The Effectiveness of Health Care Teams in the National Health Service

The Effectiveness of Health Care Teams 

in the National Health Service 

Report 

Carol S. Borrill, Jean Carletta, 

Angela J. Carter, Jeremy F. Dawson, Simon Garrod, 

Anne Rees, Ann Richards, 

David Shapiro and Michael A. West 

Aston Centre for Health Service Organization Research, 

Aston Business School, University of Aston 

Human Communications Research Centre, 

Universities of Glasgow and Edinburgh 

Psychological Therapies Research Centre, University of Leeds

Contents 

______________________________________________ 

__ 

Key Findings 

Acknowledgements 

Health Care Team Effectiveness Project: Summary 

Chapter 1 Teamwork, Communication and 

Effectiveness in Health Care: A Review Page 1 

Chapter 2 Primary Health Care Team 

Research Methods and Sample Details Page 25 

Chapter 3 Primary Health Care Team Results from Survey 

and External Ratings Page 44 

Chapter 4 Qualitative Research: Developing Objectives and 

Effectiveness Measures for Primary Health Care Teams Page 57 

Chapter 5 Community Mental Health Teams 



Results from Survey and External Ratings Page 103 


Results from Qualitative Research Page 121 

Chapter 8 Secondary Health Care Teams 


Chapter 9 Secondary Care Teams Ratings Page 157 

Chapter 10 Meetings and Communication 

Research Methods Page 172 

Chapter 11 Analysis of Communication in PHCT Teams Page 182 

Chapter 12 Analysis of Communication in CHMT's Page 197 

Chapter 13 Conclusions and Recommendations Page 215 

Appendix I Survey Instruments/Rating Measures/Interview Schedules

Appendix II Knowing the way: Effectiveness in Primary Health Care 

Appendix III Developing Effectiveness Measures for Primary Health Care Teams 

Appendix IV Training Programme – Tools and Techniques for Assessing 

Performance 

Bibliography

Acknowledgements 

________________________________________________________ 

Liaison Officers: Liz Meerabeau 

Sue Longsdate 

John Wilkinson 

Advisory Group Members: Debbie Mellors 

NHS Executive 

Research Team: 

Sarah Connors 

NHS Executive 

Jim Ford 

NHS Executive 

Bonnie Sibbald 

NHS Executive 

Eileen Robertson 

NHS Executive 

Sheila Roberts 

Department of Health 

Terry Breugha 

University of Leicester 

Anne Netton 

University of Kent 

Thelma Sackman 

NHS Executive 

Dr Carol Borrill January 1997 - December 1999 

Aston Business School 

Aston University 

Birmingham 

Sam Bedlingham June 1997 - December 1999 

City University 

London 

Jean Carletta January 1997 - December 1999 

Human Communication 

Research Centre 

Edinburgh

Christine Carmichael June 1997 - February 1998 

Institute of Work Psychology 

Sheffield University 

Sheffield 

Angela Carter January 1998 - December 1999 



Sheffield 

Jeremy Dawson July 1999 - December 1999 




Simon Garrod January 1997 - December 1999 

Human Communications Research Centre 

Glasgow University 

Glasgow 

Heidi Frazer-Krauss January 1997 - June 1997 

Medical School 

Glasgow University 

Glasgow 

Anne Rees January 1997 - June 1997 

Psychological Therapies Research Centre 

Leeds University 

Leeds 

Anne Richards January 1997 - December 1999 



Leeds 

Carein Todd April 1997 - May 1998 



Sheffield 

David Shapiro April 1997 - May 1998 



Leeds 

Michael West January 1997 - December 1999 




David Woods January 1998 - June 1999 


Sheffield University

______________________________________________ 

Summary 

______________________________________________ 

________ 

A primary prescription that policy makers and practitioners have offered for meeting 

the challenges facing the National Health Service is the development of 

multidisciplinary team working. The importance of team working in health care has 

been emphasised in numerous reports and policy documents on the National Health 

Service. One particularly emphasised the importance of team working if health and 

social care for people are to be of the highest quality and efficiency: 

"The best and most cost-effective outcomes for patients and clients are 

achieved when professionals work together, learn together, engage in clinical 

audit of outcomes together, and generate innovation to ensure progress in 

practice and service." 

Over the last thirty years this has proved very difficult to achieve in practice because 

of the barriers between professional groupings such as doctors and nurses. Other 

factors such as gender issues also influence team working. For example, G.P.s are 

predominantly men while the rest of the primary care service population is 

predominantly women; community mental health psychiatrists are predominantly 

men, whereas the rest of the population of community mental health teams is 

predominantly women, and in hospital settings the ranks of consultants continue to 

be largely made up of men. Other factors which impede the creation of effective 

multidisciplinary teams include multiple lines of management, perceived status 

differentials between different professional groups, and lack of organisational 

systems and structures for supporting and managing teams. 

The Health Care Team Effectiveness Project was commissioned by the Department 

of Health. The overall aim of the research described here was to determine whether 

and how multidisciplinary team working contributes to quality, efficiency and 

innovation in health care in the NHS.

The objectives of the research were to establish: 

• which team member characteristics such as age, gender, occupational group, 

experience, qualifications, and team size, influence how well the teams work 

together; 

• how team working processes, such as participation, reflexivity, communication, 

decision-making and leadership contribute to the effectiveness of teams, 

particularly the quality of health care and the development of innovative practice; 

The research programme was carried out over a three year period by a team of 

researchers based at the universities of Aston, Edinburgh, Glasgow, Leeds and 

Sheffield. During the course of the study information on team working was gathered 

from some 400 health care teams. This involved consulting over 7,000 NHS 

personnel and a large number of NHS clients. Five national workshops were held 

with key representatives from primary health care and community health care. A wide 

range of research methods was used, including questionnaire surveys, telephone 

interviews, in-depth interviews, observation, focus groups and video and audio tape 

recordings of meetings 

The research was carried out in two stages: quantitative data collection from 100 

primary health care teams (PHCTs), 113 community health care teams (CMHTs) and 

193 secondary health care teams (SHCTs), and in-depth work with a sub-sample of 

teams. 

Key findings 

Effectiveness 

Quality of teamworking is powerfully related to effectiveness of health care teams: 

� The clearer the team's objectives 

� The higher the level of participation in the team 

� The higher the level of commitment to quality 

� The higher the level of support of innovation 

…. the more effective are health care teams across virtually all domains of 

functioning

Innovation 

Quality of teamworking is powerfully related to innovation of health care teams: 

• The clearer the team's objectives 

• The higher the level of participation in the team 

• The higher the level of commitment to quality 

• The higher the level of support of innovation 

….. the more innovative are health care teams across virtually all domains of 

functioning 

Mental Health 

Those working in teams have much better mental health than those working in looser 

groups or working individually. The benefits appear to be due to: 

• Greater role clarity 

• Better peer support 

Those working in teams are also buffered from the negative effects of organizational 

climate and conflict. 

The better the functioning of team with respect to… 

• Clarity of objectives 

• Levels of participation 

• Commitment to quality 

• Support for innovation 

… the better the mental health of team members across all domains of health care. 

Organisational performance 

There is a significant and negative relationship between the percentage of staff 

working in teams and the mortality in these hospitals, taking account of both local 

health needs and hospital size. Where more employees work in teams the death 

rate is significantly lower (calculated on the basis of the Sunday Times Mortality

Index, Dr Foster; deaths within 30 days of emergency surgery and deaths after 

admission for hip fracture) 1 . 

Retention and turnover 

Within health care, those working in well functioning teams are more likely to stay 

working in their settings than those working in poorly functioning teams. 

Leadership 

In Community Mental Health and Primary Health Care, where there is no clear 

leader/co-ordinator or where there is conflict over leadership team objectives are 

unclear, and there are…. 

� Low levels of participation 

� Low commitment to quality 

� Low support for innovation 

� Poor team member mental health 

� Low levels of effectiveness and innovation 

Communication 

Communication, integration and regular meetings in PHC and CMC health care 

teams are associated with higher levels of effectiveness and innovation, yet the 

quality of meetings (particularly in Primary Health Care) is often poor. 

Professional diversity 

Diversity of professional groups in Primary Health Care is clearly linked to levels of 

team innovation. In newly formed Community Mental Health Teams, this relationship 

does not appear. The same findings emerged from research carried out with 85 

breast cancer care teams 2 . 

1 This finding is based on research recently completed by the research team at the Aston Centre for 

Health Services Organisation Research (further details available from West or Borrill). 

2 This finding is based on research recently completed by the research team at the Aston Centre for 

Health Services Organisational Research (further details available from West or Borrill).

Conclusions 

• Systematic and revolutionary organizational change is necessary if the positive 

results of this research are to be implemented in practice. 

• NHS organizations have to developed as team-based, rather than hierarchical. 

• Structure, culture, work design, HRM and management have to accommodate 

and enable rather than impede team-based working. 

• NHS employees should be trained in the KSAs for working in teams. 

• NHS managers should be trained to manage team-based organizations.

Chapter 1 

Teamwork, Communication and Effectiveness in Health 

Care: 

A Review 

The challenges of organising health care in the modern United Kingdom context are 

considerable. There are continual improvements in medical technologies, greater 

levels of knowledge and awareness amongst patient populations and increasing 

demands for the variety of sources of health care available within the National Health 

Service. The provision of free health care at the point of delivery to the population 

has become one of the most important issues in the national political agenda in the 

early part of the twenty-first century. At the same time the National Health Service 

has become a massively complex institution characterised by large organisations, 

repeated restructurings, and subject to a wide range of political and economic 

pressures. The response of the government has been to promise a huge increase in 

spending on the NHS; a key question to be answered in relation to this political 

agenda is how can we organise health care and achieve good, fair and cost effective 

services for the whole population. This report focuses on determining whether, and if 

so, how teamworking can help. 

In this first chapter we review the research evidence about the potential benefits of 

teamworking and the factors that influence the effectiveness of teams, focusing 

particularly upon their use in health care settings. We draw on empirical evidence 

from research conducted in the United Kingdom, mainland Europe, North America 

and Australia. The literature on team composition and the processes which influence 

team performance is briefly reviewed with particular emphasis on communication, 

decision-making and problem-solving. We then explore the influences of 

organisational context and leadership, before presenting the theoretical model which 

guided the research programme described in this report. 

First we consider what a ‘team’ means. The activity of a group of people working 

co-operatively to achieve shared goals is basic to our species (Baumeister & Leary, 

1995). The current enthusiasm for teamworking in health care reflects a deeper,

perhaps unconscious, recognition that this way of working offers the promise of 

greater progress than can be achieved through individual endeavour. Mohrman, 

Cohen, and Mohrman (1995) define a team as: 

“a group of individuals who work together to produce products or deliver 

services for which they are mutually accountable. Team members share 

goals and are mutually held accountable for meeting them, they are 

interdependent in their accomplishment, and they affect the results 

through their interactions with one another. Because the team is held 

collectively accountable, the work of integrating with one another is 

included among the responsibilities of each member". 

Benefits of teamwork 

The belief that teamwork is the most effective way of delivering products and 

services has gained increasing ascendancy within diverse organisational settings 

(Guzzo & Shea, 1992; West, 1996). As organisations have grown in size and 

become structurally more complex, the need for teams of people to work together in 

co-ordinated ways to achieve objectives that contribute to the overall aims of 

organisations has become increasingly urgent. Mohrman et al. (1995) offer ten 

reasons for implementing team-based working in organisations: 

• Teams are the best way to enact the strategy of organisations, because of the 

need for consistency between organisational environment, strategy and design 

(Galbraith, Lawler, & Associates, 1993). 

• Teams enable organisations to speedily develop and deliver services cost 

effectively, while retaining high quality. 

• Teams enable organisations to learn (and retain learning) more effectively 

(Senge, 1990). 

• Cross-functional teams promote improved quality of services (Deming, 1986; 

Juran, 1989). 

• Cross-functional teams can undertake effective process re-engineering 

(Davenport, 1993). 

• Time is saved if activities, formerly performed sequentially by individuals, can be 

performed concurrently by people working in teams (Myer, 1993). 

• Innovation is promoted within team-based organisations because of cross- 

fertilisation of ideas (Senge, 1990; West & Pillinger, 1995).

• Flat organisations can be monitored, co-ordinated and directed more effectively if 

the functional unit is the team rather than the individual (Galbraith, 1993, 1994). 

• As organisations have grown more complex, so too have their information 

processing requirements; teams can integrate and link in ways individuals cannot 

(Lawrence and Lorsch, 1969, Galbraith, 1993, 1994). 

This approach to the delivery of services and products is not simply a managerial fad, 

since there is substantial empirical evidence that the introduction of teamwork can 

lead to increased effectiveness in the delivery of both quantity and quality of goods or 

services (Guzzo & Shea, 1992; Weldon & Weingart, 1993). 

Macy and lzumi (1993) conducted an analysis of 131 organisational change studies 

in order to determine their effectiveness. Those interventions with the greatest 

effects on organisational performance and 'the bottom-line' were team-related 

interventions. They also reduced turnover and absenteeism more than did other 

interventions, showing that team oriented practices can have broad positive effects in 

organisations. Other research by Kahleberg & Moody (1994), who studied over 700 

work establishments, found that those in which teamwork was developed were more 

effective in their performance than those in which teams were not used. Finally, 

Applebaum and Batt (1994) offer similar evidence. They reviewed the results of a 

dozen surveys of organisational practices, as well as 185 case studies of innovative 

management practices. They too found compelling evidence that teams contribute 

to improved organisational effectiveness, particularly increasing efficiency and 

quality. 

Teamwork in health care 

The importance of teamworking in health care has been emphasised in numerous 

reports and policy documents on the National Health Service (NHS). One (NHSME, 

1993) particularly emphasised the importance of teamworking if health and social 

care for people were to be of the highest quality and efficiency: 

"The best and most cost-effective outcomes for patients and clients are 

achieved when professionals work together, learn together, engage in 

clinical audit of outcomes together, and generate innovation to ensure 

progress in practice and service."

Some limited research has suggested the positive effects of multidisciplinary 

teamworking in health care. However, there are many difficulties inherent in 

comparing evaluation studies, which include teams having different objectives and 

organisation patterns, studies variously controlling for other concurrent changes in 

local services and the pre-existing variations in services and cultures (Jackson, 

Gater, Goldberg, Tantam, Loftus & Taylor, 1993). 

In terms of the delivery of care, teams have been reported to reduce hospitalisation 

time and costs, improve service provision, enhance patient satisfaction, staff 

motivation and team innovation. We review the literature relevant to each of these 

outcomes below. 

Reduced hospitalisation and costs 

Sommers and colleagues (2000) compared primary health care teams with physician 

care across 18 private practices, and concluded that primary health care teams 

lowered hospitalisation rates and reduced physician visits while maintaining function 

for elderly patients with chronic illness and functional deficits. Significant cost savings 

were born from reduced hospitalisation, which more than accounted for the costs of 

setting up the team and making regular home visits. Jones (1992) also reported that 

families who received primary health team care had fewer hospitalisations, fewer 

operations, less physician visits for illness and more physician visits for health 

supervision than control families. A similar pattern emerged for terminally ill patients, 

where their increased utilisation of home care services more than offset savings in 

hospital costs, such that there were average savings of 18% in hospital costs 

(Hughes, Cummings, Weaver, Manheim, Brown & Conrad, 1992). 

In another study in the U.S., Eggert and colleagues (1991) concluded that a team 

focussed case management system generated similar benefits for elderly, chronically 

ill patients. The team approach reduced total health care expenditures by 13.6%, 

when compared to an individualised case management system. The team combined 

earlier discharge, more timely nursing home placement and better-organised home 

support and care, to reduce patient hospitalisation by 26%. Similarly, the cost 

increases in ambulatory and nursing home care were offset by fewer and shorter stay 

hospital admissions and reduced home care utilisation. For patients with dementia in 

this study, the team model of case management reduced overall costs even further, 

by 41% (Zimmer, Eggert & Chiverton, 1990). At the end of the 27-month study, there 

were more team than control patients living at home and fewer in nursing homes. An

audit of the case managers' records highlighted more intense management activity in 

the team group, where patients were referred more frequently for medical evaluation, 

respite and day care. Team case managers had smaller caseloads, made more 

home visits and had more case conferences. Teams were more familiar with local 

community resources and were reported as being more responsive to patient crises. 

The team approach was reported to offer greater intensity of case management, 

which resulted in more efficient care provision in hospitals and home health services. 

Improved service provision 

Primary care teams appear to produce better detection, treatment, follow-up and 

outcome in hypertension (Adorian, Silverberg, Tomer & Wamosher, 1990). 

Specifically, nurses in England reported that working together in primary health care 

teams reduced duplication, streamlined patient care and enabled specialist skills to 

be used more cost-effectively (Ross, Rink & Furne, 2000). 

Jansson, Isacsson and Lindholm (1992) analysed the records of general practitioners 

and district carers over 6 years in Sweden. Care teams (GP, district nurse, assistant 

nurse) were introduced into one region but were absent in another comparative 

region. The care teams reported a large rise in the overall number of patient contacts 

and in the proportion of the population who accessed the district nurse. Concurrently, 

there was a reduction in emergency visits, which they attributed to better accessibility 

and continuity of care in the teams. 

Jackson and colleagues (1993) reported a similar pattern twelve months after the 

introduction of a community mental health team in England. They reported a 

threefold increase in the rate of inception to care, a doubling in the prevalence of 

treated psychiatric disorder and a reduction in demand on the hospital’s outpatient 

services. It was suggested that the team was making specialist care more available 

to patients with severe mental illness who would not have previously received care 

from mental health services. The team also provided care in a timelier manner that 

was accessible and continuous. 

Enhanced patient satisfaction 

Hughes and colleagues (1992) compared the provision of hospital-based team home 

care and customary care for 171 terminally ill patients in a large U.S. Department of 

Veterans Affairs hospital. They noted increased access to home care services and 

improved patient and carer satisfaction with hospital-based team home care. Both

patients and caregivers of the team expressed significantly higher levels of 

satisfaction with continuous and comprehensive care at one month, and they 

continued to express higher levels of satisfaction at six months. The team program 

maintained patients at home for significantly more days than the control group, who 

were kept in hospital in general wards for longer. Patients of the team received 

almost twice as many home visits as the control group and visited the clinic 

significantly fewer times. 

Increased satisfaction by patients who had access to a primary health care team was 

reported to include a higher mean number of social activities, fewer symptoms and 

slightly improved overall health. These differences were noted in comparison to 

patients who only had access to a physician (Sommers et. al., 2000). 

Staff motivation 

Primary care teamworking has been reported to improve staff motivation (Wood, 

Farrow, & Elliott, 1994). In a study in Spain, Peiro, Gouzalez-Roma & Romos (1992) 

showed relationships between work team processes, role clarity, job satisfaction and 

leader behaviours. Effectiveness of teamwork was also related to job satisfaction 

and mental health of team members. Sommers and colleagues (2000) suggested 

that lower rates of hospitalisation for patients of primary health care teams were more 

likely to be found in teams where individual members were most satisfied with their 

working relationships. 

Innovation 

Teamwork is reputed to promote innovation in organisations including those in the 

health care sector. In order to promote organisational innovation, policy makers and 

practitioners are increasingly asking for clarification of the factors that determine 

innovation in teams. Many input and process variables have been demonstrated to 

predict innovation in teams. 

In relation to inputs, there is some evidence that heterogeneity of team composition 

is related to team innovation (Hoffman & Maier, 1961; McGrath, 1984; Jackson, 

1996). West and Anderson (1996) carried out a longitudinal study of the functioning 

of top management teams in 27 hospitals and examined relationships between team 

and organisational factors and team innovation. Their results suggested that team 

processes best predicted the overall level of team innovation, while the proportion of 

innovative team members predicted the rated radicalness of innovations introduced.

Specifically, West and Wallace (1991) found that team collaboration, commitment to 

the team and tolerance of diversity were positively related to team innovativeness. 

By what means are these various benefits of teamworking in health care realised? 

Partly at least through their composition and through effective team processes such 

as communication, decision-making and problem-solving. We therefore briefly 

review research in these areas before turning to consider the influence of the 

organisations within which teams function. 

Team composition and Processes 

There is considerable agreement that heterogeneity of skills in teams performing 

complex tasks is good for effectiveness (e.g., Campion et. al., 1994; Guzzo & 

Dickson, 1996; Jackson, 1996; Millikan & Martins, 1996; Maznevski 1994). 

Heterogeneity of skills and knowledge automatically implies that each team member 

will bring a different knowledge perspective to the problem, a necessary ingredient 

for creative solutions (Sternberg & Lubart, 1990; West, 1997). 

However, teams that are diverse in task-related attributes are often diverse in 

individual attributes. Variation in individual characteristics can trigger stereotypes 

and prejudice (Jackson, 1996) which, via interteam conflict (Tajfel, 1978; Tajfel & 

Turner, 1979; Hogg & Abrams, 1988), can affect team processes and outcomes. As 

an example, Alexander, Lichtenstein and D’Aunno (1996) found that individuals in 

multidisciplinary treatment teams in U.S. Department of Veterans Affairs hospitals, 

who were members of larger and more heterogeneous teams, reported poor team 

functioning. Physicians and social workers assessed team functioning more 

positively than did nurses. The greater the diversity of individual characteristics of 

team tenure, age and occupation within teams, the more negatively did team 

members assessed team functioning. 

Gender 

Gender is an important influence on communication within teams. Not only are men 

consistently more assertive in public situations and confrontations (Kimble, Marsh & 

Kiska, 1984; Mathison & Tucker, 1982), but also communication expectations differ 

for men and women. Sex-role stereotypes prescribe passive, submissive and 

expressive communication for women while men are expected to be active, 

controlling and less expressive communicators (LaFrance & Mayo, 1978). 

Punishment for violation of expectations (Jussim, 1986; Jussim, Coleman & Lerch,

1987; Jackson, Sullivan & Lodge, 1993) may influence both the perceptions of 

women in teams and their willingness to participate in team communication. Such 

considerations are vitally important in health care teams where women dominate in 

number, but men predominate in the highest status positions (in the present 

research, GPs and psychiatrists, for example). 

In support, Alexander, Lichtenstein and D’Aunno (1996) reported that the greater the 

gender diversity, the more positive were team members’ assessment of how 

cohesively and harmoniously teams operated. Their research suggested that mixed 

gender teams included different orientations to work, namely a female focus on 

workplace processes and relationships and a male focus on tasks and outcomes. 

Team roles 

It is important that teams have the appropriate mix of clearly defined team roles. 

Jansson, Isacsson and Lindholm (1992) analysed the records of general practitioners 

and district carers over a six-year period across 2 districts in Sweden following the 

introduction of care teams into one region. They found that through the independent 

roles of nurses and doctors were retained in the primary health care teams, all team 

members interacted with the population in various situations, including home visits 

and complemented each other across different competencies. 

