support patients and their families to have greater involvement in driving their health care.
Put simply, in the collective leadership model, multiple parties come together to take forward a care process where, at any point in time, one party can take the lead. That lead can change without any loss of momentum or detriment in the patient’s health care journey.
A GP could draw on the collective leadership model to methodically guide the development of a highly skilled professional team that works with a patient to provide care that responds to their needs. Rather than the GP being the leader, that role would be shared collectively in a transparent way, for example through a shared plan for the care process. Sharing the leadership of care in this way may facilitate better sharing of information and responsibility for decisions made, thus alleviating the burden of responsibility felt by many GPs for decision making and care.
While sharing a similar ethos to the integrated care model (ie, orchestrating a smooth journey for the patient through the fragmented health system), rather than the leadership responsibility resting with one player, usually the GP or the parent of a child with complex needs, a collective leadership model seeks to ensure that responsibility is shared and that those navigating health care, particularly as consumers, are supported.
How might this look in practice?
An individual may have a diagnosed mental health condition for which they receive ongoing support from a range of health and social care practitioners. They come to their GP with concerns about the side effects of a current medication and the implications for their work function. They would like more information about the alternatives in order to make an informed decision. With a collective leadership model in place, the GP could turn to other professionals, such as the community mental health care team and local pharmacist who are already familiar with the patient. Together, this team, including the patient, decide that the pharmacist is best placed to lead discussions with the patient to explore their concerns and the implications of a new medication. The community mental health team will then support the decision-making process with reference to the patient’s broader context. Ultimately, the patient will lead the decision making to reach a final outcome, supported by the information and guidance of their highly collaborative care team.
Collective leadership models have proven useful in many contexts such as education and business. They are less well used in the health care context but are identified as highly relevant with great potential. Our systematic review of the literature around the use of collective leadership interventions identified studies in acute care inpatient settings in several countries and was published as a Cochrane review. We found that collective leadership interventions were likely to improve the leadership of care and team performance. As a relatively new approach in health care, limited evidence of the impact of collective leadership models on clinical interventions and patient outcomes was established and the relationship is less clear. We did find a positive impact on staff wellbeing including reduced work-related stress.
So, while an inpatient setting differs from a community setting, we can see potential for collective leadership models to improve the wellbeing of staff and leadership of health care processes in the context of general practice in which multiple practitioners are involved.
The potential for collective leadership to support patient-driven health care is supported by qualitative research in which relationships between patients, families and health care professionals were renegotiated to balance responsibility, leading to a higher level of trust, mutual respect and understanding of roles.
In a recent review of interprofessional collaboration between community pharmacists and GPs, we further identified several strategies to promote success for those seeking to engage in collective leadership:
- professionals being co-located;
- creating mutually agreed shared care plans;
- demonstrating strong understanding of each profession and its scope of work.
Other research supports the view that to create successful co-leadership, those engaged need to be open to learning from one another, to trust and provide mentorship to one another. Face-to-face rather than technology-led meetings may also be more effective in fostering interprofessional relationships.
As with other sectors exploring the implementation of collective leadership models, health care faces several barriers, including addressing the differing administrative, governance and financial requirements between health professions and services. For instance, how do practitioners share the cost of collectively, collaboratively and compassionately caring for a patient? Under the current funding models in the Australian health system, this is unclear.
GPs have traditionally held the responsibility for navigating access through the siloed care required for their patients. Yet with the increasing patient volume, system complexity, comorbidities and chronic illness, a more robust framework is needed to support GPs and offer patients an opportunity to direct their care. With the required structures and funding model, the collective leadership approach could deliver that support.
Associate Professor Reema Harrison is from the Centre for Health Systems and Safety Research, at the Australian Institute of Health Innovation.
This article was originally published at MJA Insight+.