Team affective tone 

Another important, but more controversial approach to understanding work team 

processes and effectiveness, is offered by research on team affective tone. George 

(1990) suggests that if members of a team experience similar kinds of affective 

states at work (either negative or positive), then affect is meaningful not only in terms 

of their individual experiences, but also at a team level. A number of studies have 

demonstrated a significant relationship between team affective tone and behaviour 

such as absenteeism (George, 1989, 1990, 1995). George proposes that teams that 

are interested, strong, excited, enthusiastic, proud, alert, inspired, determined, 

attentive and active, enable cognitive flexibility, creativity and effectiveness (George, 

1996). However, she argues that team affective tone may not exist for all teams, so 

it cannot be assumed a priori that it is a relevant construct for every team. George 

(1996) sees team affective tone and team mental models as having a reciprocal 

influence. So in a team with a negative affective tone, members would have different 

cognitive processes from those in a team with a positive affective tone, which then 

may influence team effectiveness.

There is some evidence that team mental models play an important role in team 

decision-making (Klimoski & Mohammed, 1994), impacting on aspects of team 

decision-making such as problem definition, speed and flexibility, alternative 

evaluation and implementation (Walsh & Fahey, 1986: Walsh, Henderson & 

Deighton, 1988). A team that has a high negative affective tone may tend to be more 

rigid when making decisions. The nature and outcomes of team decision-making are 

therefore likely to be affected by the interaction between team affective tone and 

team mental models. 

Communication 

The study of communication in teams has a long history in social psychology, but 

recent reviews by Guzzo & Dickenson (1996) and Guzzo and Shea (1992) reveal the 

paucity of thorough industrial and organisational research in this area. Blakar (1985) 

proposes five pre-conditions for effective communication in teams. Team members 

must have shared social reality within which the exchange of messages can take 

place, including a shared language base and perception. Team members must be 

able to “decentre”, to take the perspective of others into account in relation to both 

their affective and cognitive position (Redmond 1989, 1992). Team members must 

be motivated to communicate. There must be “negotiated and endorsed contracts of 

behaviour” (i.e. agreement among team members about how interactions take place). 

Finally, the team must attribute communication difficulties appropriately, so if one of 

the other preconditions is not being met, the team is able to correctly identify the 

problem and develop a solution. 

Several research studies in England have highlighted interprofessional 

communication problems within primary health care teams. West and Field (1995) 

and Field and West (1995) interviewed 96 members of primary health care teams 

and described factors that impacted upon teamworking and communication in health 

care. Structured time for decision-making, team cohesiveness and team-building all 

influenced communication within teams. They highlighted the failure of health care 

teams to set aside time for regular meetings to define objectives, clarify roles, 

apportion tasks, encourage participation and handle change. Other reasons for poor 

communication included differences in status, power, educational background, 

assertiveness of members of the team, and the assumption that the doctors would be 

the leaders (see also West & Pillinger, 1995; West & Slater, 1996).

Communication difficulties between different professional groups have been 

highlighted particularly. Bond, et. al., (1985) surveyed 161 pairs of General 

Practitioners (GPs) and health visitors, and 148 pairs of GPs and district nurses who 

had patients in common. They reported low levels of communication and 

collaboration between GPs and community nursing staff and suggested that GPs had 

a very poor understanding of the health visitor's role. Similarly, McClure (1984) 

describes low levels of communication in a survey of 48 health visitors and 45 district 

nurses attached to general practices. Community nurses reported that 

communication with practice staff was usually only about specific immediate patient 

issues rather than team objectives, strategies, processes and performance review. 

Health visitors were noted to be similarly unenthusiastic about progress in teamwork. 

Ross, Rink and Furne (2000) found that health visitors perceived teams as less 

effective. They suggested that health visitors were comparatively more defensive 

about the benefits of changing role boundaries and considered themselves less able 

to contribute to the teams as currently constituted. Cant and Killoran (1993) reached 

similar conclusions, based on their research study with 928 practice nurses, 682 

health visitors and 679 district nurses. They argued that joint professional training 

and the instigation of regular team meetings were necessary to promote good 

communication. 

Cott (1997) used a social network analysis of 93 health care workers across 3 

multidisciplinary long-term care teams to explore communication processes within 

teams. She concluded that higher status multi-professional members communicated 

most openly and worked fairly autonomously across loosely structured tasks, with 

low levels of authority. In contrast, hierarchical nursing sub-teams did not report high 

levels of information sharing. 

West and Slater (1996) reported that much of the potential benefit of teamwork was 

not being realised, with less than one in four health care teams building effective 

communication and teamworking practices (see also West & Poulton, 1997). In a 

similar vein, the Audit Commission report in 1992 drew attention to a major gap 

between the rhetoric and reality: 

"Separate lines of control, different payment systems leading to suspicion 

over motives, diverse objectives, professional barriers and perceived 

inequalities in status, all play a part in limiting the potential of multi- 

professional, multi-agency teamwork. . . for those working under such

circumstances efficient teamwork remains elusive" (Audit Commission, 

1992). 

A number of researchers in different countries have highlighted the impact of 

communication problems on patients across different types of teams. Nievaard 

(1987) interviewed 112 nurses and 298 patients across 6 medical and surgical wards 

of 2 general hospitals in the Netherlands. The study demonstrated the phenomenon 

of problem shifting, where communication problems within the team were transferred 

onto patients. It was reported that for hospital teams with a good communication 

climate, nurses perceived patients as more attractive and interesting and less 

dependent. However, if nurses viewed relationships with doctors, managers and 

nurses in the team as problematic, their images of patients tended to be more 

negative (unattractive, non-cooperative, dependent) and they did not want to 

increase their contacts with patients. 

Yeatts and Seward (2000) reported similar findings when they compared 3 self- 

managed work teams in a medium size U.S. rural nursing home. They concluded that 

enhanced communication between team members positively affected the service to 

residents. Observations of a high performing team’s meetings showed that team 

members had a high level of respect for each other, listened to each other, and were 

not afraid to disagree when they held different views. Team members sought and 

valued approval from each other, and they assisted each other to complete tasks. 

Several studies have demonstrated how individual perceptions about teamwork and 

roles can influence communication in teams. Dreachslin, Hunt & Sprainer (2000) 

developed a grounded theory of the role that race plays in the self-perceived 

communication effectiveness of nursing care teams in the U.S. They concluded that 

racially diverse team members evaluated team communication according to different 

perspectives and alternative realities. 

When team members develop belief systems that are consistent with their 

perspective and incongruent with other vantage points, differences in 

perspective can result in alternative realities. Alternative realities encourage 

participants to attribute causality differently which in turn fuels team conflict and 

miscommunication by diminishing the team’s ability to reach a common 

understanding of both the source of the conflict and the optimal path to its 

resolution through effective communication (p. 1408).

Black participants were more likely to suggest that race exacerbated team conflict 

and miscommunication, whereas white participants attributed problems to role and 

status in the team. Further, different emphases and responsibility for communication 

were acknowledged amongst the diversity of races, ethnicities, ages and genders. 

Social isolation, selective perception and stereotypes also served to reinforce these 

differences and deepen communication problems. Fewer occasions for social 

interaction reduced opportunities to develop shared beliefs and a common social 

reality across racial groups. The researchers therefore suggested that team 

members be encouraged to understand different perspectives and appreciate 

alternative realities, in order to lessen social isolation and reduce selective 

perceptions and stereotyping behaviours. 

Freeman, Miller and Ross (2000) also developed a grounded theory about 

collaborative practice at the levels of the organisation, group and individual. They 

conducted case studies of 6 teams working in a variety of specialist healthcare 

services (diabetes, medical ward, primary healthcare, neuro-rehabilitation unit, child 

development assessment, community mental health) and concluded that the 

meanings different professionals ascribed to teamwork shaped how they 

communicated and what they communicated about. When there was a lack of 

congruence about aspects of teamwork, communication could potentially be 

compromised. Individual perceptions determined the level of role understanding 

considered necessary, and the value assigned to others’ contributions. Differences in 

the understanding and valuing of team roles and levels of team learning exacerbated 

underlying resentments, undermined professional esteem and created conflict. 

Individual perceptions also influenced communication regarding tasks and about 

sharing professional knowledge and ideas. 

Decision making 

Effective decision-making processes are central to team performance. Several 

studies have reported the positive benefits of participative decision making in health 

care teams. Yeatts and Seward (2000) compared 3 self-managed work teams in a 

medium size U.S. rural nursing home. Team members of highly performing teams 

reported that their ability to participate in work related decisions greatly increased 

their job satisfaction and desire to come to work. These team members adopted a 

consensus model of decision making, in which they clarified the problem, considered 

alternatives, weighed the strengths and weaknesses of each alternative, and

selected the best option. Following their participation in making decisions, team 

members reported an enhanced self-image and self-confidence, and they described 

more positive interactions amongst themselves and with residents. 

In contrast, Cott (1997) suggested that team members may not be equally 

empowered to participate in decision making. Using a social network analysis of 93 

health care workers across 3 multidisciplinary long-term care teams, she reported 

that the highest status nurses and the core multidisciplinary professionals 

participated most in decision making and problem solving activities. In comparison, 

the lower status nursing sub-team primarily planned and assisted each other with 

their more mechanistic tasks. 

Problem solving 

Team problem solving improves when members examine their definitions of a 

situation to ensure they are solving the "right" problem (see for example, Bottger & 

Yetton, 1987; Hirokawa, 1990; Landsberger, 1955; Maier, 1970; Schwenk, 1988). In 

contrast, teams that detect problems too slowly or misdiagnose them often are 

ineffective. Attributing problems to the wrong causes, or not communicating about 

potential consequences, often undermine team effectiveness, especially when team 

members fail to reflect on the possibility of error (Schwenk, 1984; Staw & Ross, 

1989). 

Teams that engage in more extensive scanning and discussion of their environments 

perform better than those which do not identify problems (Ancona & Caldwell, 1988; 

Main, 1989; Billings, Milburn & Schaalman, 1980). Tjosvold (1985; 1990) linked the 

open exploration of opposing opinions within teams with effectiveness. Maier and 

colleagues also suggested that cognitive stimulation produced novel ideas, and that 

team effectiveness could be improved if teams were encouraged to be "problem 

minded" rather than "solution minded" (Maier & Solem, 1962; see also Maier, 1950, 

1970). Effectiveness was improved when teams questioned current approaches or 

considered other aspects of problems (Maier, 1952). Similarly, Hackman & Morris 

(1975) found that additional process discussions facilitated the quality of team 

performance. The judged creativity of team decisions was related to the number of 

comments made about performance strategy. When teams produced alternative 

solutions to a problem, or separated and recombined problem solving strategies, 

enhanced productivity was reported (Maier, 1970).

Teams that have to make complex decisions report that planning enhances their 

performance (Hackman, Brousseau & Weiss, 1976; Smith, Locke & Barry, 1990). 

However, when the environment becomes more uncertain, problem identification is 

more difficult (Hedburg, Nystrom & Starbuck, 1976; Kiesler & Sproull, 1982). 

Ineffective teams tend to deny, distort or hide problems (Stein, 1996). In some 

teams, the identification of problems is discouraged as problems are regarded as 

threats to morale, or a source of conflict (Janis, 1982; Miceli & Near, 1985; Smircich, 

1983). 

Thus far we have reviewed the benefits (and potential difficulties) of teamworking in 

health care organisations - but the fact that teamworking takes place within 

organisations is often ignored in the zeal to promote team effectiveness. 

Accordingly, we now turn to address what is currently known about the influence of 

their organisations upon teams. 

Organisational context 

Recent research suggests the broader context within which teams work has an 

influence on their performance. Indeed the major change in emphasis in research on 

teams in the last 15 years has been the shift from discussion of intrateam processes 

to the impact of organisational context on teams. The organisation within which a 

health care team functions can influence team effectiveness in a variety of powerful 

ways. Researchers, such as Hackman (1990) and Tannenbaum, Beard and Salas 

(1992) have suggested that the following are among the contextual factors that 

influence team effectiveness: 

• Team and organisational rewards 

• Team objectives and performance feedback 

• Training and technical assistance 

• Physical work conditions 

• Organisational climate 

• Inter-team relationships 

• Contracts and management structures 

• Team size 

These factors will be discussed further, in turn.

Team and organisational rewards 

It has long been known in the social sciences that rewards are important for 

improving performance. Reward systems, such as public recognition, preferred work 

assignments and money enhance motivation and performance, particularly when the 

rewards are contingent upon task achievement (Hackman, 1990; Sundstrom et al., 

1990; Vroom, 1964). However, team performance is most effective when rewards 

are administered to the team as a whole and not to individuals, and when they 

provide incentives for collaboration and communication rather than individualised 

work (Hackman, 1990). This reinforces individuals working together as a team. 

Gladstein (1984) found that in sales teams, pay and recognition affected the leader’s 

behaviour and the way the team structured itself. Yet, NHS management directly 

undermines teamwork in primary health care when they provide bonus systems to 

GPs as independent contractors, despite the whole team contributing to the final 

outcome. 

Clear team objectives and performance feedback 

In healthcare environments, team members need information about local health 

needs and services, and national policies and guidelines, in order to set objectives 

and target their activities appropriately. Further, feedback on team performance is 

important for setting realistic goals and fostering high team commitment (Lathom, 

Erez & Locke, 1988). Job satisfaction requires accurate feedback from both the task 

and other team members (Drory & Shamir, 1988). However, team feedback can be 

difficult to provide to teams with either long cycles of work or one-off projects 

(Sundstrom et. al., 1990). 

Training and technical assistance 

Hackman (1990) argued that training and technical assistance is required for teams 

to function successfully. Knowledge and training about team functioning is needed to 

supplement team members’ own technical and medical skills and knowledge 

(Poulton & West, 1993; Poulton & West, 1994a, 1994b; Poulton & West, 1997). 

Limited empirical evidence suggests training is correlated with both self-reported 

effectiveness (Gladstein, 1984) and managers’ judgements of effectiveness 

(Campion et. al., 1993) in teams. 

Physical Work Conditions 

Physical conditions are another situational constraint that affect the relationship 

between performance dimensions and team effectiveness. For example, a health

care team whose members are dispersed across sites, will find decision making 

more difficult and ineffective than a team whose members share the same physical 

location. 

Organisational Climate 

The climate of the organisation - how it is perceived and experienced by those who 

work within it - will also influence the effectiveness of teams (Allen, 1996). Where the 

climate is one characterised by high control, low autonomy for employees, lack of 

concern for employee welfare and limited commitment to training, it is unlikely 

teamworking will thrive (Markiewicz & West, 1997). 

The extra commitment and effort demanded in team-based organisations requires 

organisational commitment to the skill development, well-being and support of 

employees (Mohrman, Cohen & Mohrman, 1995). Competition and intrigue can 

further undermine team based working in health care, since teamwork depends on 

shared objectives, participative safety, constructive controversy and support (West, 

1990; West & Anderson, 1996). Ross, Rink and Furne (2000) reported that team 

members’ willingness to work in teams was limited by the lack of a common set of 

values about the benefits of teamwork. They recommended the need for clear 

objectives, leadership, commitment and wide organisational ownership as precursors 

for working in teams. 

Professional subcultures also influence team effectiveness. Kinnunen (1990) used 

an anthropological approach to distinguish different subcultures between medical, 

nursing and management staff in a large primary health care organisation in Finland. 

These three professional groups described different relationships to formal power 

structures, which influenced their group behaviour, leadership style, administrative 

orientation, decision-making preferences and patient interactions. In general, doctors 

and managers shared basic assumptions about work that were paternalistic, 

proactive, dominant and emphasised loyalty to authorities. In contrast, nurses 

stressed participation, delegation, traditions and symbiotic harmony in work relations. 

Inter-team relationships 

In a comprehensive study of team-based organisations involving both questionnaire 

and case study methods, Mohrman et. al. (1995) demonstrated that inter-team 

competition is a major threat for team-based working. Teams that compete may 

develop greater commitment to the team’s success than the organisation’s success.

Thus the health care team may focus on increasing the financial benefits to their 

team at the expense of the wider National Health Service. Teams competing against, 

rather than supporting each other may withhold vital information or fail to offer 

valuable support in the process of trying to achieve team goals, without reference to 

the wider goals of the organisation. Thus, health care teams may fail to pass on 

information about former patients to other teams, focusing their efforts on their own 

team’s immediate demands. 

Ross, Rink and Furne (2000) reported a lack of focus on patient care in their 

evaluation of primary care nursing teams in England. Nurses perceived that current 

organisational change promoting teamwork was concerned with structure, 

professional and organisational issues rather than with patient care. Some nurses 

were concerned that moves towards integrated nursing were primarily motivated to 

cut costs. 

Contracts and Management Structures 

Other relevant aspects of the organisational environment in health include the 

independent contractor status of GPs and different management structures. There 

are very few organisations where one or more senior team members work as 

independent contractors and the rest of the team work within a variety of 

organisations. Even the most sophisticated management practices, in environments 

such as the oil and gas industry, are struggling with notions of how to operate joint 

venture systems - whereas health care teams must deal with these issues constantly 

but without the training and support given to teams in these other sectors. 

Team size 

The size of the team is also important, since bigger teams experience much greater 

strains on effective communication. In most other sectors, teams tend to be divided 

once they reach 12 or 13 members. But primary and secondary health care teams 

(for example) can be 20, 30, 40 or more members in size. These ‘teams’ would be 

more correctly termed ‘organisations’. In and of itself, this would not be a problem, if 

those who run such organisations are adequately trained to manage large 

operations. They require knowledge of the management of culture, power, conflict, 

spans of control, strategies, innovation and above all, people. Yet primary health 

care team leaders are rarely given such training (West, 1994). It is to the topic of 

leadership that we now turn.

Leadership 

There is considerable research evidence that leaders affect team performance (e.g. 

Brewer, Wilson & Beck 1994; Komaki, Desselles & Bowman, 1989) and evidence of 

the relationship between leadership style and team effectiveness. Eden (1990) 

examined the effects of platoon leaders’ expectations on team performance. His work 

with the Israeli Defence Forces showed that those platoons which trained under 

leaders with high expectations, performed better on physical and cognitive tests. 

Podsakoff and Todor (1985) investigated the relationship between team members’ 

perceptions of leader reward and punishment behaviours and team cohesiveness, 

drive and productivity. Results showed that both leader contingent reward and 

punishment were positively related to team drive and productivity. Leader contingent 

reward was also related to cohesiveness, while leader noncontingent punishment 

behaviour was negatively related to team drive. Jacob and Singell (1993) examined 

the effects of managers on the won-lost record of professional baseball teams over 

two decades and found that leaders did influence team performance by exercising 

tactical skills and improving the performance of team members. George and 

Bettenhausen (1990) studied teams of sales associates reporting to a store manager 

and found that the favourability of leader’s moods was negatively related to related to 

employee turnover. 

Primary health care team members in England rated their effectiveness more highly 

when they had strong leadership and high involvement of all team members (Ross, 

Rink & Furne, 2000). In nursing care teams, Dreachslin, Hunt and Sprainer (2000) 

concluded that leadership mitigated the influence of race in self-perceived 

communication effectiveness. Participants’ comments supported the theme that 

team leaders who encouraged discussion about differences enhanced perceived 

team effectiveness. They suggested that leaders provided a unifying force through 

validating the alternative realities and appreciating the different perspectives of team 

members, thus moderating the potentially negative effects of racial diversity on team 

processes. 

Developing Teams in Organisations 

To what extent is it possible to develop team working to ensure higher levels of 

effectiveness? Tannenbaum, Salas, & Cannon-Bowers (1996) have reviewed 

research in this area and related results to a comprehensive model of team which

integrates interventions (Tannenbaum, Beard and Salas, 1992). They describe a 

number of intervention types include team member selection and teambuilding: 

Team member selection 

Although organisations tend to use quite sophisticated methods for 

selecting employees for individual jobs, they rarely use systematic 

methods for selecting for teams. But systematic selection methods can 

help identify people with greater skill levels. There is strong evidence 

that a team composed of skilled and motivated people will be more 

effective than other teams (Tziner, 1988). Selection interventions could 

improve team effectiveness by increasing the professional or skill 

diversity of health care team members, thereby increasing the range of 

competencies in the team. 

Teambuilding 

Some teambuilding interventions focus on role clarification, some on 

interpersonal relationships or conflict resolution issues, while others take 

more of a general problem-solving approach (Tannenbaum, Salas & 

Cannon-Bowers, 1996). Team norms, attitudes, climate and power 

distribution can be affected by teambuilding approaches. Many team 

processes, including communication, decision-making and mutual role 

understanding, are often direct targets of team building interventions. 

Weldon and Weingart (1993) describe the importance of planning in teams for 

achieving team goals, and suggest that team members are characteristically slow to 

respond to changes in their tasks or their environments that make their strategies 

ineffective or their goals obsolete. They propose five ways of supporting team work. 

Goals should be set for all dimensions of performance that contribute to the overall 

effectiveness of the team; feedback should be provided on the team's progress 

towards its goal; the physical environment of the team should remove barriers to 

effective interaction (consider the difficulties faced by members of a dispersed health 

care team); team members should be encouraged to plan carefully how their 

contributions can be identified and co-ordinated to achieve the team goal; and team 

members should be helped to manage failure, which can damage the subsequent 

effectiveness of the team.

Pritchard, Jones, Roth, Stuebing and Ekeberg (1988) tested some of these ideas by 

measuring the effects of team feedback, goal setting and incentives on productivity. 

Five organisational units in the military were studied. One, a maintenance section, 

repaired a variety of electronic equipment used for aircraft communications. The 

other four sections together made up a material storage and distribution branch. 

Productivity baselines were established before each team received new "treatments" 

(i.e., performance feedback eight months after the study began, goal setting five 

months later, and incentives a further five months later) to determine the incremental 

effects of these "treatments". First, the level of performance of the teams was 

measured over a period of eight months and then information on their performance 

was given to each unit for five months. The teams next set clear targets in addition to 

the performance feedback, and their performance was measured for another five 

months. Feedback was in the form of computer-generated reports, given monthly to 

the personnel of each unit. Finally, incentives were offered for high performance, in 

the form of time off from work. Using these approaches, the average increase over 

baseline productivity was 50% for feedback, 75% for goal setting and 76% for 

incentives. The results showed a major increase in productivity among the teams, 

though the unique contribution of each component of the intervention is difficult to 

estimate accurately. Both goal setting and feedback had powerful effects on 

performance. 

Transition of organisations to teamworking 

One of the most exciting developments in the field is the new emphasis upon the 

development of team-based working in organisations (Mohrman, et. al., 1995; 

Markiewicz & West, 1996, 2001). This reflects a concern amongst practitioners with 

how team-based working can be effectively introduced into organisations. Mohrman 

et. al., studied 25 teams in four companies using a grounded research methodology, 

involving managers and internal customers. In the second phase of their research 

they surveyed 178 teams across seven corporations, involving team members, 

managers and customers. In this way, they developed a five stage design sequence 

for the transition to a team-based organisation: 

1. Identifying work teams and the nature of the task 

This involves process analysis to determine essential work activities that have to be 

conducted and integrated to produce products or services; deliberations analysis 

which identifies dialogues about issues that have to be repeatedly resolved in order

to provide shared direction and enable people to complete their tasks; and task 

interdependence analysis which determines where and to what extent individuals and 

teams have to rely on each other to complete their tasks. 

2. Specifying integration needs 

In order to integrate across multiple teams and components of business units, 

Mohrman et al recommend management teams, representative integrating teams 

(where an overall co-ordinating team had representatives from each of those teams 

collectively involved in producing a product or service), individual integrating roles, 

and improvement teams. 

3. Clarifying management structure and roles 

This stage involves putting as much self-management responsibility into the teams 

as possible; involving team members in determining how leadership tasks will be 

performed and by whom; using lateral mechanisms for cross-team and organisation- 

wide integration so that teams participate in that integration; and creating 

management roles which link teams to the organisational strategy and ensure they 

are responsive to the organisational and wider environmental context. 

4. Designing integration processes 

The research evidence suggests that team-based organisations should set clear 

directions in the organisation, (for example by defining, communicating and 

operationalising a strategy at all levels, aligning goals, assigning rewards in 

accordance with organisational goals, and planning collectively); managing 

information distribution and communication; and developing an appropriate decision 

making strategy (by clarifying decision making authority, and appropriately involving 

organisational contributors). 

5. Developing performance management processes 

Finally, the model suggests the need to manage performance - defining, rewarding 

and reviewing performance and involving internal and external customers, and team 

members. Mohrman et. al., report that the more people were rewarded for individual 

performance, the worse team performance was. The more people were rewarded for 

team performance, the better was the team and the business unit’s performance and 

the more process improvements the team and the business unit instituted.

Conclusions and Research Mode 

A review of the literature reveals that progress has been made in understanding the 

factors that influence the ability of people to work effectively together in teams. 

However, in the health care domain progress is still patchy and only a few studies are 

constructed on firm theoretical bases. Progress is further inhibited by the added 

difficulty of operationalising the concept of effectiveness. In the research described 

in this report we attempted to build our research on a well-accepted theoretical base 

and to engage a large number of health care teams in the research endeavour. 

Moreover, we were charged with grasping the nettle of effectiveness in health care 

and developing robust and sufficiently broad measures of this difficult concept. 

Finally, the research team, drawn from a wide range of epistemological backgrounds 

and theoretical orientations, determined to employ diverse, powerful and innovative 

research methods to answer the question of what factors influence the effectiveness 

of health care teams. The starting point for the research was a model of the factors 

influencing team effectiveness and which distinguishes between at least three major 

domains of effectiveness. Theoretical approaches to understanding teams at work 

have been dominated by the input-process-output structure, mainly because of its 

categorical simplicity and utility (see Figure 1 below) (West, Borrill, & Unsworth, 

1998). This is the model used to guide the research described in this report. 

Figure 1: Input, process, output model of team effectiveness 

INPUTS GROUP PROCESSES OUTPUTS 

Domain 

Health Care 

Environment 

Organisational 

context 

Team task 

Team composition 

Leadership 

Clarity of objectives 

Participation 

Task orientation 

Support for innovation 

Reflexivity 


Communication/ 

integration 

Effectiveness - self and 

externally rated 

Clinical 

outcomes/quality of 

health care 

Innovation - self and 

externally rated 

Cost effectiveness 

Team member mental 

health 

Team member turnover

Inputs 

Teams work within a domain such as primary care, secondary care or community 

mental health. They also work in a health care environment that may be more or less 

deprived. The team works for and within an organisation; thus it will be affected by 

the interaction with the surrounding organisational context. A team has a task that 

potentially impacts upon team processes and effectiveness (the management of 

immunisation for children under five years; intensive care nursing; or care of the 

elderly with mental health problems). The team consists of a collection of individuals 

- who represent the group’s composition – varying in professional background, 

gender, age, personality etc. Finally, the team exists within a wider society that will 

affect the teams’ fundamental beliefs and value systems, i.e., the cultural context. 

Processes 

Processes within teams enable them to achieve their goals. A fundamental 

requirement for effectiveness is that teams have clear objectives to which their 

members are committed. Other processes include participation in decision-making, 

emphases on quality, and support for innovation. Another fundamental process is 

the extent of coordination and integration of team members’ work (Worchel, Wood, & 

Simpson, 1992). And of course, leadership and communication are likely to be 

important to team effectiveness. Another potentially important process variable is 

reflexivity or the extent to which team members collectively reflect on the objectives, 

strategies, processes and environment of the team and make changes appropriately 

and accordingly. 

Outputs 

Six principle outputs can be distinguished: overall effectiveness, clinical outcomes, 

team 

member mental health, innovation, team member turnover, and cost effectiveness. 

In the research programme described in this report we explore the relationships 

between inputs and processes; inputs and outputs; and processes and outputs in 

390 UK NHS teams, during the course of which we consulted with over 7,000 NHS 

personnel and with a large number of NHS clients.

Using this model, we determined to explore the extent to which team working was 

associated with better quality health care for patients and to identify the factors 

associated with effective teamwork.

Chapter 2 

Primary Health Care Team 

Research Methods and Sample Details 

The research with Primary Health Care Teams had two stages. The first was a 

questionnaire survey, and related data collection methods, involving large numbers 

of teams conducted in order to gather data on team inputs, processes and outcomes. 

The second stage involved intensive examination of a sub-set of teams to explore in 

more depth targeted team processes and outputs. 

Quantitative Methods 

An overview of the methods used is given in Figure 2.1. 

Figure 2.1: Details of the three samples and research methods 

Sample size Survey data 

100 teams 

1156 respondents 


Team functioning 

Team effectiveness 

Team innovation 

Member stress 

The Sample 

Additional 

questionnaires/ 

Telephone 

interviews 


Team meetings 

Team management 


External ratings 


Team innovation 

The research design required data to be gathered from 100 Primary Health Care 

teams (PHCTs) varying across a number of dimensions, including size (number of 

team members, number of GPs, list size); Jarman index; location (urban, rural, inner 

city), and geographical location. Databases of GP practices were accessed from 19 

Health Authorities and 300 teams were randomly selected. 

Letters explaining the objectives of the research and inviting teams to participate in 

the research, together with an information sheet were sent to the senior GP partner,

senior health visitor and practice manager/senior receptionist in each practice. A 

reply slip was included, which also solicited additional information about the team 

(fund holding status, frequency and type of meetings, Jarman index, number of GPs, 

list size etc.) 3 

The initial letter was followed up with a telephone call to the practice manager/senior 

receptionist at all 300 practices. If teams had already indicated a willingness to 

participate, practical arrangements for questionnaire distribution were made. 

Researchers requested the name of a contact person in the team to enable 

continued effective liaison. The contact person was telephoned at a later date to 

determine whether the team was willing to take part in the research. Teams that did 

not return a reply slip were also telephoned and provided with additional information. 

Further follow-up telephone calls were made until the team made a decision about 

participation in the research (some PHCTs were contacted six or seven times before 

a decision was made). When teams agreed to collaborate in the research, 

questionnaires were sent to the contact person for distribution to team members. 

After three months the response rate from 10 teams was below 30% and 23 had not 

returned any questionnaires. These teams were dropped from the sample and 

replaced with 7 teams based in an inner city area, and 7 from a rural location, 

resulting in a final sample of 100 teams. The total response rate was 55.8%. 

Response rates for teams ranged from 21.4% to 100%, with a mean of 57.6%. 

Data Collection Methods 

Data on team functioning and effectiveness were collected using three methods: self 

report questionnaires completed by individual team members; self report and 

telephone interview surveys with the team contacts; and external ratings from 

primary health care representatives and health authority staff. 

1156 respondents from 100 PHCTs completed questionnaires on their perceptions of 

team functioning and team effectiveness. Of these, 85% were female; 15% were 

GPs; 14.2 % practice nurses; 23% trust nurses (health visitors, district nurses, 

3 Copies of interview schedules, questionnaires and all data collection instruments are 

available from the first author of this report.

midwives); 33.5% administrative staff, 7.3% managers and 4.3% professions allied to 

medicine (PAMs). 

Team contacts from 77 PHCTs provided information on team context, team 

composition and team processes in a self-report questionnaire survey, and 100 

provided information via a telephone interview. This enabled a reliability check on the 

data for 77 of the teams. 

Questionnaires completed by individual team members 

This questionnaire was in four sections (a copy of the primary health care 

questionnaire is included in Appendix I). 

Section 1: Team working 

This contained seven measures of team working. Four of these were drawn from the 

Team Climate Inventory (Anderson & West, 1994,1998) that is based on a well- 

developed theoretical model of team functioning (West, 1990). The four measures 

assess levels of: 

• team participation 

• clarity of and commitment to team objectives 

• emphasis on quality 

• support for innovation. 

Three other measures were included: 

• reflexivity – the extent to which team members reflect upon their team 

objectives, strategies and processes and make changes accordingly (West, 

1996; Swift & West, 1998). 

• team innovation – the extent to which the team has introduced innovations in 

objectives, work strategies, processes and relationships 

Respondents were also asked to write descriptions of the major changes or 

innovations introduced by the team in their work in the previous 12 months. 

Section 2: Effectiveness 

This included 21 measures of primary health care team effectiveness adapted from 

Poulton and West (1999). There are three underlying dimensions:

• team working 

• patient orientation 

• organisational efficiency 

Section 3: Team member stress 

This included a measure of psychological stress, the GHQ-12 (Goldberg, 1972; 

Goldberg & Williams, 1991). The GHQ-12 is widely used as a screening tool for 

detecting minor psychiatric disorder in the general population, and in occupational 

mental health research. It covers feelings of strain, depression, inability to cope, 

anxiety based on insomnia, lack of confidence and other psychological problems. 

Within a Department of Health-funded study of the mental health of the NHS 

workforce, the GHQ-12 showed good validity against a psychiatric interview (Hardy, 

Shapiro, Haynes, & Rick, 1999). 

Section 4: Biographical information 

This section included questions on biographical and team characteristics (e.g. age, 

gender, ethnic origin, job title, employer, team composition, team leader). 

Additional Practice Information – Survey 

This was completed by the contact person in the PHCT (usually the practice 

manager). It included questions on: team context (relationships with external 

agencies such as health authorities and trusts); type of primary health care practice 

(fundholding, non-fundholding, dispensing) quality of premises; team composition 

number in each occupational group, grade, hours worked, time working in the team); 

staff development; and team processes (communication and decision making in 

meetings). 

Additional Practice Information - Telephone Interview Schedule 

The contact person in the team (usually the practice manager) responded to the 

telephone interviews. The focus of the questions was on decision-making and 

communication in the team: specifically who was involved in making operational, 

strategic and clinical decisions in the team, how these decisions were communicated 

in the team and what mechanisms were in place within the team to promote 

communication (memo systems, message books, informal meetings, email). 

Information was also gathered on the services and clinics provided by the team.

External ratings – team effectiveness and innovation 

Health Authorities employ staff to provide support to primary health care teams, a 

role involving working closely with a wide range of teams. Contact was made with 

staff in this role at each of the Health Authorities where the teams in the sample were 

located. They were asked to provide ratings of effectiveness and innovation for all of 

the teams from their area that were participating in the research. External ratings of 

effectiveness were obtained for 84 teams. They were rated on the same 21 

effectiveness dimensions included in the primary health care team questionnaire. 

Examples of the dimensions include: 

� The extent to which teams made efficient use of the practice budget 

� The extent to which teams previewed and adjusted skills in line with 

the identified health care needs of the practice population 

External ratings – changes introduced by teams 

Three representatives from Primary Care rated the changes or innovations 

introduced by the teams (reported in the questionnaire for individual team members). 

One of the raters was employed by a Local Health Authority and had responsibility 

for developing team working in primary care. Another was employed by a community 

trust, also in a role which supported primary care teams. The third rater was a part 

time general practitioner who had been involved in development and research 

projects in primary care. They rated teams on four dimensions (West & Anderson, 

1996): 

• magnitude - how great would be the consequences of changes introduced 

• radicalness - to what extent the status quo would change as a consequence 

• novelty - how new in general were the changes 

• impact - to what extent changes would improve PHCT effectiveness. 

Using the ICC (2) (Shrief & Fleiss, 1979) the inter rater agreement was calculated for 

each dimension: Magnitude - 0.663, Radicalness - 0.630, Novelty - 0.539, Impact - 

0.779. 

Sample Details 

In this section we describe characteristics of the primary health care team sample 

that participated in the questionnaire and interview component of the research

programme. Following the model used to guide this research (see page 1) we 

describe four categories of inputs: 

• team task - Indicated by the size of the practice population and its 

fundholding status 

• team composition - team size, ratio of part-time team members, gender mix, 

number of occupational groups represented in the team 

• health care environment - the Jarman Index (an index of social deprivation), 

its location (city, urban, urban/rural or rural) 

• organisational context - the NHS Region within which the team is located. 

We also describe the relationships between these four domains of inputs. The 

reader will also find an account of the frequency and content of meetings held in the 

teams, and of the team members’ perceptions of leadership in the team in 

subsequent chapters. 

Team Task 

Practice population or ‘list’ size 

The practice population or ‘list’ size ranged from 1500 to 21,850. The mean size was 

6,902 patients with a standard deviation of 4,692 (see Figure 2.2). 

Figure 2.2: Percentages of primary health care teams with patient populations or ‘list 

sizes’ of various sizes 

30% 

25% 

20% 

15% 

10% 

5% 

0% 

20000 

List Size

Location 

Four location categories were used: city, urban, urban/rural and rural. Sixty-five 

percent of teams were located in urban areas other than cities, 20% in cities, 6% in 

areas described as both urban and rural, and the remaining 8% were in rural 

locations. 

Health care environment 

Jarman index 

The Jarman index is a measure of social deprivation. The higher the score the 

greater the health needs of the practice populations served by the team. 

Scores in the sample included in this research programme ranged from 0% to 

100. The mean Jarman score was 15.52 and the standard deviation 22.72. 

Figure 2.3 shows the percentage of teams with each category of Jarman 

score. 

Figure 2.3: Team Location 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Figure 2.4: Jarman index 

25 

20 

15 

Frequency 

10 

5 

0 

City Urban Urban/Rural Rural 

0% 

1 - 10%

Whole time equivalents 

Using hours worked to calculate team size enabled an estimate to be made of the 

number of ‘whole time equivalents’. This statistic shows that team size varied from 

1.49 to 31.9 members. The mean size was 9.35 with a standard deviation of 6.75. 

The size of teams working in so-called ‘single handed GP practices’, ranged from 

1.88 to 16.13, with a mean of 7.48 and a standard deviation of 3.74. 

Number of GPs 

The number of GPs in the teams ranged from 1 to 11. The mean number of GPs 

was 3.7 and the standard deviation was 2.4 (Figure 2.5). 

Whole time equivalent GPs 

The range of whole time equivalent GPs was from one to 

ten. The mean was 3.16 and the standard deviation 2.0. 

Figure 2.5: Number of GPs in the primary health care teams 

30% 

25% 

20% 

15% 

10% 

Gender 

5% 

0% 

Team Size (no of GP's) 

1 2 3 4 to 5 6 to 8 9 to11 

The majority of team members (85.5%) of the Primary Health Care team sample 

were female. The break down for gender by occupational group is shown in Figure 

2.7 and this reveals that the only imbalance in favour of men is in the highest status 

group – GPs. Otherwise, primary health care is a domain in which women form the 

vast majority of the workforce. Primary health care is largely in the hands of women 

in the UK. And of course, this has important implications for our understanding of its

functioning, issues of team processes and, given the anomalous preponderance of 

male GPs, of leadership issues. 

Fig 2.7: Distribution of gender by occupational group in primary health care teams 

GPs Practice 

Nurses 

Trust 

Nurses 

Admin 

staff 

Managers PAMs Other 

Male 99 5 16 10 24 8 1 

Female 75 160 249 378 61 42 4 

Fig 2.8: The distribution of mean age across the occupational groups 

Mean Age Standard Deviation 

GPs 41.2 7.6 

Practice Nurses 42.1 7.6 

Trust Nurses 42.2 8.3 

Admin/clerical 43.7 10.2 

Managers 44.3 8.4 

PAMs 41.6 11.0 

Others 40.8 8.2 

Age 

The distribution of age across the occupational group is shown in Figure 2.8. 

Occupational Groups 

The majority of teams comprised: GPs, practice nurses, 

administrative staff, district, health visitors and one or 

more practice managers. Less than 15% of teams did not 

include trust nurses, and only 6% of teams had no 

manager. Twenty four percent of teams included ‘other’ 

types of staff (counsellors, community psychiatric 

nurses, physiotherapist etc). 

Proportion of occupational groups 

The proportion of each of the main occupational groups in the teams is shown in 

Figure 2.9.

Figure 2.9: Proportion of occupational groups in the sample 

PAM's 

Others 

Managers 

Admin/cleri 

cal 

A different picture of team composition emerges when hours worked is taken into 

account and team membership calculated using 'whole time equivalent' figures. This 

shows that largest grouping is GPs, with only 10.7% of the input to the team being 

provided by trust nurses. 

GPs 

Trust 

Nurses 

2.10: Proportion of occupational groups in the sample 

Managers 

Admin/ 

clerical 

PAM's Others 

Trust 

Nurses 

Practice 

Nurses 

GPs 

Practice 

Nurses

Organisational Context 

Figure 2.11 Regional variations 

Location Number of teams 

South East and London 18 

Midlands 4 

East Anglia 4 

Nottinghamshire 18 

South Yorkshire 43 

West Yorkshire 13 

Teams were distributed across six regions with the 

distribution shown in Figure 2.11. 

Relationships between Input Factors 

In this section we describe the relationships between aspects of team task, team 

composition, health care environment and organisational context. As we might 

predict, there are some important and significant relationships between them. 

• The number of team members and the number of 

patients on the team’s list were positively correlated 

(0.85), with an average of 291 patients on a team’s 

list per member of staff. This ratio did not vary 

across location (city, urban, urban/rural, rural), 

Jarman index, or average of number of hours 

worked by team members. 

• There were no significant differences in the composition of the teams 

between different types of locations (city, urban, urban/rural, rural). Nor were 

there differences in the composition of fundholding and non-fundholding 

practices.

• There was a significant relationship between Jarman score and number of 

managers; teams with fewer managers had a higher Jarman score. 

• Teams with a higher Jarman index also had significantly more ‘other’ types of 

staff in the team. This may reflect the fact that the range of services required 

is much greater in socially deprived than socially enriched areas. 

• There was a higher proportion of Professions Allied to Medicine (PAMs) in 

teams with a larger list size. 

Jarman index / location 

73 teams provided a Jarman index score of more than 0%. The mean score was 

15.52 and the standard deviation 22.72. These were distributed across locations as 

follows: 

City – 18 

Urban – 39 

Urban / rural - 5 

Rural – 6 

Unclassified - 5 

• The Jarman index for city practices was significantly higher (mean = 32.6%) 

than for urban practices (mean = 11.9%) 4 

Qualitative Research Methods 

Research in the second stage of the research programme explored in depth, and 

using a variety of consultation and qualitative research methods, all issues of team 

functioning and effectiveness. The methods used are shown in Fig 2.12. 

4 The data collected as part of this research can be subjected to much further analysis and 

information extraction. The researchers are committed to working with others to ensure the 

maximum exploitation of this hard won data set. If there are analyses readers wish to conduct 

the researchers would urge them to contact the first author of this report.

Figure 2.12: Consultation and Qualitative Research Methods used for Primary Health 

Care Teams 

Analysing PHC 

team processes 

� Audio and video 

recording of two 

meetings for each 

of twelve teams 

Development of PHC 

objectives 

� Series of four national 

workshops with 

domain relevant 

experts from primary 

care. 

� Work with 12 teams to 

validate objectives. 

Video and audio recordings of team processes 

Development of PHC 

effectiveness measures 

� In-depth work with two PHCTs 

to develop measures. 

� Training and dissemination to 

ten PHCTs. 

� Training team facilitators. 

All teams involved in the questionnaire and interview components of the research 

programme were invited to participate in the next stage of the research. This involved 

analysis via video and audio recording of two of their team meetings. Teams were 

selected randomly for this element of the research. Twelve teams volunteered. 

We selected meetings that were multidisciplinary in composition and that involved 

decision-making (as opposed to information dissemination only). This is because 

understanding team working in this context demands that we observe professionals 

from different backgrounds working together dynamically, and integrating their 

different perspectives to initiate action and change. Multi-disciplinary meetings were 

those in which a range of disciplines (doctors, nurses, health visitors, practice 

managers, etc.) was represented and participated. For the most part, primary health 

care teams allowed us to observe the practice business meetings, in which the day- 

to-day running of the practice was discussed. In one team, the GP partners made all 

decisions affecting the practice. In this case we recorded the partners’ meeting. 

Wherever possible, we recorded two meetings of the same type for each team. 

Dates for meeting recordings were at the discretion of the practice, so the two 

meetings recorded were not always in sequence. Researchers requested that 

recorded meetings should be held in their usual locations, with their usual meeting 

protocols (agendas, minutes, chairing procedures, etc.), and that attendance should 

be the same as if the meeting was not being recorded. The researcher who managed 

the recording equipment made herself as unobtrusive as possible. Meeting size 

ranged from three people to twenty-five.

Audio recording was done with two omni-directional PZM tabletop microphones 

linked to different channels of a high quality audiotape recorder; the microphones 

were set up so as to maximise channel differentiation but to be unobtrusive enough 

that participants would not move them. A single static video camera on a tripod was 

trained to record the gross movements of as many of the participants as possible; 

this record was used only to aid speaker identification during transcription. Before 

each meeting was opened all participants introduced themselves and their 

occupation and upon the basis of this each was allocated a speaker number. 

Therefore the first person to introduce him or herself became speaker 1, the second 

speaker 2 and so on. 

Meetings were transcribed from the audiotapes by an audio typist who had not 

attended the meeting. Audio typists transcribed complete contributions in order, 

according to when they began, labelling each contribution by speaker number, but 

did not code finer timing information. Speaker identification was facilitated both by 

the video recording and by a seating plan drawn up during the meeting by the person 

recording the meeting. A contribution was defined as a period of speech from one 

individual in which the only major pauses coincided with silence from the other 

speakers, so that the pause was likely to be caused by the speaker thinking and not 

by the speaker listening to someone else's contribution. Under this definition, 

speakers cannot follow themselves in the speaking order. Overlapped speech was 

transcribed, with the extent of the overlap roughly marked. Infrequently, parts of the 

meetings were omitted because they were so badly overlapped that we could not 

track individual contributions. After transcription, the transcripts were completely 

anonymised taking out all staff, patient, place names, place and local authority 

names or possible team or person identifiers. 

An example transcription excerpt is given in Figure 2.13. Transcription proceeds one 

contribution per row. Column one contains the speaker number. Column two 

contains the words said, with coding information in a different font, and column three 

contains any notes which the transcriber wished to make (for instance, about people 

entering or leaving the room). 5 

5 In previous work using these methods on four to twelve person meetings, transcribers were 

able to agree very reliably who made any one contribution; using the kappa statistic, K=.93, k 

= 2, N = 230, with an average of 2% and a maximum of 6% non-backchannel contributions 

left as unidentified.

Figure 2.13: An example of the layout of the transcription format used for PHCT 

meeting transcription 

1 Shall I open /4 the meeting 

4 Yep, let’s get on with it. 

3 My apologies I am going to have to leave before 

the end. I have an appointment in Place 1. 

1 Are you skiving off? 

Group laughter 

Because one of the factors of interest in our study is how well teams communicate 

across disciplines, our analysis relies on a classification of meeting participants by 

occupation. For ease of reference, categories are identified by colour as well as 

number. For primary health care teams, Figure 2.14. shows the categories used. 

Figure 2.14: Categories used for PHCT meeting participants 

1 GPs 

2 practice managers 

3 practice nursing staff, including nurse practitioners 

4 attached staff (mostly health visitors, midwives and district nurses) 

administrative staff (mostly secretaries and receptionists) 

6 miscellaneous (visitors, resident caretakers, medical students) 

Development of Performance Measures for PHCTs 

In the broader organisational literatures on team effectiveness, a widely adopted 

approach is the Productivity Measurement and Enhancement System (ProMES) 

based on research by Naylor, Pritchard & Ilgen (1980) (see also Pritchard, 1995). 

Effectiveness criteria are established in group discussions with team members and 

managers. The variables are then “psychologically scaled” to a common 

effectiveness scale. Based on group consensus about expected levels of 

effectiveness, which are given a zero value, maximum effectiveness levels (set at 

+100), and minimum levels (-100) are set. Each variable is also weighted in terms of

its perceived contribution to the overall effectiveness of the team or organisation. 

The system is then used to set objectives, develop indicators, monitor and improve 

performance and give feedback to the team (Pritchard, 1995). The approach has 

been spectacularly successful in many settings (Pritchard, 1995) and is promising for 

primary health care, because of the sophistication of the approach, its theoretical 

robustness and practical utility in complex contexts. 

The ProMES was implemented in three main stages: 

1. Core objectives for primary health care teams were developed using the 

constituency approach and ProMES in four national workshops with 

representatives from Primary Care. 

2. Usable ProMES effectiveness measures were developed and applied within 

primary health care teams. 

3. Primary health care team members and trust representatives were trained to 

develop and implement effectiveness measures using ProMES in primary 

health care teams. 

An initial ‘stakeholder analysis’ identified 13 stakeholders in primary health care. 

These included: 

� GPs 

� Health Visitors 

� District Nurses 

� Practice Nurses 

� Midwives 

� Administrative staff 

� Department of Health 

� NHS Executives 

� Patients 

� Health Authority 

� Researchers 

� PAMs 

� CPN 

Advice was sought from contacts in primary health care about key experts who could 

represent the views of each stakeholder group, and about whether the initial list of

stakeholders was sufficiently comprehensive. The experts suggested by the contacts 

were sent information about the research programme, invited to attend the four one- 

day workshops, and asked to suggest additional or alternative key experts who could 

also make a contribution. In addition, professionals who were currently engaged in 

clinical practice in primary health care teams were invited. The majority of those 

contacted were able to commit themselves to attending two or three of the 

workshops. A full list of those attending and their institutional affiliations is given in 

Appendix II. 

During the workshops focus group methods were used. Delegates were divided into 

three working groups. These were designed so that (a) a range of stakeholder views 

was represented, and (b) one or two or group members had attended most or all of 

the workshops and so could share with new members the learning and experience 

from previous workshops. Each group worked with a trained facilitator, and a note 

taker recorded the group discussion and the decisions made. 

Workshop 1 

Objective: to develop objectives for primary health care. 

The delegates were presented with a set of objectives for primary health care 

developed by the researchers (based on the work of Poulton & West, 1994) and then 

worked together to discard, add or refine objectives. The revised objectives were 

discussed with members of four primary health care teams (who endorsed their 

relevance and value), and combined into a single list. 

Workshops 2 and 3 

Objective: to develop measures of effectiveness in relation to the primary health care. 

Delegates were presented with the refined and agreed objectives for primary health 

care. Each group worked on developing effectiveness measures for objectives. 

Workshop 4 

Objective: to plan the implementation of effectiveness measures in primary health 

care.

In the fourth Workshop, participants critically appraised the objectives and measures 

developed, and considered how they could be applied in practice by PHC teams and 

others. This session was used to plan the implementation and evaluation of the 

effectiveness measures in practising teams. Seven core objectives, with associated 

sub-objectives, were identified and agreed by the professionals attending the 

workshops and 19 effectiveness measures were developed (see Appendix II). 

Work implementing performance measures was carried out in two phases. In the 

first phase, we carried out in-depth work with two primary health care teams to 

develop performance measures, based on the objectives and measures developed in 

the four national workshops, and used these to provide feedback on team 

performance. Details of this work are provided in Appendix III. We worked with one 

team over a period of 15 months, and with the second for a period of 8 months. A 

design team was established in each PHCT that included at least one representative 

from each of the occupational groups in the team. In one-hour workshops held every 

fortnight, ProMES was used to develop performance measures specific and 

appropriate to each team. Teams carried out further development work between 

meetings such as gathering data and consulting colleagues. 

In the second phase, PHCT representatives and trust employees attended a 

‘ProMES in Primary Health Care’ training programme. etters inviting representatives 

from PHCTs to attend the ProMES training were sent to 60 PHCTs that had 

participated in the first stage of the research (all teams with a response rate of 50% 

and above). Letters were sent to the practice manager, senior health visitor and 

senior partner. Follow-up phone calls were made to the teams, but representatives 

from only two attended the training. The other participants were service 

representatives, employed by community trusts, to support and develop primary care 

team working. 

The training programme included an overview of the ProMES approach; the 

development of performance measures; guidance on running ProMES workshops in 

PHCTs; training in how to collect and use performance information. The programme 

for the training is outlined in Appendix IV. After the training, three follow-up 

workshops were held with participants. The purpose of these was to provide support 

to those using ProMES with primary health care teams, and to critically review the 

measures developed in the training. Feedback from the participants about the 

success of their interventions in teams has been positive and suggests there is real

enefit to all aspects of primary health care team functioning from employing this 

approach. At the same time, it is a demanding exercise that requires commitment by 

team members to implement. 

The results from stage 1 and 2 of the research programme are described in the 

following two chapters. Details of the findings from the primary health care team 

surveys and external ratings are outlined in Chapter 3, and the objectives and 

effectiveness measures developed for primary care, outlines in Chapter 4.

.Chapter 3 

____________________________________________________________________________ 

Primary Health Care Team 

Results from Survey and External Ratings 

Summary of Findings 

• Large PHC teams are rated as more effective and innovative by external raters. 

• The greater the number of professional groups represented in the primary health 

care teams, the more highly rated is the innovativeness of the team. 

• The better the team processes and reflexivity, the more innovative they are rated 

by external raters. 

• The greater the number of team meetings, the higher the level of innovation in 

primary health care teams. 

• PHC teams with clear leaders have good team processes. 

• Conflict over leadership leads to poor quality team working. However, teams 

where leadership roles are shared are more innovative.

Introduction 

The data analysis explored two main questions 

• Is there an association between the composition of a primary health care team 

and team processes? 

• Is there an association between the composition and processes of the primary 

health care team and the effectiveness of the team? 

The team characteristics, team processes and measures of 

team effectiveness are summarised in Figure 3.1. 

Figure 3.1: Team Inputs, Processes and Effectiveness Variables 

Characteristics Processes Effectiveness 

Individual 

Age 

Gender 

Ethnicity 

Grade 

Time in job 

Time in team 

Team 

Occupational groups 

Size (number of members) 

Number of GP's 

Hours worked 

Grade Mix 

Training 

Team context 

List size 

Location (urban, rural, city) 

Jarman index 

Fundholding status 

Dispensing 

Purchasing 

Quality of premises 

External contacts 

Relationships with HA 

Team inputs 

Team processes 

Participation 

Innovation 

Objectives 

Emphasis on quality 

Reflexivity 

Number meetings 

Types of meetings 

Frequency of meetings 


Leadership 

Integration and 

communication in the group 

Team ratings 

Organisation 

Team working 

Patient focus 

Innovation 

External ratings (innovation) 

Magnitude 

Radicalness 

Novelty 

Impact 

External ratings (effectiveness) 

Organisation 


Patient focus 

Types Innovations 

Quality of care 

External collaboration 

Responsibility of health 

Use of resources 

Professional development 

Team satisfaction 

Responsiveness 

Stress (GHQ 12) 

Information about the team members’ ages, gender, ethnicity, grade, professional 

group, employer, tenure and team leadership was collected from each team member.

Information was also gathered on team size, hours worked, qualifications, training, 

list size, practice location (urban/rural/city), Jarman index, fundholding status, and 

whether the practice was purchasing and/or dispensing. 

Team Processes 

Individual team members rated team processes on six dimensions: participation; 

support for innovation; clarity of team objectives; emphasis on quality; reflexivity; and 

integration. The variables participation, support for innovation, clarity of team 

objectives and emphasis on quality were very highly correlated and were combined 

to form one variable describing team processes. Information about decision-making 

processes, communication, number and types of meetings, who attended meetings, 

and how the team was managed was collected from practice managers. The 

information on team meetings was categorised according to who contributed to 

operational, strategic and clinical decisions. In addition, a new variable 

‘interdependence’ was developed which assessed the extent to which there were 

mechanisms within the team to encourage interdisciplinary communication. 


This was assessed using information from a variety of sources. Team members 

rated their teams’ effectiveness on three dimensions: team working, organisational 

efficiency and patient orientation. Team members also rated their teams’ 

innovativeness and described the innovations implemented by the team in the 

previous year. These reports were categorised to determine the types of innovations 

implemented. External raters assessed the innovations reported by the teams on 

four dimensions: magnitude; radicalness; novelty and impact on team effectiveness. 

External ratings of team effectiveness were provided by Health Authority 

representatives on two dimensions – clinical and organisational. Individual team 

members also completed the GHQ-12 (a measure of mental health or psychological 

stress). The measures of interest for this report are overall effectiveness, 

effectiveness of patient-centred care (both externally rated and self-rated), overall 

innovation (both externally rated and self-rated), number of innovations to do with 

healthcare, and mental health measured by GHQ-12. 

Results 

The main method of analysis was multiple regression. For each dependent variable, 

possible predictors were split into groups according to type of variable (e.g. 

occupational group, team context), and stepwise regression was used to identify

those which might ultimately predict the dependent variable. The second stage of 

each analysis involved entering all those identified into a further stepwise regression, 

to find out which variables had significant effects independent of other predictors. 

This way, process variables were predicted by team characteristics, and 

effectiveness, innovation and mental health were predicted by team characteristics 

and team processes. 

Since there was often evidence of relationships between size and other variables, 

this was always dealt with first. Where relationships were apparent, later analysis 

revealed whether this was due to team size per se or another feature of having a 

larger team. 

Question 1 – Is there an association between the composition of a primary 

health care team and team processes? 

There was no evidence that PHC team size had an association with any team 

process except frequency of meetings. Here we see that teams of 20 or less have, 

on average, 2.6 meetings a month; teams of 20-30 members have 6.1 meetings a 

month, and teams of over 30 have 6.5 meetings a month. 

Other predictors of team processes (after the second stage of analysis) are shown in 

Figure 3.2. 

Figure 3.2: Relationships between Team Composition and Team Processes 

Dependent variable Predictor variables β p R 2 

Team processes Proportion of managers 0.305 0.010 

Proportion of “other” staff 0.253 0.032 

No. of GPs (WTE) 1 

-0.244 0.036 0.192 

Reflexivity None 

Integration Proportion of managers -0.256 0.035 0.065 

Number of meetings No. of practice nurses 0.418 0.001 0.175 

Consensus on leadership Proportion of “other” staff 0.366 0.002 

No. of managers -0.290 0.012 0.237 

1 WTE = whole time equivalents 

Patterns emerging here are mainly to do with the representation of managers and 

“other” staff types in the teams (anyone other than GPs, nurses, admin/clerical staff,

managers and PAMs). Having a larger proportion of “other” staff in the team has a 

positive effect on team processes and consensus on leadership. A larger number of 

managers also has a positive effect on team processes, but has the opposite effect 

on integration. There is a negative association between a larger number of managers 

and agreement about who leads the team. 

Question 2 – What affects the effectiveness and innovation of a primary 

health care team? 

Team size was positively associated with a number of dimensions of effectiveness 

and innovation, as shown in Figure 3.3. Generally, larger teams were rated as more 

effective by external raters and introduced more innovations overall, and specifically 

in relation to patient care. 

Figure 3.3: Relationship between team size and ratings of effectiveness, innovation 

and mental health 

Variable Correlation p 

Overall effectiveness (external) 0.284 0.012 

Overall effectiveness (self-rated) 0.086 0.401 

Effectiveness of patient care (external) 0.255 0.002 

Effectiveness of patient care (self-rated) 0.125 0.222 

Innovation (external) 0.403 < 0.001 

Innovation (self-rated) 0.123 0.226 

Number of innovations re: patient care 0.255 0.013 

Mental health 0.056 0.585 

Further analysis revealed that the relationships between team size and all the 

innovation variables was curvilinear, with teams of sizes around 40 being the most 

innovative. Notice that there were no relationships between team size and self-rated 

effectiveness, innovation or mental health. 

It is also interesting to note the associations between team size and the individual 

items of the external effectiveness ratings, to see what aspects of effectiveness are 

most related to team size. These are shown in Figure 3.4. Larger teams appear to 

be more responsive to patients and are more likely to conduct clinical audit.

Figure 3.4: Relationship between team size and individual externally rated 

effectiveness items 

Effectiveness item Correlation p 

Provision of information about services 0.131 0.236 

Implementing procedures for dealing with patients’ 

comments, suggestions and complaints 

Maintaining clinical competence in line with patient 

needs 

0.269 0.015 

0.186 0.083 

Auditing clinical practice 0.263 0.017 

Setting protocols 0.373 0.001 

Commitment to professional and personal development 0.273 0.012 

Understanding and valuing roles of all members 0.003 0.981 

Implementing a clear strategy for communication 0.132 0.203 

Profiling health needs and targeted interventions 0.160 0.165 

Reviewing and adjusting skill mix 0.209 0.068 

Collaborating with other agencies 0.094 0.389 

Making effective use of budget 0.126 0.265 

Implementing recommendations of the PHC Charter 0.311 0.004 

Concentration on achievement of The Health of the 

Nation targets 

0.258 0.024 

The main reasons for larger teams being more effective appear to be their 

effectiveness in setting protocols and implementing recommendations of the PHC 

charter. 

Results of the stepwise regression analyses of effectiveness on team characteristics 

and processes are shown in Figure 3.5. 

Figure 3.5: Relationships between Team Composition and Processes, and 

Ratings of Effectiveness 

Dependent variable Predictor variables β P R 2 

Overall effectiveness No. of admin. staff 0.400 0.003 

(external) Proportion of GPs -0.279 0.035 0.199 

Overall effectiveness (selfrated) 

Effectiveness of patient care 

(external) 

None 

Team size 0.357 0.010 0.127 

Effectiveness of patient care Team processes 0.632

(self-rated) 

The relationship between self-rated effectiveness of patient care and team processes 

is not entirely surprising, given that both variables were constructed from the 

individual questionnaires sent out and hence this analysis is prone to common 

method variance. The relationship between team size and externally rated 

effectiveness of patient care is shown in Figure 3.6. This relationship is more reliable 

and suggests that better patient care is delivered in larger primary health care teams 

sizes, up to 30 to 40 members. 

Figure 3.6: Relationship between team size and effectiveness of patient care 

(externally rated) 

Effectiveness of patient care 

6 

5 

4 

3 

2 

1 

0 

Team size 

10 

20 

Figure 3.7: Relationships between Team Composition and Ratings of Innovation 

30 

Dependent variable Predictor variables β P R 2 

Innovation – overall Professional diversity 0.308 0.002 

Reflexivity 0.318 0.001 

Team size 0.290 0.003 0.363 

No. of healthcare innovations Professional diversity 0.263 0.024 

No. of practice nurses 0.299 0.011 

Team processes 0.342 0.005 

Lack of clear leadership 0.274 0.023 0.298 

Innovation (self-rated) Reflexivity 0.384 0.018 

Team processes 0.315 0.050 0.454 

40 

50 

60 

70

It seems that professional diversity in the team, reflexivity (taking time out to review 

objectives, strategies and processes) and team processes all have positive effects on 

innovation. Some of these relationships are illustrated in figures 3.7 to 3.11. 

Figure 3.8: Healthcare innovations and professional diversity 

Figure 3.9: Overall innovation and professional diversity 

Overall innovation - external rating 

Mean number of innovations re: 

quality of healthcare 

5 

4.5 

4 

3.5 

3 

2.5 

2 

1.5 

1 

7 

6 

5 

4 

3 

2 

1 

0 

< 7 7 8 9 10 11 12 > 12 

Number of professions represented in team 

6 or fewer 7 8 9 10 11 12 or more 

Number of professions represented in team

Figure 3.10: Relationship between reflexivity and overall innovation 

Overall innovation 

2.0 

1.5 

1.0 

.5 

0.0 

-.5 

-1.0 

-1.5 

2.5 

3.0 

Reflexivity 

3.5 

4.0 

LFigure 3.11: Relationship between team processes and number of innovations in 

healthcare 

Innovations in healthcare 

10 

8 

6 

4 

2 

0 

-2 

2.4 

2.6 

Team climate 

2.8 

3.0 

3.2 

3.4 

4.5 

3.6 

5.0 

3.8 

5.5 

4.0 

6.0 

4.2

Bearing in mind that a larger score represents poorer mental health, results show 

that teams which are composed of members who are relatively similar in terms of 

age, have a larger proportion of managers, and avoid conflict over who leads the 

team, are characterised by better mental health for their members. This is shown in 

Figure 3.12. 

Figure 3.12: Relationships between Team Composition, Processes and Team 

Members’ Mental Health 


Mental health Proportion of managers -0.420

Figure 3.14: External Ratings of Overall Innovation and Number of Meetings 

Overall innovation 

4 

3.8 

3.6 

3.4 

3.2 

3 

2.8 

2.6 

2.4 

2.2 

2 

1 or less 1 to 4 4 to 6 6 to 10 More than 10 

PHCT Meetings per month (average) 

It was also shown that this effect is independent of both self-rated processes and 

team size. 

Leadership 

Research evidence suggests that leadership is an important factor contributing to 

team effectiveness. We therefore explored the contribution of leadership to team 

effectiveness and innovation in primary care teams separately. We explored the 

extent to which there was a clear leader in the PHC teams, and who was regarded as 

the leader. Only a third of PHC teams reported having a single clear leader. Nearly 

half reported having a number of people lead the team, which, in most contexts, is 

likely to cause considerable confusion. The most frequently named leader of PHC 

teams is the Practice Manager. Only a third of team members nominated a GP. 

Clarity of leadership was examined as an explanatory variable. Figure 3.15 shows 

that team processes were poorer where there was no clear leadership, (from either 

one individual or several people), or where there was conflict over leadership.

Figure 3.15: Clarity of Leadership in the PHC team predicting processes 


TCI mean score Lack of clear leadership -0.311 0.001 

Conflict over leadership -0.294 0.002 0.180 

Reflexivity Lack of clear leadership -0.366

These effects, and those for externally rated effectiveness, are all entirely mediated 

by group processes suggesting that the mechanism by which leadership influences 

effectiveness is through developing good team processes, such as shared 

objectives, participation, emphasis on quality and support for innovation. 

We also find that there is less clarity of leadership in teams which have a greater 

proportion of part time workers (r = 0.309, p = 0.016), and there is less likely to be a 

single clear leader in teams with greater professional diversity (r = 0.309, p = 0.016). 

Both of these support the finding in Figure 3.2 that there is less consensus on who 

the team leader is in teams with a larger proportion of “other” staff types. 

Overall, the findings from this stage of the research reveal a very clear picture 

of the factors predicting the effectiveness and innovations of primary health 

care teams: size, clear leadership, professional diversity and integration 

through regular meetings are key factors in predicting PHC team 

performance. Of course, it could be that teams that innovate and are effective 

have the confidence to recruit members from diverse professional 

backgrounds, and are required to meet more often because of the innovations 

they introduce. Clear leadership may emerge as a consequence of innovation 

and as a consequence of the cohesiveness arising from effective 

performance. Such interpretations are feasible and need to be explored 

empirically. However, the interpretation implied in our presentation of results 

(inputs and process predict performance) is consistent with research into 

effectiveness of teams from across a range of sectors and countries (Cohen & 

Bailey, 1998, West, Borrill & Unsworth, 1999).


Chapter 4 

Qualitative Research: 

Developing Objectives and Effectiveness Measures 

for Primary Health Care Teams 

• Using the constituency approach seven core objectives were developed which 

were judged relevant and covered all the main aspects of primary health care 

activity. 

• Measures which could be used to measure performance on each of the 

objectives were developed in workshops with a range of primary health care 

stakeholders. 

• Primary health care teams used the ProMES approach to develop measures 

which could be used to measure their performance against the objectives for 

primary care. 

• Primary health care teams were able to use the measures developed to get 

feedback on their performance, and use this information to introduce 

improvements in patient care.

Measuring Effectiveness in Health Care 

There is little agreement in primary health care about what constitutes effectiveness. 

One reason for this is that primary health care comprises a wide range of 

stakeholders (health care professionals, trusts, health authorities, patients, carers, 

voluntary groups) each with their own aims, objectives and priorities which influence 

how effectiveness is conceptualised. In addition, there is considerable variation in 

philosophies of care among the professionals groups within primary care (Toon, 

1994), and different approaches and perspectives on what is judged to be high 

quality of care (Maxwell, 1992). One consequence of this is that health care will be 

judged as more or less effective depending upon the criteria adopted by the 

particular stakeholder, or on the philosophy or care espoused by a professional 

group. 

To enable these differing priorities and perspectives within health care to be taken 

into account the qualitative research carried out by the research team used the 

constituency approach (Connolly 1990) to develop objectives, and the Productivity 

Measurement and Enhancement System (ProMES) developed by Naylor, Pritchard 

and Ilgen (1980) to develop effectiveness measures. There were two main stages to 

the work: developing objectives and effectiveness measures in national workshops; 

developing effectiveness measures with primary health care teams. 

Stage 1 - National Workshops: Developing Objectives and Effectiveness 

Measures for Primary Health Care 

The aim of this stage of the qualitative research was: 

• To develop a set of objectives for primary health care which was acceptable to all 

perspectives in primary health care 

• To develop effectiveness measures which were acceptable to all perspectives in 

primary health care. 

The constituency approach was used to develop objectives for primary health care in 

four national workshops with representatives from primary health care (see chapter 

2). These objectives were then validated in workshops with representatives from 12 

primary health care teams. The objectives and sub-objectives developed as a result

of the workshops and consultations with primary health care team representatives 

are shown in Fig 4.1. 

Figure 4.1: Core Objectives for Primary Health Care teams 

Promote, maintain 

and improve health 

Enable personal 

and community 

responsibility for 

individual health 

Efficient use of 

resources 

Continuous 

personal and 

professional 

development 

High team member 

commitment, stress 

and satisfaction 

Responsiveness to 

clients and 

community 

Collaboration and 

partnership with 

other relevant 

organisations 

� Provide high quality health care 

� Accurate identification of individual and population health 

care needs 

� Review and improve the effectiveness of health care 

provision 

� Manage illness, injury and disease taking account of 

agreed standards and evidence based practice 

� Enable patients/clients to make informed decisions about 

their own health. 

� Proactively encourage positive health behaviour 

� Implementation of health education and preventative 

care programmes 

� Human resources – skills, knowledge, expertise, time 

� Physical resources – budgets, equipment, premises 

� Individual annual training plans which take account of the 

plans of the PHCT 

� Equal access to training/development resources 

� Team working 

� Mechanisms for reviewing and acting upon staff 

dissatisfactions, conflicts and complaints 

� Gather information and feedback from clients/community 

stakeholders/opinion leaders 

• Build external relationships with clear objectives and high 

levels of participation, interaction and trust 

The first aim of the national workshops was to get agreement on the objectives for 

primary health care, and to develop a set of objectives that cover all aspects of team 

activity. The work carried out by workshop participants, and the subsequent 

amendments made as a result of the rating and discussions with PHCT 

representatives, enabled this main objective to be achieved. Given the diversity of

views, agendas and perspectives in primary health care it was a major achievement 

that by the end of the four workshops agreement had been reached. 

The second aim of the workshops was to develop effectiveness measures for primary 

health care. A preliminary set of effectiveness measures was developed during the 

workshops that reflect the range of stakeholder perspectives. These can be 

developed further and used by primary health care teams. The research team 

carried out additional work on some of the preliminary measures, developing 

indicators of team effectiveness that could be used to measure performance. 

Effectiveness Measures Developed in the Workshops 

Objective 1 - Promote, maintain and improve health 

Quality of care 

• Patient Charter taken into account 

• health promotion activities carried out 

• appropriate skill mix in the team to meet patient needs 

• measure - % of appropriate consultations as % of total consultations 

• measure - appropriate immunisation rates (without adverse incidents) 

• measure - effective management and knowledge of chronic diseases (epilepsy, 

diabetes, asthma) 

• measure - quality of patient consultations 

• measure - appropriate admissions to hospital 

Accessibility of service 

• appropriate number of surgeries offered and times (also flexibility) 

• appropriate length of consultation (also flexibility) 

• waiting times. Time taken to get routine and emergency appointments (with any 

member of the PHCT) 

• availability of non face to face contact i.e. telephone access 

• clients seen consistent with the severity of their needs (e.g. emergencies seen 

quickly)

Chronic disease management 

• effective management and knowledge of incidence of critical diseases: E.g. 

Epilepsy, Diabetes, Asthma 

In terms of - 

Diagnosis 

Registers 

Protocols 

Interviews 

Referral/use of other services 

• appropriate referrals to other services. Such a measure could indicate a lack of 

skills in the team or illness in the community 

• number of effective or appropriate contacts with agencies such as palliative care, 

social services etc. i.e. good network of services 

• level of appropriate access to the right services. Quality of partnerships and 

alliances in referrals is important here. This indicator might also be linked with 

the range of skills in the team 

• identification and reduction of health and social care “grey areas” e.g., when 

health care professionals do social care activities 

• appropriate waiting times for admission to hospital i.e., for treatment from other 

agencies 

• rates of emergency admissions/self referrals 

Treatment 

• use of evidence based treatment and prescribing protocols 

• appropriate intra-team referral. The group felt this was possibly more important 

than referral to other agencies 

• low adverse complications incidence 

• care delivery derived from plan of care. Having action plans helps evaluation of 

goals 

• the team produces R&D strategy (based on consensus) 

• the team produces clinical audit and clinical supervision action plans (based on 

consensus)

• care packages/episodes of care (rather than just number of contacts) 

• progress towards Health of the Nation targets 

Identification of health needs 

• identification of health needs and the mechanisms to adjust efforts to match 

these needs 

• utilisation of external bodies to identify service plans and needs met 

Data Collection: Practice level 

• measure - types of information collected demographics/diseases/conditions/ 

activity levels) 

• measure - accessibility of data collected to PHCT 

• measure - PHCT contributing to data 

• compare with national/regional data 

Data collection: Local, regional and national sources 

• Assess completeness of data set 

Use of data for: 

• daily planning 

• longer term planning - strategy/direction 

• identifying gaps in provision and skill mix 

• measure - number of action taken/changes made 

- up-take of training 

- modification of skill mix 

- review process 

- formal service plans 

• budget allocation consistent with priorities 

• Identifying and utilising opinion leaders in the community and community 

networks

Accountability 

• meeting NHS care standards 

• meeting NHS reporting requirements 

• meeting requirements of other appropriate external agencies 

• progress towards Health of the Nation targets 

Objective 2 - Enable personal and community responsibility for individual 

health 

• effective health education and preventative health care programs 

• appropriate immunisation rates (without critical adverse incidents). What is 

appropriate will vary in accordance with local needs) 

• information to patients and health education 

- includes information and knowledge and explanation for patients 

- making it personalised - so patient is recognised as an individual 

• increasing knowledge about health in the population 

- i.e. with employers, teachers etc. 

• patients educated to make appropriate self-referrals to members of the PHCT. 

Where is the locus of control, within the team or with the patient? 

• number of health problems revealed by screening 

• provision and take up of preventative health care programmes 

Objective 3 - Efficient use of resources 

• monitor appointment management - DNAs 

• protocols: new, renewed, rejected 

• use of accommodation/equipment 

• develop skills inventory and monitor use of skills 

• measure - input costs: GP: practice size 

• measure - initiatives developed to use time effectively and review process 

• measure - balance between outputs and resources/monitor over time 

• measure - % of time with patients 

• review duplications of roles/effort

• existence of evidence based prescribing protocols for practice (and review of 

these). There is a need to close the loop between cost effectiveness and clinical 

effectiveness of prescribing 

• existence of evidence based treatment protocol (including shared protocols and 

reviews) 

• use of clinical guidelines (not just medical - so incorporates everyone in team) 

• planned clinical audit 

• degree to which safety standards were being complied with (Baseline could be 

minimum standards set by Health and Safety Executive) 

• how effectively the PHCT computer systems are being used 

Objective 4 - Continuous personal and professional development 

Development of skills 

• Regular development and learning needs to be considered at the level of the 

individual, the team, the national governing bodies, and the professional bodies 

that monitor health care professionals 

• strategy plan for training and development 

- long term and short term 

- individual skills/job description 

- match health needs/individual needs 

- match to organisational objectives 

- who contributes to developing the plan 

- take account of each individual’s understanding of ‘development’ 

• measure - commitment to development of skills in the team 

• equal access to/management of training budget 

• research activities carried out - how funded, quality and quantity. 

• utilisation of a full range of training methods (e.g., on the job, networking) 

• opportunities for job exchange 

• skill sharing - opportunities and time spent 

• mechanism in place to evaluate the effectiveness of training and development 

that is done, including publication of the existence of training opportunities, time 

available, equipment, instructors, etc. 

• job performance of staff should be assessed on a regular basis using an agreed 

upon procedure

Checklist of activities which contribute to the development of skills: 

• availability of peer support/mentoring (inside and outside)/advocacy 

• individual career development plans 

• reviews of development plans 

• IIP in place 

• staff appraisal - linked to short term and long term goals 

• identification of training needs - and review of these 

• training equally available across team 

• feedback on training attended/portfolio maintained/accreditation 

• protected time available for professional development 

• access to resources to support training and development 

• indicators for learning and training 

Team member mental health/stress 

• procedures to resolve conflict between patient/practitioner needs 

• procedures for taking account of personal needs/family commitments 

• staff allowed to be off sick 

Objective 5 - High team member commitment, stress and satisfaction 

• measure - staff turnover/absence 

• measure - how valued staff feel/commitment/grievances 

• mechanism in place for reporting satisfaction levels back to team members and 

dealing with dissatisfaction when it becomes a problem 

Team development 

• team participate in team development activities? 

• availability of social budget 

• shared understanding of roles and values 

• the team contribute to the annual report/business plan? 

• the team has regular meetings 

• procedure for coordinating sub-groups and whole team 

• procedures for communication

• procedures to integrate roles/expectations across professional groups 

• processes for critically evaluating and improving decision making 

• equal opportunity for participation in decision making 

Learning organisations 

• measure - support for innovation 

• measure - resulting changes 

Objective 6 - Responsiveness to clients and community 

• a commitment to client satisfaction within the team 

• complaints procedures in place 

• accessible information produced for patients 

• patient choice re health care 

• take account of patient perceptions of improved health and stress 

• use questionnaires/surveys to assess patient satisfaction 

• user involvement in decisions about their own health 

• actions taken in response to patient suggestions for improvement not the same 

as complaints - giving patients the opportunity to make comments without feeling 

as if they are complaining. 

• carefully listening to the client 

• giving clients the information to make informed choices 

• getting inputs on client needs from clients, community and opinion leaders, 

groups representing clients 

Objective 7 - Collaboration with other organisations 

• measure - staff use of skills and resources available 

• effective contacts with related agencies and groups outside the PHCT 

Development Work Carried Out by the Research Team 

The research team carried out additional work after the national workshops refining 

some of the measures of effectiveness identified in the workshops. These are 

described below.

Objective 1 - Promote, maintain and improve health 

• The PHCT would have a monthly (or more frequent) staff meeting where a 

sample of cases was reviewed. This review would include the appropriateness of 

who saw the client, what procedures used, and whether that client was handled 

appropriately in all aspects. The measure would be the percentage of cases 

which were considered as being managed appropriately. This would also be the 

basis for discussion of what improvements need to be made for those specific 

clients and for clients in general. 

• The task of developing a health needs analysis can be broken down into 

definable steps, e.g. get information on how to do such an analysis, decide on a 

plan for doing the analysis for that particular PHCT, gather the information, put 

the information together into a form that the PHCT can use to make decisions. 

Each of these steps would be given a time for completion. The indicator would 

be the percentage of the analysis completed compared to the anticipated time for 

completion. 

Survey on client perceptions of health improvement after treatment. For 

example, each client is given a questionnaire or a sample of clients are called by 

phone and asked about improvements. Measure is the percentage of clients 

improving. For the various specific targets given by agencies outside the PHCT 

such as immunisation rates, develop a scoring system whereby each level of 

meeting the objective gets a certain number of points, e.g. if the target 

immunisation rate was 80%, actually doing 80% would give 100 points, 60% 

immunised would be 20 points, 70% 80 points, 90% 130 points, etc. The 

number of points would be based in the importance of that target. The index 

would be the percentage of actual points earned compared to the maximum 

possible points received if all targets were met. 

• The percentage of required reports completed on time 

• The number of required reports returned by agencies requesting corrections or 

additional information. (This would be an index of the quality of the reports.)

Objective 3 - Effective use of Resources 

• Number of new initiatives developed that are designed to help team members 

use their time better. These initiatives should also be reviewed on a regular basis 

to ensure they are still effective. 

• Percent client contact time as a percentage of total time. This measure gets at 

how much time is devoted to clients. It does not measure how well that time is 

being spent. Other indicators are needed to address this issue. (Note that this 

indicator is one where there is probably an optimal level between the extremes. 

Too little time with clients may suggest too much administration time. Too much 

time with clients may suggest too little administration time.) 

• Percentage of staff turnover over time. High staff turnover leads to inefficient 

resource utilisation because it takes time to teach procedures to new staff and 

work is lost as a departing staff member leaves. This measure would also be an 

indicator for the satisfaction of team members. 

• Percentage of appointments which are unfilled or where the client did not come. 

Objective 4 - Continuous personal and professional development 

• Training and development. A list of training and development experiences for 

each person on the team would be developed each year. For example, 

attendance at a certain type of conference, training on a piece of office 

equipment, learning a new procedure, etc. This list would be the development 

plan for that person for that year. There would be two measures for training and 

development. The first would be the percentage of team members who had the 

written plan. The second measure would be the percentage of the development 

plan items actually completed. 

• Which team members are reviewed, given feedback, and have a formal, jointly 

developed action plan for making improvements.

Objective 5 - High team member commitment, stress and satisfaction 

• Measure overall satisfaction on a monthly or bi-weekly basis with a very brief 

questionnaire that would take no more than 2 minutes to compete. Measure 

would be the percentage of staff indicating Satisfied or Very Satisfied with their 

jobs. 

• Staff turnover is also a satisfaction measure. Note this measure under Effective 

Management of Resources. 

Objective 6 - Responsiveness to clients and community 

• Establish a formal procedure where clients can make complaints including a 

process for following up on these complaints. Measure is the number of such 

complaints which were not concluded to the client’s satisfaction within one week. 

Stage 2 - Effectiveness Measures Developed by Primary Health Care Teams 

The ProMES approach is based on a theory of motivation which proposes that effort 

is maximised when there is a clear link between effort and outcomes, there is 

agreement about what are valued outcomes, feedback is provided on performance 

and the evaluation of performance is judged to be fair (Pritchard, Jones, Roth, 

Stuebing & Ekeberg (1988). Research evidence shows that involving individuals in 

the process of agreeing the valued outcomes from their work and developing 

methods for assessing their performance has a greater impact on performance than 

when these are imposed (Pritchard, 1995). The research team therefore carried out 

ProMES work with primary health care teams so they had the opportunity to develop 

their own effectiveness measures. 

There were two main aims for this work: 

• To demonstrate that primary health care teams could develop effectiveness 

measures using the ProMES approach 

• To demonstrate that primary health care teams could use the measures 

developed to get feedback on their performance.

Qualitative work using ProMES was carried out with two PHCTs (see Chapter 2). 

There were four distinct stages to the work: 

1. Establishing a 'design team', these were representatives from the team who were 

primarily responsible for developing the measurement and feedback system. 

2. Reaching agreement that the objectives developed in the constituency 

workshops, were relevant and related to all the main activities of the 

organisation/team. 

3. Develop measures that could be used to assess the extent to which these 

objectives are being achieved. 

4. Using measures to gather information about how well the team was performing. 

The researchers worked with the primary health care design teams over a period of 

eighteen months, meeting for one hour once a fortnight. As a result of this work the 

primary health care teams successfully developed effectiveness measures that they 

could use to assess performance on all of the objectives for primary health care. A 

major issue in primary health care is the considerable work pressures and demands 

made on all members of the team. This is a major constraint on the time team 

members have available to engage in activities which do not directly contribute to the 

delivery primary health care team services. It was therefore a significant 

achievement that teams were able to develop measures, and demonstrates what can 

be achieved as result of a relatively small investment of time. 

The measures developed by the teams are listed below. Information on how to use 

the measures is provided in Appendix III. 

Objective 1: Promote, maintain and improve health 

Measure 1 - Review of quality in case management 

Percentage of cases judged to be managed appropriately on the most relevant 

quality dimensions.

Measure 2 - Young People’s Sexual Health 

Percentage unwanted teenage pregnancies in a 6-month period 

Percentage of teenagers prescribed the morning after pill in a 6-month period 

Percentage of teenagers requesting pregnancy tests in a 6-month period 

Measure 3 - Young People’s Health - Alcohol and Drug Misuse 

Number of teenagers attending A & E after drug overdose in a 3-month period 

Number of teenagers attending A & E after excessive alcohol consumption in a 3- 

month period. 

Measure 4 - Patient access to consultations with a GP 

The number of days that patients wait to see a GP of their choice 

Measure 5 - Patient access to a quality consultation with GPs 

Percentage of patients whose appointment with a GP is minutes duration in a 

3-month period. 

Measure 6 - Use of out of hours services by patient 

Percentage reduction in the use of private out of hours services by patients in a 6-month 

period. 

Measure 7 - Patients have access to an appropriate health professional 

Percentage of patients, in a 6 month period, who have contact with a 

health professional from the team at a time and location most appropriate 

to them and to the professional. 

Measure 8 - Patients have access to a home visit from an appropriate health 

professional. 

Percentage of patients in a 6 month period who have a home visit from the 

health professional judged by the patient and the health professional to be 

most appropriate. 

Objective 2: Enable personal and community responsibility for individual 

health 

Measure 9 - Patients understand the role and function of the PHCT.

Number of patient requests, use health professionals’ time and PHCT services which 

are inappropriate in a 3 month period. 

Objective 3: Efficient Use of Resources 

Measure 10 - Patients able to manage minor illness 

Percentage of patients seen by health professionals in the team who had a minor 

illness which could have been managed themselves. 

Measure 11 - Patients/clients who do not attend for an appointment 

Average percentage of total patients' appointments not kept in a week 

(calculated over a 3-month period). 

Measure 12 - Efficient use of administrative systems 

Percentage of patients not attending appointments with health professionals in the team which 

result from errors in the administrative system. 

Measure 13 - Efficient use of GP resources in the team 

Average number of patients seen by a GPs in a week 

Objective 4: Continuous personal and professional development 

Measure 14 - Team member access to training 

Percentage of who are satisfied with the extent to which their training needs are assessed and 

met in the previous year. 

Objective 5: High team member commitment, stress and satisfaction 

Measure 15 - Team member commitment and satisfaction 

Percentage of staff in the team who feel committed and satisfied 

Measure 16 - Team members use each other's skills, knowledge and expertise 

appropriately

Percentage of team members who report that skills, 

knowledge and expertise within the team are used 

appropriately in 3-month period. 

Measure 17 - Effective team working 

Percentage of requests for help and information and referrals from other team 

members which are inappropriate in a 3 month period. 

Objective 6: Responsiveness to client and community 

Measure 18 - Patients’ Experiences of the PHCT service (1) 

Percentage of patients who report that their experiences of the PHCT services match 

the range and standard agreed by the PHCT. 

Measure 19 - Patients’ experiences of the PHCT services (2) (Using the existing 

measure) 

Percentage of patients whose experiences of the PHCT services meet the standard 

set by the team. 

Measuring Performance 

The second aim of the qualitative work with primary health care teams was to 

demonstrate that it was possible for primary health care teams to use effectiveness 

measures to obtain feedback on performance. Both of the primary health care teams 

were able to used effectiveness measures to gather feedback information. Below we 

detail the procedure used by one of the teams to develop a measure of patient 

satisfaction, gather feedback from patients and then make changes on the basis of 

this feedback 

Measure 19 = Percentage of patients who report that their experiences of the 

PHCT services match the standard agreed by the PHCT. 

The measure was developed by the design team as follows. 

The team listed all of the services they provided (e.g. consultations with a health care

professional, clinics, district nursing and health visiting services) and also considered 

features of the delivery of services which they believed would be associated with 

patients satisfaction (e.g. short waiting times, prompt repeat prescriptions, phone 

answered quickly, access to advice). 

A questionnaire was developed which enabled patients to report their experiences of 

the services and the features associated with satisfaction (see Appendix III, p…..). 

The areas covered by the questionnaire were: waiting time to see a GP; waiting time 

for the phone to be answered; waiting time for a repeat prescription; waiting time to 

see a practice nurse; awareness of health visitor services, waiting times at health 

visitor clinics; and waiting time for district nurse visits. Patients were also asked to 

provide comments on how different services they had experienced could be 

improved. 

Patients were asked factual questions about their experiences, not for opinions. 

For example: 

The last time you wanted an appointment with any of the GPs, how soon did you get 

one? 

Same day [ ] 

Next day [ ] 

After 2 days [ ] 

Longer_________ 

The last time you asked for a repeat prescription, how long did you have to wait to 

get it? 

1st time ___________ days. Not Applicable [ ] 

2nd time___________ days 

The team identified additional patient information that would help to understand the 

information collected on patients’ experiences (age, gender, number of visits to the 

surgery in the previous month). 

Before distributing the questionnaires the team determined the standards they 

wanted to achieve. For each question they decided what would be acceptable and 

unacceptable responses, and the standard they would like to achieve. They

determined the percentage of patients they would expect to experience the service in 

a particular way, the percentage that was unacceptable, and the percentage that 

would be an ideal. For example, the team decided what percentage of patient they 

would expect to see a GP on the same day, the next day, after 2 days, or after a 

longer period of time, the percentages for each which was unacceptable and the 

percentages that they would like to achieve. 

Over a one week period all patients (or for children, their carers) attending the 

surgery were asked to complete a questionnaire. 100 questionnaires were sent to 

home addresses, and an additional 100 distributed via district nurses and health 

visitors. The information from patients was collated and a mean score calculated for 

each item on the survey. 

The score for each item was then compared with the expected standard, 

unacceptable standard and ideal standard, and the differences between the actual 

mean and these percentages calculated. This provided the team with feedback 

about the extent to which the experiences of patients matched the standards the 

team were trying to achieve, where experiences fell below standards, and where they 

were achieving the ideal standard. 

Results from the patient satisfaction survey 

Responses were received from 320 patients which provided a valuable source of 

feedback on the services provided by the primary health care team. On many 

aspects the reported experiences of patients matched or exceed that of the 

standards set by the team. Where the reported experiences fell below the team's 

standards the reasons for this were explored by the design team and changes made 

to the provision of this service. For example, the survey revealed that 50% of 

patients had waited for between 10 and 15 minutes to see the practice nurse after 

their appointment with the GP. This was below the target set, 90% of patients 

waiting a maximum of 5 minutes. 

Two main reasons were identified for the longer waiting time: patients were not clear 

about the procedure for seeing the practice nurse after their GP consultation; and 

there were insufficient consultation rooms to accommodate the patients who needed 

to see these nurses. Two changes were proposed to reduce the waiting time. 

Firstly, an information slip explaining the procedure for seeing the practice nurse was

produced which GPs could give to patients when they referred them to the nurse. 

Secondly, the use of consultation rooms was reviewed. An antenatal clinic, which 

used two consulting rooms, was held at the same time as the morning surgery. It was 

proposed that this clinic was run at a different time thus providing two additional 

rooms the practice nurses could use for patient consultations. 

Discussion 

The aims of the qualitative research were to develop agreement among primary 

health care professional about the objectives for primary health care, to develop 

measures that would provide feedback on the extent to which effectiveness was 

being achieved, and to demonstrate that primary health care teams could develop 

and use effectiveness measures. 

The national workshops brought together a wide range of primary care stakeholders; 

representatives from district nursing, health visiting, general practice, practice 

nursing, midwifery, mental health, professions allied to medicine, social services, 

health authorities, the Department of Health, NHS Executive, NHS trusts, patient 

actions groups and academia. During the course of the workshops these 

stakeholders, who had differing aims, objectives, priorities and philosophies of care 

were able to reach agreement about the objectives for primary health care. The 

practitioners at the workshops judged these objectives relevant and useful, as did 

members of primary health care teams who were consulted during the development 

process. 

Using the objectives developed in the workshops, the ProMES approach was used 

with two primary health care teams to develop measures. This stage of the research 

also involved working with multidisciplinary groups of health professionals who 

developed a set of effectiveness measures that could be used to assess the team's 

performance. These measures were used by the teams to get feedback on how 

effectively they functioned, and, as illustrated in the example discussed above, this 

feedback was used to improve the quality of care to patients and to use the 

resources available to the team more efficiently. 

The second stage of the research demonstrated that it is possible for primary health 

care teams to develop and use effectiveness measures. Further work is required to 

improve and refine the measures developed by the primary health care teams, and to

test their generalisability for primary health care teams in a range of settings.

The qualitative research has demonstrated that a combination of the constituency 

approach and ProMES provides a practical method that can be used to help primary 

health care teams clarify their objectives and to obtain feedback on the effectiveness 

of the services provided. This will help health professionals to prioritise resources 

and to deliver high quality, cost-effective health care.

Introduction 

Chapter 5 

Community Mental Health Teams 

Research Methods and Sample Details 

NHS secondary mental health care is delivered primarily through multidisciplinary 

community mental health teams (CMHTs). These face many challenges. They are 

tasked with complex statutory and professional responsibilities (Peck & Parker, 

1998). The demands of a primary care-led NHS often conflict with the policy 

imperatives of the sensitive area of risk management relating to severe mental health 

problems (Onyett, 1995). In addition, the voice of service users gains strength, 

adding to workload and pressures. Team members are employed within two very 

different bureaucracies; those of health and social care, and come from diverse 

professional backgrounds. However, the development of joint commissioning 

approaches between health and local authority social services requires them to 

function as integrated teams (Hannegan, 1999). Their constituent professions may 

jibe at the adjustments this requires (Mistral & Velleman, 1997), for which their 

training may not prepare them well. 

The current policy agenda is increasingly outcomes-focussed. Accordingly, CMHTs 

are required to monitor their performance (Bhugra, Bridges, & Thompson, 1995) and 

effectiveness, as a strong commitment to monitoring and evaluation is considered 

essential for adequate management of CMHT services (Carter Evans, Crosby, 

Prendeergast & De Sousa Butterworth, 1997). The competition for resources 

amongst elements of health and social care provision requires that each provide data 

to demonstrate the value of its contribution. More positively, effectiveness measures 

may also bring some clarity to teams' efforts to chart their own progress towards 

meeting diverse expectations. 

The organisation of CMHTs is central to their functioning (Bhugra, et. al., 1995; 

Onyett, 1997). Their core rationale is to bring together a range of professions in 

order to deliver more effective care co-ordination than could be achieved without an 

integrated, multidisciplinary team. Achieving that integration is by definition an 

organisational task (Onyett, 1995; Pincu, Zarin & West, 1996), requiring that the team

e more than the sum of its diverse constituent members acting individually. This 

task is rendered considerably more challenging by the need for multi-agency working 

across the health-social services divide (Department of Health, 1995). 

User and carer perspectives are increasingly important. The National Health Service 

Patients' Charter for Mental Health Services (Department of Health, 1997) sets out 

rights and expected standards of service for users and potential users of these 

services. It aims to ensure that the NHS 'listens and acts upon people's views and 

needs'. A continuing push for users and carers to be involved in decisions relating 

to mental health care (Faulkner, 1997), and also to be included at the level of 

planning and developing services, presents a further challenge to teams which 

deliver integrated care within the Care Programme Approach (Department of Health, 

1990). 

There is a growing international literature on CMHTs as a mode of delivery of mental 

health care. Within the UK, a notable source of this has been the Sainsbury Centre 

for Mental Health. The key issues with emerge from the research literature include 

the following, for each of which a representative citation is provided: 

• The many managerial, professional and clinical barriers to effective 

multidisciplinary teamwork (Peck & Norman, 1999). 

• The importance of integrated operational management of CMHTs (Onyett, 

1997). 

• Leadership, integration and agency as key precursors of effectiveness 

(Grusky, 1995). 

• The threats to effectiveness arising when resource constraints lead teams to 

over-emphasise control and efficiency at the expense of creative thinking and 

innovation (Drolen, 1990). 

• The mismatch between current training arrangements and current and future 

service needs (Sainsbury Centre for Mental Health, 1997). 

• The specific leadership skills required by CMHTs, in which training is 

necessary (Reed, 1995; Sluyter, 1995. 

• The highly demanding nature of CMHT work (Prosser, Johnson, Kuipers, 

Szmukler, Bebbington & Thornicroft, 1996). 

• Detriments to morale and effectiveness from excessive workload (King, 

LeBas & Spooner, 2000).

As the Health Team Effectiveness research programme was nearing completion, the 

National Service Framework for Mental Health (NSF; Department of Health, 1999) 

was published. This seeks to establish national standards for mental health care. 

Within the NSF, national support for local action includes workforce planning, 

education and training. This aims to enable mental health services to ensure that 

their workforce is sufficient and skilled, well led and supported, to deliver high quality 

mental health care. A Workforce Action Team (WAT) has been established to 

provide national leadership in developing and taking forward the workforce action 

plan. We have identified within the WAT interim report (dated April 2000) several 

themes that a study of mental health team-working can usefully address: 

• Education and training: What are the training requirements for effective 

teamworking and how might these be met? 

• Recruitment and retention: What are the salient features of team 

composition? What factors are associated with staff turnover, and how might 

retention be improved? 

• Leadership: How does this impact on quality of care? How can it be best 

developed? 

• Primary care: What characteristics of primary health care teams are 

conducive to high-quality mental health care? 

• Professionally non-affiliated staff: What can the contributions of support 

workers tell us about the potential for further development of non-affiliated 

staff? 

Before offering answers to some of these questions, we describe the methods used 

in our research. 

The research with Community Mental Health Teams (CMHTs) had two stages. The 

first was a questionnaire survey, and related data collection methods, involving large 

numbers of teams to gather data on team inputs, processes and outputs. The 

second stage involved intensive examination of a sub-set of teams to explore in more 

depth targeted team processes and outputs. An overviews of the methodology for 

stage 1 is given in Figure 5.1. 

Figure 5.1: Details of CMHT research methods stage 1 

Additional questionnaires/

Sample size Survey data Telephone 

interviews 

113 teams Team composition Team composition 

Team functioning Team meetings 

1443 

Team effectiveness Team management 

respondents Team innovation Decision making 

Stress 

Clinical systems 

management 

Summary of Research Methods 

A. National workshop to derive CMHT effectiveness criteria 

� Survey of all team members 

B. 113 Community Mental Health Teams 

� Questionnaires or telephone interviews with team leaders 

� External ratings of team effectiveness 

� External ratings of innovations introduced by the teams 

C. 10 Community Mental Health Teams 

� Videotaping and analysis of team meetings 

� Caseload analysis and client selection 

� Interviews with practitioners on two occasions, 6 months apart 

� Use of HoNOS to record client outcomes 

� User and Carer Service Satisfaction Questionnaires 

Quantitative methods 

The Sample 

External 

ratings 

Team 

effectiveness 

Team 

innovation 

The research design required data to be gathered from 100 CMHTs. Initially, chief 

executives of 101 community mental health trusts in 4 regions, Northern and 

Yorkshire, North West, Trent, and North Thames, were approached, to inform them 

of the study and to encourage participation of all CMHTs managed by that trust. The 

aim was to limit the geographical spread while accessing representative CMHT’s, in 

terms of different socio-economic locations, skill mix and client base. Three months 

after the first mailshot, follow-up letters were sent to all trusts not responding. Of the 

101 approached, 81 responded: 11 had no community adult mental health services; 

12 declined to participate and the remaining 58 provided names and contacts for all

CMHTs managed. The main reasons for not participating were either that (a) 

caseloads were such that teams were too busy (3 trusts); or (b) the Trust was in the 

process of reorganisation (7 trusts); or (c) the teams were already taking part in other 

research (2 trusts). 

With the CMHT names provided we made direct contact with 162 CMHT’s, inviting 

participation in the study after consensus to participate had been achieved within 

each team. The final number of participating teams was 113 from 45 trusts. Details 

of the sample are shown in Table 1. At different stages of the access procedure, it 

was open to Trusts or CMHTs to refuse to participate; the sample was therefore 

made up of volunteering CMHTs. We performed a post hoc check on socio- 

economic representativeness, which indicated that the whole range of deprivation 

scores was represented (Mental Illness Needs Index (MINI) range 91.3 (low need) to 

118.5 (high need), mean 103.3). 

Data collection Methods 

Data on team functioning and effectiveness were collected using three methods: self 

report questionnaires completed by individual team members; self report or 

telephone interviews with team leaders; and external ratings from community health 

care representatives, social services and health authority staff. 

The named contact for each of the 113 participating CMHTs provided a 

comprehensive list of all team members, which included all personnel attending 

regular team meetings. Survey questionnaires were sent to 1925 named individuals, 

with returns from 1450 (75%). The return rates for professional groups were: 

administrative staff 57%; community psychiatric nurses 82%; occupational therapists 

83%; psychiatrists 55%; clinical psychologists 90%; social workers 53%; and support 

workers 68%. Overall, 925 women (64%) were included in the sample, and the 

mean age was 40 (SD 8.37). 

Team leaders from 91 CMHTs provided information on team context, team 

composition, team processes, and clinical management in a self-report questionnaire 

survey. 

Questionnaires completed by individual team members 

This questionnaire was in four sections (the CMHT survey is included in Appendix I).


This contained six measures of team working. Four of these were drawn from the 

Team Climate Inventory (Anderson and West, 1994; 1998) that is based on a well- 


assess levels of 

� team participation 

� clarity and commitment to team objectives 

� emphasis on quality 

� support for innovation 

Two other measures were included: 

• reflexivity, the extent to which team members reflect upon their team objectives, 

strategies and processes and make changes accordingly (West, 1996; Swift & 

West, 2000) 

� team innovation, the extent to which the team has introduced innovations in 

objectives, work strategies, processes and relationships 

Respondents were also asked to describe the major changes or innovations 

introduced by the team in their work in the previous 12 months. 

Section 2: Effectiveness 

These included 27 measures of community mental health team effectiveness derived 

at a stakeholder workshop (Rees, Stride, Shapiro, Richards & Borrill, in press; 

Richards & Rees, 1998). Three underlying dimensions were evident: 

� team working 

� patient/client orientation 

� organisational efficiency 

Section 3: Team member stress 

This included a measure of psychological stress, the GHQ-12 (Goldberg, 1972). The 

GHQ-12 is widely used as a screening tool for detecting minor psychiatric disorder in 

the general population, and in occupational mental health research. It covers 

feelings of strain, depression, inability to cope, anxiety based on insomnia, lack of 

confidence and other psychological problems. Within a Department of Health funded 

study of the mental health of the NHS workforce, the GHQ-12 showed good validity 

against a psychiatric interview (Hardy, Shapiro, Haynes & Rick, 1999).


This section included questions on biographical and team characteristics (e.g. age, 

gender, ethnic origin, job title, employer, team composition, team leadership). 

Additional Team Information – Survey 

This was completed by the team leader or co-ordinator in 92 CMHTs, and combined 

the PHCT data collection via survey and telephone interviews. Besides the 

information on decision-making and communication systems, data were collected 

relating to the clinical systems the CMHT implemented for dealing with referrals, both 

emergency and routine, and for accessing inpatient beds. 

External ratings – team effectiveness 

Each of the 113 CMHTs in the survey sample was approached to nominate three 

professionals external to the team, within the local Trust, Social Services, Health 

Authority, or GP practices in their catchment area, in order to collect corroborative 

data on team effectiveness. Thirty-three teams nominated up to 4 external judges 

each. Judges’ ratings were made using the same 27 effectiveness dimensions that 

team members had used to rate their team’s effectiveness. 

External ratings – team innovation 

Two experts known to the research team rated the descriptions of changes or 

innovations introduced in each CMHT over the previous 12 months, and which team 

members had described in their questionnaire responses. The changes were rated 

on the following dimensions (West & Anderson, 1996): 

� magnitude, how great would be the consequences of changes introduced 

� radicalness, to what extent the status quo would change 

� novelty, how new in general were the changes 

� impact, to what extent changes would improve CMHT effectiveness 

Sample Details 

The aim of the research programme is to determine which team characteristics are 

associated with good team functioning and team effectiveness. In this section, we 

describe characteristics of the CMHT sample that participated in the survey 

components of the research programme. Following the model used to guide this 

research see Chapter 1) we describe four categories of inputs:

� team characteristics – indicated by size, mean age, mean tenure, gender mix, 

ratio of full-time members, length of time the team had been in existence. 

� team composition – indicated by the distribution of occupational groups within the 

team. 

� team task – indicated by the MINI (high or low deprivation scores), how quickly 

the CMHT saw emergency referrals, pooling of referrals, the use of a single 

integrated set of client case notes, whether waiting lists were in operation for 

client assessment. 

� team environment – indicated by how the CMHT was commissioned and the 

English NHS region within which the team was located. 

We also describe the relationships between these four domains of inputs. The 

reader will also find an account of team members’ perceptions of leadership in the 

team. 

Team Characteristics 

Number of team members 

In terms of the number of individuals employed within each team, this ranged from 6 

to 51. The mean size was 17.04 members, SD 7.99. Distribution of sample team 

size is shown in Figure 5.2 below. 

Age and gender distribution 

Overall, 925 women (67%) were included in the sample. Figure 5.3 shows the 

percentage of women in CMHTs. The mean age was 40, SD 8.37. Across the 113 

CMHTs, only one CMHT was made up of only women. The age distribution appears 

normal, but it is noteworthy that there are very few CMHT workers below 30 or above 

50 years old. This age profile resembles that of qualified nurses. 

Figure 5.2: Distribution of team size (number of team 

members) across the sample

Number of 

members 

% of women 

35 

30 

25 

20 

15 

10 

5 

0 

up to 10 11 to 15 16 to 20 21 to 25 > 25 

Figure 5.3: Percentage of women in CMHTs in the 

sample 

35 

30 

25 

20 

15 

10 

5 

0 

80 to 

100% 

70 to 

79% 

60 to 

69% 

50 to 

59% 

Tenure 

25 to 

49% 

% of teams 

All team members indicated how long they had been in the CMHT. Mean tenure 

across teams was 37 months, SD 19 months. This relates to the short life of one 

third of teams in the sample, which had been in existence for less than 2 years. 

Whole time equivalents 

Number of Teams

Taking account of hours worked to calculate team size in terms of whole time 

equivalents shows that team size varied from 5.5 to 48.5. The mean size was 15.81 

WTEs, SD 7.53. The small size of the mean difference between numbers of 

members and WTEs suggests that the great majority of team members were 

employed on a full-time basis. Twelve per cent of CMHTs in the sample were 

comprised solely of full-time workers. Across the sample, mean percentage of full- 

time workers was 77.49, SD 13.74. 

Length of time CMHT in existence 

CMHTs were formally introduced on a national basis in 1990, to provide integrated 

care in the community for mentally ill people. In this sample, the length of time the 

teams had been existence varied from 6 months to 7 years. For subsequent 

analysis, these were categorised as less than 2 years (n = 31); from 2 to 5 years 


(n = 36); and 5 or more years (n = 25). 

Figure 5.4 gives the breakdown of the sample by professional group and by gender 

(n = 1363).

Figure 5.4: CMHT occupational groups by gender 

WOMEN MEN 

ADMIN 181 7 

CPN 316 214 

OT 92 14 

PSYCHIATRY 27 55 

COUNSELLING/PSYCHOLOGY 43 17 

SOCIAL WORK 129 83 

SUPPORT WORK 68 22 

OTHER 62 32 

TOTAL 918 444 

As expected, the largest occupational group was nursing, making up 39% of the 

sample. The next largest groups were social work (16%) and administrative staff 

(14%). Occupational therapy (8%), support work (7%), psychiatry (6%) and 

psychology/counselling (4%) were the smaller occupational groups. As compared 

with the overall preponderance of women, who formed two-thirds of the respondents, 

administrative staff were, unsurprisingly, even more predominantly female. Almost 

90% of occupational therapists were women. In contrast, two-thirds of psychiatrists 

were men. The gender mix of nursing and social work showed a modest 

preponderance of women. 

At the team level, multidisciplinary mix was as shown in Figure 5.5. Noteworthy here 

is the fact that just 12% of teams included members from all disciplines (psychiatry, 

social work, psychiatric nursing, clinical psychology, occupational therapy).

Figure 5.5: Multidisciplinary mix within CMHTs 

All disciplines except psychology/OT 

Team Task 

All disciplines 

All disciplines except psychiatry 

All disciplines, no SW 

CPN plus SW 

CPN plus 2 other Health 

CPN Psychiatry and SW 

CPN plus one other Health 

Mental Illness Needs Index (MINI) 

0 5 10 15 20 25 30 35 

Number of CMHTs 

MINI scores for the Health Authority areas within which CMHTs’ populations were 

based ranged from 91.3 (low need) to 118.5 (high deprivation), mean 103.34, SD 

6.91. Figure 5.6 shows the distribution of CMHTs across Health Authorities with low 

(30%), medium (40%) and high (30%) deprivation scores. 

Figure 5.6: Teams in areas of high of high, medium and low need as indicated 

by the MINI 

high need 

medium 

need 

low need

CMHT response to emergency referrals 

CMHTs indicated how quickly, on average, emergency referrals were seen. Elapsed 

time before emergencies were seen ranged from ‘within the hour’ to ‘within two 

weeks’. Across all teams, the mean wait for emergencies was 26 hours, SD = 44 

hours. 

Within-CMHT pooling of referrals 

CMHTs provided information on how referrals, other than emergencies, were dealt 

with. Five CMHTs did not pool referrals; 20 CMHTs pooled some referrals; and 63 

CMHTs pooled all referrals. 

Use of integrated case notes 

In 40 CMHTs, each discipline kept client case notes separately; in 12 CMHTs, notes 

were separate but available for reference by other disciplines; and in 34 CMHTs, 

each client had one integrated set of case notes. 

Assessment waiting list implementation 

Fifty-three CMHTs indicated that they did not operate a waiting list prior to 

assessment, and 36 CMHTs indicated that they did operate a waiting list. 

CMHT Organisational context 

NHS Region 

CMHTs were sampled from four NHS regions in England. The participating regions 

contributed 32, 26, 32 and 23 respectively. To safeguard the anonymity of the 

participating teams, these regions are not identified in this report. 

Local commissioning arrangements 

There were three models of commissioning for these teams: 25 CMHTs were 

commissioned by Health Services only; 39 by Health and Social Services jointly; and 

33 by Health and Social Services separately. CMHTs are constituted on a multi- 

agency basis between health and social services. Most CMHTs necessarily combine 

staff working within the management structures of each of the two agencies, tasked 

with meeting the objectives of both. However, each CMHT must function as a 

coherent entity working towards mutually agreed objectives and following mutually

understood and functionally interdependent practices. Local commissioning 

arrangements may impact on integrated team functioning. 

CMHT constructed process and outcome variables 

Apart from scales derived from survey items, for example, those from the Team 

Processes Inventory, CMHTECQ and GHQ, others were computed to measure the 

clarity of team leadership, within-team variation in relations to the clarity of team 

leadership, the team’s efforts to communicate other than in a formal meeting 

environment, and the team’s turnover. 

Clarity of CMHT leadership 

All team members provided information about the clarity of leadership in the CMHT. 

Team means were aggregated from the single survey item: ‘ Does the team have a 

single clear leader or co-ordinator?’ where ‘yes’ scored 1 and no entry was 

scored ‘0’. Members of 13 CMHTs in the sample were unanimous in reporting that 

their team had a single clear leader, while members of six CMHTs were unanimous 

in declaring that the team had no single clear leader or co-ordinator. The aggregated 

measure was treated as a process variable. 

Within-team variation in relation to the clarity of team leadership 

Blau’s index of variation was used to calculate the extent of disagreement within the 

team about the clarity of leadership. Five variables with values ranging from 0 to 1 

were constructed for the proportion of each team giving each of the five possible 

responses. The resulting variable was treated as a process variable. 

Internal Communication 

In the Additional Team Information survey, team leaders were asked two 

questions to indicate (a) how much team members had access to information 

other than that conveyed in meetings, for example, with the use of memos, 

whiteboards, newsletters; and (b) how much social activity team members 

participated in together. Responses were combined to give a measure of the 

CMHT’s intent to communicate both informally and socially, on a scale of 1 

(poor) to 5 (high quality effort to communicate). Figure 5.7 shows how teams 

varied on this dimension, which was treated as a team process variable. 

Figure 5.7: CMHTs' Intent to Communicate

number of teams 

50 

40 

30 

20 

10 

0 

Turnover 

1 to 2 

2 to 3 

interdisciplinary communication 

3 to 4 

4 and above 

In the Additional Team Information survey, team leaders were asked to indicate how 

many staff had left the team in the previous 12 months. Turnover was computed as 

the percentage of staff in the team (size) who had left, and was treated as an 

outcome variable.

Relationships between ‘input’ dimensions 

Team size 

Figure 5.8: Scatterplot of CMHT climate against team size 

self report: combined TCI scales 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

0 

10 

team size going by team members declared 

20 

Three CMHTs were larger than all others, and scatterplots (e.g. Figure 5.8) 

showed that on some dimensions of team functioning these were outliners. 

They were removed from all analysis involving team size. Team size was 

clearly associated with the diversity of disciplines within the team: larger 

teams were more likely to have psychiatrists (r = .20, p < .05) and 

psychologists (r = .25, p < .01). Larger teams also had a lower percentage 

of full-time staff (r = -.22, p < .05). Team size was associated with only one 

aspect of the team’s task or organisational environment: larger CMHTs were 

more likely to operate a waiting list for assessment, 

r = .29, p < .01. 

30 

Team average age 

The average age of the CMHT was likely to be greater if social workers (r = 

.30, p < .01) and psychologists (r = .25, p < .01) were members. However, 

it was likely to be lower if the MINI score of deprivation was high (r = -.36, p 

< .001). 

40 

50 

60

Team average tenure 

Average job tenure was lower if there were social workers in the team (r = -.20, p < 

.05). Predictably, average job tenure was strongly associated with the length of time 

the team had been in existence (r = .51, p < .001). 

Length of time CMHT in existence 

Beyond the relationship with average job tenure in the team, the life of the 

team was associated with whether it operated at separate sites (r = -.23, p < 

.05), that is, the longer the team had been in existence, the less likely was it 

that staff were based at different locations. 

Percentage of full-time workers 

We saw above that larger teams were likely to have a higher percentage of 

part-time workers. Such part-time practitioners were likely to be psychiatrists 

(r = -.26, p < .01), psychologists (r = -.31, p < .01) and occupational 

therapists (r = -.28, p < .05). Although they described themselves as being 

‘part-time’, these disciplines may well have divided their time between the 

CMHT in question and other responsibilities. 

Percentage of women in the team 

A lower percentage of women in the team was associated with a higher 

deprivation rating, R = .21, p < .05. 

Further effects of team composition 

When psychiatrists were in the team, it was less likely that the team would implement 

a single, integrated set of case notes for each client (R = -.32, p < .01), but if an 

occupational therapist was in the team, the opposite was the case (R = .31, p < .01). 

Again, psychiatrists were more likely to be in the team if the deprivation rating was 

high (R = .23, p < .01). If there were social workers in the team, emergencies were 

likely to be seen more quickly (R = -.27, p < .05). The team was more likely to 

operate a waiting list for assessment if there were social workers (R = .28, p = .01), 

psychologists (R = .23, p < .05) or occupational therapists (R = .23, p < .05) in the 

team. 

Further effects of clinical system implementation 

Where the team pooled referrals at a central point, they were also likely to operate a 

single, integrated set of case notes for each client (R = .25, p < .05), although a 

single referral point was also associated with lower deprivation scores (R = -.29, p

.01). Where the deprivation score was higher, waiting lists for assessment were less 

likely to be in place (R = -.26, p < .05). 

Intensive analysis 

Selection procedure 

Teams rating themselves as highly effective or as highly ineffective, in 

comparison to the self-ratings of the full sample of 113 teams, were selected. 

This recruitment strategy was designed to maximise the power of betweenteam 

analyses to detect associations between intensive analysis variables and 

effectiveness. We computed aggregate team scores on the CMHT 

teamworking questionnaire scales. These comprised the Team Climate 

Inventory (TCI) participation, support for innovation, and task orientation 

scales; the user orientation, use of resources, and internal process scales 

from the service delivery effectiveness (SDE) items; and the 12-item GHQ. 

The standardised team scores on the TCI and the SDE were summed, and the 

standard team score on the GHQ-12 subtracted from this total. This 

algorithm yielded 14 teams above the 80th percentile and 14 below the 20th 

percentile. To achieve a target sample size of 16 teams in this phase of the 

study, all 28 were invited to participate after the team had gained consensus 

amongst members. Ten volunteered, distributed across the 4 NHS regions as 

follows: A, 3; B, 2; C, 1; and D, 4. MINI scores for the 10 teams covered a 

wide range, 91.3 to 110.0, with a mean of 101.4. Three of the 10 had rated 

their activity as effective, leaving 7 who rated their team as ineffective. We 

followed up the 4 teams rated as effective which had not already responded, 

but failed to increase the number. To a considerable degree, therefore, this 

was a self-selected sample. The 10 teams comprised three self-rated as 

‘effective’ and seven self-rated as ‘ineffective’. 

Representativeness of sub-sample CMHTs 

Independent t-tests were used to compare group means on appropriate dimensions, 

together with Levene’s test for equality of variances. This process included 

comparisons for: 

� Team characteristics and composition: size; age; tenure; percentage of full-time 

workers in the team; percentage of men in the team; length of time the team had 

been in existence; professional mix. 

� Task environment: MINI; number of GP’s linked to the CMHT; ; whether the team 

held a single, integrated set of case notes for each client; whether referrals were 

pooled or not; use of a waiting list for emergency referrals.

� Team processes: team processes scale; perceived clarity of leadership; intent to 

communicate informally; amount of meeting time available; perceived quality of 

relationship with GP’s, Health Trust, and Social Services. 

� Team effectiveness: levels of stress; self-report effectiveness; external judges’ 

ratings of performance; external judges’ ratings of team innovations; self-report 

innovativeness; turnover. 

For the most part, group means were similar, with t values ranging from .07 to 1.65. 

Exceptions are shown in Figure 5.9. Levene’s tests for equality of variances did not 

reach significance for any dimension. 

Figure 5.9: Significant differences between survey sample and sub-sample 

Percentage of 

full-time staff 

Average tenure 

of staff (months) 

Psychologist in 

the CMHT 

CMHT stress 

level (GHQ) 

External ratings 

of CMHT 

effectiveness * 

Survey 

sample mean 

(SD) 

Sub-sample mean 

(SD) 

T value probability 

78.48 (13.27) 67.28 (15.09) 2.52 .01 

38.66 (18.89) 24.62 (20.39) 2.23 .03 

0.34 (0.48) 0.80 (0.42) 3.26 .007 

0.96 (0.16) 1.09 (0.20) 2.20 .03 

3.59 (0.38) 3.25 (0.47) 2.07 .05 

* The Ns on this dimension were 25 in the survey group, 8 in the sub-sample group 

These comparisons showed that, in relation to most team characteristics, and most 

aspects of task environment, team process and effectiveness, the sub-sample group 

did appear to be reasonably representative of the full survey sample. However, sub- 

sample teams had a lower percentage of full-time staff, their members were likely to 

have been in the team for a shorter time, were more likely to have a psychologist or 

counsellor in the team, their members experienced a higher level of stress, and 

teams were rated lower on effectiveness by external judges. This last finding is not 

surprising, given that more self-ratedly ineffective than effective teams had 

volunteered to take part in this phase of the research. Chi-square tests showed that 

the sub-sample teams were representatively distributed throughout the 4 NHS 

regions, but were not representatively distributed in terms of local commissioning

arrangements, chi square = 6.33, p < .05, with 7 teams being jointly commissioned 

by Health and Social Services, and 3 by the Health Service only. 

Descriptives on the 10 CMHTs in the intensive phase 

Figure 5.10 shows the characteristics of the ten teams. All had CPNs, all were 

multidisciplinary, although only 3 of the 10 teams had access to psychiatry input 

within the team. 

Figure 5.10: Team characteristics of sub-sample CMHTs 

Team Team Team Team Team Team Team Team Team I Team J 

A B C D E F G H 

Size 16 12 15 15 22 12 18 17 46 12 

Mean age 44.9 37.1 34.6 41.2 38.2 40.4 45.2 41.9 43.3 41.0 

Mean tenure 

(11.70) (7.43) (7.94) (7.22) (7.44) (8.05) (6.45) (8.02) (9.85) (8.43) 

(months) 13.58 23.56 21.07 35.73 10.55 12.00 9.80 3.85 47.11 69.00 

Length of life of Less than 2 to 5 2 to 5 Over 5 Less Less Less Less 2 to 5 Over 

CMHT 

2 years years years years than than than than years 5 years 

2 2 2 2 

years years years years 

Psychiatry in No no no Yes no no No No yes yes 

OT in Yes yes yes Yes yes no Yes No yes yes 

Psychology in Yes yes yes Yes no no Yes Yes yes yes 

SW in Yes no no Yes yes yes Yes Yes yes yes 

% men 33 38 15 27 36 62 27 23 37 42 

% full-time 83 56 54 55 64 100 60 77 67 58 

MINI 97.4 110.0 110.0 91.3 96.6 94.8 97.4 102.6 - 104.2 

Linked GP’s 34 38 26 30 - - 24 35 120 35 

Commissioning H & S H H H & S H & S H & S H & S H & S H & S H only 

jointly only only jointly jointly jointly jointly jointly jointly 

NHS region B A A B C B B C D A 

It is apparent that there were differences between the teams on all structural 

dimensions. For example, team 1 stood out as a large team compared with 

others, and teams B and C were in Health Authorities which had a higher 

MINI score than others, indicating localities with higher deprivation. All teams 

had a mix of disciplines, although team F had only social work input, over and 

above the CPNs who were present in all teams. Percentages of male and fulltime 

workers in these teams varied widely. Half of the teams had been in 

existence for less than 2 years, and this partly accounted for shorter tenure of 

staff, although there is commonly high turnover of staff in the CMHT 

environment. 

Audio and video recording of Community Mental Health Team meetings 

The ten teams volunteering for the intensive stage research also agreed that their 

meetings could be recorded; meeting sizes ranged from six to twenty five members. 

The meetings were multi-disciplinary business meetings in which decisions were

made about the running of the team. This meeting was chosen by the teams as the 

one to record because it is the main forum, outside clinical meetings, that are multi- 

disciplinary meetings. Wherever possible, we recorded two meetings of the same 

type for each team. Dates for meeting recording were at the discretion of the CMHT. 

For details of recording procedures, equipment and transcription see Chapter 2. 

Longitudinal data collection: clinical outcomes; use of resources; patient and 

carer satisfaction 

Two site visits six months apart were arranged with each participating CMHT. Before 

the first, every practitioner in the team completed a caseload audit summary to define 

as precisely as possible the population the CMHT was serving (Manchester Audit 

Tool, recommended by the Kings Fund mental health team). This required a 

breakdown by 19 classifications of the care worker’s entire current caseload in terms 

of diagnosis, severity, complexity and chronicity. Simple guidelines for completing 

the audit questionnaire were included. For the purposes of patient selection, an 

individual breakdown was also completed by each practitioner, using either codes or 

names. Stratified sampling was carried out by the research team using SPSS 

random number generation. Stratification ensured that users selected were 

representative of (a) the individual practitioner’s caseload; and (b) the team’s entire 

caseload profile. Stratification was based on scores provided by practitioners for 

each client for severity, chronicity and complexity. Scores were then summed. For 

each of the 10 teams, 40 users were selected. 

If practitioners indicated that clients were unable to complete a questionnaire, 

because they were in an acute episode, or could not read, or did not read English 

well, they were replaced by others on the key worker’s caseload matched for 

stratification. Packs of information sheets, consent forms and return envelopes were 

sent to each key worker for each of their selected clients (and carers where 

appropriate). Practitioners were requested to discuss the research with clients and 

hand them information and consent form, and for the purposes of confidentiality, to 

ask them to send signed consent direct to the research team. Once the research 

team had received signed consent from client or carer, Patient/Carer Service 

Satisfaction questionnaires were sent out, to assess the effectiveness and 

acceptability of the service received, and users’ quality of life. The questionnaire was 

that developed by the Tameside & Glossop Rehabilitation team, who gave 

permission for its use.

First site visit 

Two researchers visited each team for a day to interview all practitioners with a 

caseload. At the interview, practitioners answered questions about each of their 

selected clients individually. Biographical data were collected: gender, age ethnic 

origin, type of housing, and whether they had a formal carer. Questions relating to a 

period of the previous 6 months covered use of resources, for example, types and 

dosage of psychoactive medication, day hospital attendance, number of contacts 

with CMHT professionals, time spent as an in-patient. Other questions covered 

referral, diagnosis, CPA level, care plan targets, whether or not the client was on 

section, and projected clinical outcomes for 6 months ahead. Practitioners were 

provided with 6 HoNOS forms for each client, to be completed by the practitioner at 

each contact over the following 6 months, or up to discharge. 

Second site visit, after an interval of 6 months 

Self-report key worker schedules were designed, following the model of the 

practitioner interviews implemented at the first site visit. The schedules were sent 

two weeks in advance of the visit to the site to collect completed schedules and 

HoNOS questionnaires, and respond to queries. All team members completed the 

survey questionnaire for a second time, so that change over time could be measured. 

The costs of use of resources were computed by combining estimates of quantity 

and cost per unit. Medication costs were based on the 1997 BNF. Contact costs 

were based on Unit Costs of Health and Social Care (Netten & Dennett, 1997). 

Elements included in the costs were medication, inpatient days, day hospital 

attendance, respite care, day centre use, drop-in use, occupational therapy groups, 

outpatient attendance and contacts with CMHT staff. 

Data analytic strategy 

Psychometric Considerations 

The self-report measures of community mental health team process and 

effectiveness used in this research were complex and novel. Accordingly, prior to 

analysis to address the substantive questions listed above, preliminary psychometric 

analysis considered the intercorrelations among these measures at the team level. 

Specifically, the extent of specificity vs. redundancy in these measures had not 

previously been assessed. To be useful in testing theories relating team processes to 

effectiveness, the measures would have to demonstrate sufficient specificity that the 

relationships among them not be most parsimoniously explained as reflecting a

single evaluative or morale factor. As shown in Figure 5.11, all intercorrelations were 

significant and substantial, ranging from .53 to .89. 

Figure 5.11: Team-level correlations among self-report measures of CMHT process 

and effectiveness 

TCI: 

participation 

TCI: 

support 

for 

innovation 

TCI: 

clarity of 

objectives 

reflexivity innovation 

CMHTEQ: 

external 

requirements 

CMHTEQ: 

internal 

processes 

TCI: support for innovation .858 

TCI: support for innovation .858 

TCI: clarity of objectives .633 .771 

TCI: clarity of objectives .633 .771 

Reflexivity .706 .816 .706 

Reflexivity .706 .816 .706 

innovation .531 .743 .662 .732 

innovation .531 .743 .662 .732 

SDE: external requirements .642 .701 .652 .566 .526 

SDE: external requirements .642 .701 .652 .566 .526 

SDE: internal processes .818 .889 .791 .744 .671 .842 

SDE: internal processes .818 .889 .791 .744 .671 .842 

SDE: monitoring/evidence .555 .676 .620 .578 .551 .878 .777 

SDE: monitoring/evidence .555 .676 .620 .578 .551 .878 .777 

All correlations have N = 113, p < .01.

We therefore considered whether the effectiveness of a team as reported by its 

members could be distinguished from its climate, also as reported by those same 

team members. We entered team means on the four Team Processes Inventory 

(TCI) scales and the three SDE scales in a factor analysis. This indicated that a 

single factor was the most efficient way to describe the differences among the teams; 

attempts to force a two-factor solution did not support a distinction between team 

processes and self-reported effectiveness, as the scales with highest loadings on 

each factor comprised a mixture of both TCI and SDE scales. 

External ratings of effectiveness were available for 33 teams. For this subsample, 

we considered whether external ratings of effectiveness were any more highly 

correlated with self-reported effectiveness than with the TCI. There was no such 

difference. External ratings of effectiveness were as highly correlated with team 

members’ ratings of team processes, r = .64, as with their reports of team 

effectiveness, r = .60. 

The quality of innovations described by the members of all 113 teams was rated by 

external judges. These ratings were no more strongly correlated with team 

members’ TCI ratings, r = .44, than with their reports of the team’s effectiveness, r = 

.39. Considering only the most relevant TCI scale, support for innovation was 

correlated at r = .48 (indistinguishable from the overall TCI correlation of .44) with 

external ratings of innovation. The fact that the TCI correlates rather more highly, at r 

= .64, with external ratings of team effectiveness than with external ratings of 

innovations, r = .44, is further evidence against specificity. Meanwhile, self-reported 

innovation (considered an effectiveness dimension) correlated very similarly at r = 

.55 with external ratings of innovation. 

These analyses rather suggest that the self-report measures should be most 

parsimoniously considered to reflect a single evaluative or morale factor, rather than 

to tap specific aspects of team process or effectiveness. The measures may not, 

therefore, be sufficiently precise to reveal subtle relationships between CMHT 

process and effectiveness. 

Sequencing of Multivariate Analyses 

Analysis proceeded in two steps. First, the questions identified above were 

addressed in sequence. For each dependent variable in turn, potential predictor 

variables were entered in groups. For example, for each team process variable in

turn, team characteristics were entered as one set of predictors, before moving on to 

a second analysis looking at team composition factors as predictors, a third analysis 

with team task factors as predictors, and a fourth with organisational context factors 

as predictors. 

Secondly, for each class of dependent variables in turn, variables that had emerged 

from the foregoing analyses as showing predictive relationships independent of the 

other variables in their respective group were entered into new analyses including all 

such variables across the groups. Analyses at this second step identified predictors 

that were independent in their effects of other significant predictors across all classes 

of predictor. Such predictors warrant closer attention; accordingly, this account of 

our findings will emphasise this second phase of the analysis. 

In the next chapter we describe the results of these analyses.

Chapter 6 


Results from Survey and External Ratings 


• Teams whose members were more positive about team processes are rated 

as more effective by external stakeholders 

• Teams whose members agree as to how clearly the team leadership role is 

defined are rated by external stakeholders as more effective 

• Teams whose members describe their team processes positively perceive 

their teams as more effective 

• Teams whose members report clarity as to the leadership role perceive 

their teams as more effective 

• Teams that have been in existence for a relatively long time tend to 

describe their team as more effective 

• Larger CMH teams are rated as more innovative by external judges 

• Teams who perceive their performance as highly reflexive are rated as 

more innovative by external judges 

• Teams who perceive their team processes and reflexive behaviour as 

positive also see themselves as more innovative 

• Teams who perceive their team processes as poor experience higher 

levels of stress 

• Teams with older members enjoy more stable membership, as do teams 

including social workers

• Teams using integrated client case notes, and teams not including 

psychiatrists, are clearer about the leadership role 

Introduction 

Our analysis was informed by the input-process-outcome model presented in 

Chapter 1. This entailed predicting process variables from input variables, and 

predicting outcome variables from both input and process variables. 

As for the analysis of PHCTs, we addressed two main questions: 

• Is there an association between the composition of a community mental 

health team and team processes? 

• Is there an association between the composition and processes of the 

community mental health team and the effectiveness of the team? 

The team characteristics, team processes and measures of team effectiveness are 

summarised in Figure 6.1.

Figure 6.1: Team Inputs, Processes and Effectiveness Variables 

Characteristics Processes Effectiveness 

Individual 

Age 

Gender 

Time in job 



Team 

Occupational groups 

Size (number of members) 

Number of GP's 

Hours worked 

Multidisciplinary mix 

Gender mix 

Team context 

Commissioning type 

MINI index 

Use of integrated case 

notes 

Response time for 

emergencies 

Waiting list in operation 

NHS Region 

Relationship with Social 

Services 

Relationships with GP's 

Relationship with Trust 



Participation 

Innovation 

Objectives 

Emphasis on quality 

Reflexivity 

Number of meetings 


Frequency of meetings 

Potential time for different 

disciplines to meet 


Leadership 

Integration and 

communication in the group 

Team ratings 

Organisation 


Patient focus 

Innovation 

External ratings (innovation) 

Magnitude 

Radicalness 

Novelty 

Impact 

External ratings (effectiveness) 

Organisation 


User/carer focus 

Types of Innovations 

Quality of Care 

External collaboration 

Responsibility for health 

Use of resources 

Professional development 

Team satisfaction 

Responsiveness 

Stress (GHQ 12) 

Turnover 


innovation; team-objectives; emphasis on quality; reflexivity; and interdependence. 

Information about decision-making processes, communication, number and types of 

meetings, who attended these meetings, and how the team was managed was 

collected from Practice Managers. The information on team meetings was 

categorised according to who contributed to operational, strategic and clinical 

decisions. In addition a new variable ‘integration’ was developed which assessed the 

extent to which there were mechanisms within the team to encourage inter 

disciplinary communication and working.

Team Inputs 

Information about the team members’ ages, gender, ethnicity, professional group, 

tenure and team leadership were collected from each team member. Information 

was also gathered on team size, hours worked, commissioning type, MINI index, 

NHS Region, whether the CMHT made use of a single integrated set of client case 

notes, how long the team took to respond to emergency referrals, whether they 

operated a waiting list for assessment, and the team’s relationships with GP’s, Trust 

and Social Services. 



support for innovation; clarity of team objectives; emphasis on quality; reflexivity; and 

integration. The variables participation, support for innovation, clarity of team 

objectives and emphasis on quality were very highly correlated and were combined 

to form one variable describing team processes. Information about decision-making 

processes, communication, number and types of meetings, and who attended 

meetings was collected from team leaders. An index of the amount of time the 

various disciplines in the team could potentially meet was computed. In addition, a 

new variable ‘integration’ was developed which assessed the extent to which there 

were mechanisms within the team to encourage interdisciplinary communication. 

Team Effectiveness 

As with PHCTs, this was assessed using information from a variety of sources. 

Team members rated their teams’ effectiveness on the three dimensions of the 

Community Mental Health Team Effectiveness Questionnaire (CMHTEQ; Rees, 

Stride, Shapiro, Richards & Borrill, in press), developed within this project: team 

working; organisational efficiency; and patient orientation. Team members also rated 

their teams’ innovativeness and described the innovations implemented by the team 

in the previous year. External raters assessed the innovations reported by the teams 

on four dimensions: magnitude; radicalness; novelty and impact on team 

effectiveness. External ratings of team effectiveness on the CMHTEQ were provided 

by external experts nominated by the team and based in local GP practices, Social 

Services, the Trust or Health Authority. Individual team members also completed the 

GHQ-12 (a measure of mental health or psychological stress). The measures of 

interest for this report are overall effectiveness of the team in delivery of services, 

user-centred care and dealing with the demands of the parent organisation (both 

externally rated and self rated), overall innovation (both externally rated and self

ated), team turnover, and mental health measured by the GHQ-12.

Results 

The method of analysis was similar to that described for the PHCT data in Chapter 3. 

Stepwise multiple regressions were carried out, with possible predictors of each 

dependent variable being split into groups according to type of variable, to identify 

those which might ultimately predict the dependent variable. As with the PHCT 

analysis of Chapter 3, to reduce the complexity of the data set and to guard against 

Type 1 errors arising from multiple statistical tests, we focused on a second-level 

analysis combining predictors across the groups. Process variables were predicted 

by team characteristics or “inputs”; and effectiveness, innovation, turnover and 

mental health were conceptualised as “outcomes” predicted by team characteristics 

(“inputs”) and by team processes. In a final stage of the analysis, both team 

characteristics (inputs) and team processes were considered together as predictors 

of the outcome variables (effectiveness, innovation, turnover and mental health). 

We found that the CMHT data called for a different approach to the issue of team 

size than we adopted for the PHCT data. It transpired that the relationship between 

team size and other variables was largely due to 3 outlying teams (with more than 36 

members). Accordingly, rather than considering team size first in all analyses as we 

had done with the PHCT data, we excluded these teams from analyses including the 

size variable, and thereafter treated team size in the same way as other team 

characteristics. 

Question 1 – Is there an association between the composition of a CMHT and team 

processes? 

Figure 6.2: Relationships Between Team Composition and Team Processes 


Consensus on leadership Team size -.250 .017 

Tenure -.215 .039 .097 

Reflexivity Presence of 

-.225 .018 .042 

psychiatrist(s) 

Integration none 

Team processes none 

Potential to meet none 

Number of meetings Tenure .212 .046 .045 

Figure 6.2 presents the significant team composition predictors of each team 

process variable. Larger teams, and teams whose members had been longer

in their jobs in the team, showed less consensus on the clarity of leadership in 

the team. Teams including psychiatrists as members were less reflexive. The 

tabled result was obtained after excluding the responses of psychiatrists 

themselves, which had inflated the observed relationship. This, our preferred 

analysis, is more conservative because it excludes the effect of the tendency 

of psychiatrists themselves to rate the team as less reflexive. It may therefore 

be interpreted as showing an association, albeit modest, between the 

reflexivity ratings of non-psychiatrist team members and the presence of 

psychiatrists within the team. 

Question 2 – What Affects the Effectiveness and Innovativeness of a Community 

Mental Health Team? 

Figure 6.3: Relationships Between Team 

Composition and Processes, and Ratings of 



Overall effectiveness 

(external) 

Overall effectiveness (selfrated) 

Team processes .643

Figure 6.4: Impact of team processes on 

externally-rated team effectiveness 

(data from 32 CMHTs) 

5.0 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

2.0 

2.5 


3.0 

Figure 6.5: Impact of clarity of leadership on 

externally-rated team effectiveness (data from 

32 CMHTs) 

external rating of team effectiveness 

5.0 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

-.2 

0.0 

.2 

clarity of team leadership 

.4 

Figure 6.3 also presents the three factors predicting self-reported team effectiveness 

on the 27-item Community Mental Health Team Effectiveness Questionnaire 

(CMHTEQ), each independently of the other two: Overall score on the Team 

3.5 

.6 

4.0 

.8 

4.5 

1.0 

5.0 

1.2

processes Inventory, as shown in Figure 6.6; clarity of leadership, as shown in Figure 

6.7; and the length of time the team had been in existence, as shown in Figure 6.8. 

In other words, members of teams whose members described their processes 

positively, members of teams whose members reported clarity as to the leadership 

role, and members of teams that had been in existence for a relatively long time, all 

tended to describe their team as more effective. 

Figure 6.6: Impact of team processes on selfreported 

effectiveness (data from 113 CMHTs) 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

2.0 

2.5 


3.0 

Figure 6.7: Impact of clarity of leadership on self-reported effectiveness (data from 

113 CMHTs) 

3.5 

4.0 

4.5

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

-.2 

0.0 

.2 

clarity of team leadership 

.4 

Figure 6.8: Impact of length of time team in 

existence on self-reported effectiveness (data 

from 113 CMHTs) 

4.0 

3.9 

3.8 

3.7 

3.6 

3.5 

3.4 

3.3 

3.2 

3.1 

3.0 

3.3 

2 years or less 

2 to 5 years 

Length of time team in existence 

.6 

.8 

5 or more years 

Relationships between Team Composition and Processes, and Ratings of 

Innovation 

3.4 

3.5 

1.0 

1.2

As shown in Figures 6.9 and 6.10, two variables predicted, independently of one 

another, the quality of the innovations reported by team members as rated by 

independent, expert judges: Reflexivity, beta = .51, t = 6.72, p < .001; and team size, 

beta = .38, t = 5.00, p < .001. In other words, teams whose members rated their 

teams as highly reflexive, as well as larger teams, described innovations that were 

judged to be of higher quality. 

Figure 6.9: Impact of reflexivity on expert 

ratings of innovation quality (data from 113 

CMHTs) 

external rating of team innovations 

5 

4 

3 

2 

1 

0 

2.5 

reflexivity 

3.0 

3.5 

4.0 

Figure 6.10: Impact of team size on expert 

ratings of innovation quality (data from 113 

CMHTs) 

4.5 

5.0 

5.5 

6.0

external rating of team innovation 

5 

4 

3 

2 

1 

0 

0 

team size 

10 

Three factors, acting independently of one another, were associated with the 

innovativeness reported by team members: self-reported reflexivity, beta = .45, t = 

3.75, p < .001, as shown in Figure 6.11; overall score on the Team Processes 

Inventory, beta = .32, t = 2.65, p = .009, shown in Figure 6.12; and freedom of 

interaction (scheduled co-presence of the different disciplines at meetings), beta = - 

.15, t = -2.20, p = .03. In other words, teams whose members reported a high level 

of reflexivity, teams whose members reported team processes as positive, as well as 

teams scheduling relatively little cross-disciplinary interaction in formal meetings, all 

tended to be described by their members as relatively strong with respect to 

innovation. 

20 

30 

40

Figure 6.11: Impact of team reflexivity on self-reported innovativeness (data from 113 

CMHTs) 

innovativeness 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

2.5 

3.0 

team reflexivity 

3.5 

4.0 

Figure 6.12: Impact of team processes on selfreported 

innovativeness (data from 113 CMHTs) 

innovativeness 

4.5 

4.0 

3.5 

3.0 

2.5 

2.0 

1.5 

1.0 

2.0 

2.5 


3.0 

Relationships between Team Composition and Processes, and Stress Levels in 

CMHTs 

Three variables predicted, independently of one another, the level of stress reported 

by team members on the General Health Questionnaire: Team processes (overall 

score on the Team Processes Inventory), beta = -.50, t = -5.22, p < .001; informal 

communication (social events, message boards, etc.), beta = .21, t = 2.20, p = .03; 

and freedom of interaction (scheduled co-presence of the different disciplines at 

4.5 

3.5 

5.0 

4.0 

5.5 

6.0 

4.5

meetings), beta = -.20, t = -2.20, p = .04. These findings indicate that the following 

team characteristics are associated with relatively high stress (or low stress levels) 

amongst staff: a positive team processes; plentiful opportunities for informal 

interaction among members; and relatively little provision for scheduled, formal, 

cross-disciplinary encounters at team meetings. Figure 6.13 shows the impact of 

team processes on stress. 

Figure 6.13: Impact of team processes on stress 

1.6 

1.4 

1.2 

1.0 

.8 

.6 

2.0 

2.5 


GHQ = General Health Questionnaire, 12 item version 

Relationships between Team Composition and 

Processes, and Turnover in the team 

3.0 

As shown in Figures 6.14 and 6.15, two compositional variables predicted staff 

turnover, independently of one another: mean age of team members, beta = - .25, t = 

-2.21, p = .03; and the presence of social workers in the sample of respondents, beta 

= -.23, t = -2.02, p = .05. These findings suggest that teams with older members 

enjoyed more stable membership, as did teams including social workers. 

3.5 

4.0 

4.5

Figure 6.14: Impact of mean age of team 

members on turnover (data from 113 CMHTs) 

1.6 

1.4 

1.2 

1.0 

.8 

.6 

2.0 

2.5 


Figure 6.15: Staff turnover in CMHTs with and 

without social workers (data from 92 teams) 

20 

15 

10 

5 

0 

15 

no 

social workers in the team 

Relationships between Team Composition and 

Leadership 

3.0 

8 

yes 

3.5 

4.0 

4.5

Two factors, acting independently of one another, were associated with the clarity of 

leadership described by team members: the use of a single, integrated set of case 

notes for each client, beta = .29, t = 2.85, p = .006, as shown in Figure 6.16; and the 

presence of one or more psychiatrists amongst team members completing the 

questionnaire, beta = -.27, t = -2.63, p = .01, as shown in Figure 6.17. It should be 

noted that, before computing the mean clarity of leadership for each team, responses 

from psychiatrists themselves were removed from the latter analysis. In other words, 

teams using integrated case notes, and teams not including psychiatrists, were 

clearer about the leadership role. 

Figure 6.16: Integrated case notes and clarity of 

leadership (data from 92 CMHTs) 

.8 

.7 

.6 

.5 

.4 

.5 

No 

partial access 

Use of one integrated set of case notes 

Figure 6.17: Psychiatric membership of the team and clarity of leadership (data from 

113 CMHTs, with responses of psychiatrists themselves removed from the analysis) 

.7 

.8 

Yes

Discussion 

.8 

.7 

.6 

.5 

.4 

.7 

no 

psychiatrists in the team 

As for primary health care teams, the findings from this stage of the research reveal a 

clear message for CMHT policy and practice, in relation to the factors predicting the 

effectiveness and innovations of community mental health teams: positive team 

processes, and clarity as to the leadership role within the team, make for a more 

effective team, as judged by external stakeholders as well as the team members 

themselves; requisite size makes for a higher quality of innovation; reflexive 

processes aids innovation; longer-established teams are rated more innovative by 

external judges and see themselves as more effective. 

We have considered policy implications of the findings reported in this chapter in 

relation to the Workforce Action Team issues identified in Chapter 1. In terms of 

education and training, it is clear that teamworking skills are key to the effective 

delivery of mental health care in the community. These skills are specific and 

trainable. They are not acquired implicitly through professional socialisation into 

such disciplines as nursing, medicine, clinical psychology, or social work. Nor are 

they attained through unfocussed, unsustained “team-building” exercises of the kind 

that are widely marketed into the NHS and other large organisations. Rather, they 

comprise key types of knowledge, skill and ability required for effective teamworking 

(Stephens & Campion, 1994). As depicted in Figure 6.18, these fall into 5 domains: 

conflict resolution; collaborative problem-solving; communication; goal-setting and 

performance management; planning and task co-ordination. Both initial professional 

training and continuing professional development for CMHT members should 

incorporate systematic training in these. To prepare and enable members of the 

constituent professions to function effectively within CMHTs, the NHS should require 

.5 

yes

that the majority of such training should be delivered in multiprofessional rather than 

uniprofessional learning environments. The requirement for such delivery may 

create difficulties for HEI’s but the NHS should work with them to ensure that training 

funded by the NHS meets the NHS’s pressing requirements for effective 

multiprofessional teamwork.

Figure 6.18: Knowledge, Skill and Ability Required 

for Effective Team-working (Stephens & Campion, 

1994) 

Conflict resolution: 

• Recognise and encourage desirable but discourage undesirable team 

conflict 

• Recognise type and source of conflict confronting the team and implement 

appropriate resolution strategy 

• Employ integrative (win-win) negotiation strategy rather than traditional 

distributive (win-lose) strategy 

Collaborative problem-solving: 

• Identify situations requiring participative group problem solving and utilise 

proper degree and type of participation 

• Recognise obstacles to collaborative group problem solving and implement 

appropriate corrective actions 

Communication: 

• Understand networks and utilise decentralised networks to 

enhance communication where possible 

• Communicate openly and supportively, sending messages which are (1) 

behaviour - or event-oriented; (2) congruent; (3) validating; (4) 

conjunctive; and (5) owned 

• Listen non-evaluatively and appropriately use active listening techniques 

• Maximize consonance between nonverbal and verbal messages, recognise 

and interpret the nonverbal messages of others 

• Engage in ritual greetings and small talk, and recognition of their 

importance 

Goal-setting and performance management: 

• Help establish specific, challenging and accepted team goals 

• Monitor, evaluate, and provide feedback on both overall team performance 

and individual team member performance 

• 

Planning and task co-ordination: 

• Co-ordinate and synchronise activities, information and task 

interdependencies between team members 

• Help establish task and role expectations of individual team members and 

ensure proper balancing of workload in the team 

Stephens, M.J., & Campion, M.A. (1994). The knowledge, skill and ability 

rquirements for teamwork: Implications for human resource management. Journal of 

Management, 20, 503-530.

In relation to recruitment and retention, we note the disturbing fact that only 12% of 

our CMHTs included all 5 key disciplines: nursing, psychiatry, social work, 

occupational therapy, and clinical psychology. This presents a challenge to effective 

delivery of the full spectrum of mental health care, and confirms the importance of the 

Workforce Action Team’s agenda. In that context, we draw attention to certain 

features of the demographics of CMHT staff identified by this research. Sixty-seven 

per cent of CMHT staff were women; the mean age of the staff was 40, with a 

standard deviation of 8.4 years, and most workers aged between 30 and 50. This 

profile highlights the importance of flexible working to accommodate family demands 

and thereby retain staff. It also confirms the importance of retaining CMHT staff 

beyond the age of 50. Within the somewhat restricted age range we observed, 

teams with older members experienced less turnover. Turnover was greater among 

smaller teams, suggesting that teams should be large enough to provide sufficient 

support. Our findings implicate poor team processes in CMHT staff stress, which is 

likely to be inimical to staff retention. Longer-established teams rating themselves as 

more effective suggests that stability of the team itself may yield greater job 

satisfaction through the experience of effectiveness. 

In relation to leadership, we see this as a key and integral feature of team functioning 

and hence, as shown by our data linking team processes to effectiveness, vital to the 

delivery of effective mental health care. We found that clarity in relation to the 

leadership role was reflected in external ratings of CMHT effectiveness, as well as in 

team members’ own ratings of their team’s effectiveness. Clear and effective 

leadership will be essential to delivery of the National Service Framework, and 

development of the required leadership skills, which are learnable irrespective of 

professional discipline, will require training resources. Training for CMHT leadership 

must relate to the complex multi-agency environment, and combine clarity with 

flexibility and innovativeness. Such training needs to be evidence-based, locally 

available, and ongoing rather than occasional or intermittent. 

In relation to primary care delivery of mental health care, we draw attention to 

findings from Chapter 3 highlighting the benefits of larger PHCTs, and of a wide 

spectrum of professions being members of the PHCT, alongside the value of clear 

PHCT leadership. In the course of our PHCT research we obtained ample anecdotal 

evidence that PHCT members are highly aware of the challenges presented to them 

by their growing responsibilities in this area.

In relation to the Workforce Action Team’s interest in developing the role of 

professionally non-affiliated staff in mental health care delivery, we have some 

indicative findings on support workers within CMHTs. They comprised 7% of 

respondents to our survey, and 75% of them were female. Their ratings of their 

teams were very favourable, and interviews with them during the intensive analysis 

reported in Chapter 7 were highly positive in tone. The intensive analysis also 

revealed the considerable dependence of CMHTs on support workers for the time- 

intensive, practical aspects of care of patients with severe and enduring mental 

health problems. Accordingly, we strongly endorse the development of 

professionally non-affiliated staff as a resource within CMHTs.

Chapter 7 


Results from Qualitative Research 

Summary of findings 

• Basic minimum standards of staffing and hence care are not yet universally 

fulfilled by NHS mental health care 

• The costs of mental health care vary across teams providing it, over and 

above the apparent clinical requirements of the caseload as reflected in 

diagnosis and severity 

• CMHTs face conflicting demands from primary care and from the needs of 

patients with severe and enduring mental health problems 

• Venturing beyond our immediate data, we suggest that such key issues are 

likely to have important effects on the morale, stress and effectiveness of 

CMHT staff and on their capacity to initiate and maintain the innovative, 

collaborative and flexible patterns of teamworking whose importance is 

highlighted by our survey findings 

Sub-sample team characteristics 

In this section, we report an analysis of the sub-sample of CMHTs taking part in the 

second phase of the project. In this qualitative work we looked in greater depth at 

CMHT effectiveness by taking account of clinical and economic performance. Its 

objectives were: 

• To develop methods to assess the economic costs and clinical outcomes for 

a representative patients seen by a CMHT 

• To examine the relationships between task context (severity of caseload), 

inputs (time, costs), team processes, and outputs (clinical improvement, goal 

attainment and CMHT practitioner stress) 

Process and effectiveness dimensions of the 10 teams

Figure 7.1 gives the aggregated team means for the primary process and 

effectiveness variables. 

Teams were selected for the second phase of the research on the basis of combined 

standardised team processes scores, self report effectiveness score, and stress 

levels (see Chapter 5). Figure 7.1 shows that the 10 teams varied on the 

performance dimensions as ‘effective’ or ‘ineffective’: Teams B, G and J perceived 

their teams as performing effectively, but this was only partly supported by external 

judgements of team performance, in which innovativeness, but not effectiveness, 

was rated highly for those teams.

Figure 7.1: Process and effectiveness dimensions of the 10 CMHTs 

Overall 

Team 

processes 

Max = 5 


meetings 

Max = 11 

Multidisciplinary 

communication 

Max = 5 

Team 

Mean stress 

level: GHQ 

item mean 

Max = 3 

Clarity of team 

leadership 

Max = 1 

Team 

relationship 

with GP’s 

Max = 5 

Team 

relationship 

with Trust 

Max = 5 

Team 

relationship 

with SS 

Max = 5 

Assessment 

WL 

implemented 

Team 

A 

Team 

B 

Team 

C 

Team 

D 

Team 

E 

Team 

F 

Team 

G 

Team 

H 

Team 

I 

2.95 3.85 3.20 2.96 3.06 3.46 4.24 3.30 2.92 3.94 

2 5 3 2 4 5 2 5 5 1 

2.75 3.50 3.50 3.00 2.00 3.50 1.50 2.50 3.00 2.75 

1.36 0.95 1.33 0.99 1.08 1.35 0.85 1.10 1.03 0.83 

0.67 1.00 0.77 0.09 0.77 0.89 0.87 0.15 0.22 0.83 

4 4 4 5 3 3 3 4 3 3 

5 5 3 4 3 4 4 3 3 3 

5 4 4 4 4 4 4 3 4 3 

no no no yes no no yes no yes No 

Integrated 

case notes yes yes yes no no no no no no Yes 

Referrals 

pooled All some all all some all all all some All 

Self report 

effectiveness 

Max = 5 

External rating 

effectiveness 

Max = 5 

External rating 

of innovations 

Max = 5 

3.10 3.70 3.28 2.82 2.66 3.41 4.00 2.72 2.85 3.65 

- 3.13 3.28 2.85 3.12 4.19 3.19 3.59 2.67 - 

Team 

J 

2.75 3.63 2.25 1.00 2.50 2.25 3.13 2.50 3.00 3.38

Caseload profile 

But how does all this relate to the quality of care provided by this sub-sample of 

CMHTs? In the intensive phase of the research, team practitioners were asked to: 

• Complete a caseload analysis describing the diagnosis, severity, chronicity 

and complexity for all clients. These factors were used to (a) describe the 

team’s caseload profile; and to (b) select a representative sample of around 

40 CMHT’s clients following procedures defined by the research team (see 

Methods) 

• Approach selected clients, and if appropriate their carers, and invite them to 

participate in the research by completing a Service Satisfaction questionnaire 

• Participate in interviews structured to elicit biographical, resource use, and 

clinical information about the team’s 40 selected clients, retrospectively for 

the past 6 months. Data on resource usage were collected relating to number 

of contacts with practitioners in the team; number of inpatient days; use of 

day hospital, day care or drop-in; medication; outpatient appointments 

• Complete the HoNOS monthly for selected clients over the following 6 months 

or up to discharge 

• To provide information during a second site visit relating to resource use and 

clinical outcomes for the team’s sample of representative clients. 

Clinical and cost data were collected for 372 CMHT clients for the first 6 months of 

the 12-month period, although an attrition rate of around 35 per cent meant that, for 

the second 6 months, data for only 241 of those clients were available. The high 

attrition rate was accounted for primarily by key workers or care co-ordinators leaving 

the CMHT, and other key workers or care co-ordinators being unable to supply 

clinical data during the second site visit. 

Psychiatrists completed a caseload analysis in only two teams, and for Team J in 

particular, this increased the number of clients on the team’s caseload. Figure 7.2 

shows the client caseload team by team, in terms of severity and diagnostic group. 

Oneway ANOVA tests showed that some teams differed in the severity of their 

caseloads F(9,362) = 4.44, p < 001. Post hoc Bonferroni tests indicated that Team 

B’s caseload (mean 2.18) was significantly milder than Team E’s (mean 2.70), p = 

.003; than Team I’s (mean 2.64), p = .019; and Team J’s (mean 2.62), p = .021; and 

marginally milder than Team H’s (mean 2.65), p = .054.

Figure 7.2: Client caseload profile by severity and diagnostic group 6 

Team A 

Team B 

Team C 

Team D 

Team E 

Team F 

Team G 

Team H 

Team I 

Team J 

Diagnostic category 

Substance misuse 3 

Mild Moderate Severe TOTAL 

Depression 42 

Anxiety 50 

Psychosis 55 

PD 14 


5 87 82 174 

Depression 43 

Anxiety 51 

Psychosis 85 

PD 9 


33 97 78 208 

Depression 43 

Anxiety 44 

Psychosis 85 

PD 12 


20 83 92 195 

Depression 59 

Anxiety 8 

Psychosis 54 

PD 8 


28 57 70 165 

Depression 24 

Anxiety 9 

Psychosis 141 

PD 18 


6 56 136 198 

Depression 86 

Anxiety 45 

Psychosis 68 

PD 8 

52 90 74 216 


Depression 38 

Anxiety 30 

Psychosis 79 

PD 8 


Depression 41 

Anxiety 24 

Psychosis 154 

PD 17 


Depression 85 

Anxiety 42 

Psychosis 144 

PD 14 


Depression 180 

Anxiety 43 

Psychosis 170 

PD 16 

21 91 70 182 

10 88 153 251 

38 84 200 322 

25 174 236 435 

6 Some disorders (e.g. adjustment to disability) presented in low numbers, therefore were not 

included

During the site visits, all CMHTs emphasised that they experienced a tension 

between policy requirements that their case load included enduring mentally ill 

people, and the referral patterns of local GPs who continued to refer all adults with 

mental health problems. The tension was increased by a third demand in some 

localities that CPNs from within the team should conduct clinics in primary care 

practices. Most teams had attempted to clarify with GPs the appropriate referrals, 

but reported little guidance from their Trust management, and little change in types of 

GP referrals. 

Varying responses to these conflicting demands emerged from the data. An 

important finding was that the three teams (B, C and F) carrying caseloads which had 

clients who were relatively moderately ill, all provided clinics in primary care, and 

inclusion of their primary care patients accounted for their lower overall caseload 

severity. 

Mental health status, health economic costs and clinical outcomes 

Mental health status, first 6-month period 

In this section we present more detailed information about the sample of 

mental health status clients selected by teams and their clinical outcomes. 

The period was 12 months, although as stated there was a 35 per cent 

attrition rate for cases. Some of the selected clients who completed the 

service satisfaction questionnaire criticised continuity of care, as a result of 

practitioners leaving the team and being allocated to a new key worker. 

Figure 7.3 gives a summary of the mental health status of a sample of clients 

selected in terms of severity and CPA level. These data were collected 6 

months into the review period. Comparing the information in Figure 7.3 with 

Figure 7.2 above shows that the severity of selected clients' mental health 

condition was broadly representative of teams’ entire caseload profiles. 

Looking at Team J, for example, Figure 7.2 showed that 236 (54%) clients 

were severely ill; Figure 7.3 below shows that 28 (62%) of Team J’s selected 

clients were severely ill.

Figure 7.3: Summary of selected clients’ mental health status 

Mild Moderate Severe 

CPA 

level 1 

CPA 

level 2 

CPA 

level 3 

On 

section 

Not on 

CPA 

Team A 1 14 19 12 13 6 2 3 

Team B 5 23 12 22 7 7 2 3 

Team C 3 17 16 11 21 1 0 1 

Team D 3 12 26 6 14 6 3 13 

Team E 1 10 29 9 21 4 4 5 

Team F 3 14 19 12 16 5 3 0 

Team G 3 19 13 19 13 1 2 0 

Team H 0 9 17 5 9 3 4 9 

Team I 1 12 26 6 23 1 3 9 

Team J 0 17 28 - - - 2 - 

During the site visits, it emerged that teams used different criteria for determining 

CPA level. Some teams had produced guidelines for assigning CPA level, while 

others had not. Most teams used the labels ‘level 1’ as least severe, but others used 

‘level 1’ as most severe. One team in the sample used ‘level A’ as the most severe. 

These had been recoded to represent severity as lowest, level 1, highest, level 3. 

Thus how CMHTs used the CPA was non-standard, and indicated variation in the 

management of CPA. 

More importantly, in terms of the role of CPA in maintaining service standards, we 

observed firstly that planned CPA reviews for selected clients were often overdue, 

and secondly, that part of the difficulty was getting access to all the practitioners who 

it was specified in the work plan must be present at the review. Some teams had a 

particular difficulty with accessing psychiatry. 

Across the teams, the percentage of CMHT clients who had a formal carer, in 

the sense that their key workers judged that clients needed carer support to 

live in the community, ranged from 22 to 55 per cent across the teams. We 

found that many clients did not have a care plan with formal targets; however, 

this varied across teams and was related to severity of caseload. Figure 7.4 

gives a team breakdown of selected clients’ diagnosis and severity.

Figure 7.4: Selected clients’ diagnosis and severity 

Diagnostic group Mild Moderate Severe TOTAL 

Team A Substance misuse 

Depression 

Anxiety 

Psychosis/PD 1/0 

Team B Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

Team C Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

Team D Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

Team E Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

Team F Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

Team G Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

Team H Substance misuse 

Depression 

Anxiety 

2 

3 

1 

6 

6/1 

6 

8 

8/1 

3 7 

5 

3/1 

1 

2 

3 

7 

2/0 

1 1 

2 

0/1 

3 

8/1 

5 

3 

5/0 

2 

3 

6 

8/0 

Psychosis/PD 8/0 

Team I Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

Team J Substance misuse 

Depression 

Anxiety 

Psychosis/PD 

1 7 

4/0 

9 

4 

4/0 

1 

1 

5 

9/2 33 

3 

8/1 40 

2 

1 

12/1 35 

2 

7 

2 

12/2 40 

2 

1 

25/1 40 

1 

5 

2 

10/1 35 

2 

3 

7/1 35 

3 

2 

10/0 23 

1 

5 

6 

10/4 38 

13 

1 

13/1 45 

Figure 7.4 illustrates that, although these 10 teams were similar in terms of 

diagnostic categories for which care was provided, the numbers seen within the 

serious and enduring categories varied. This was most apparent in team E, in which

83 per cent of selected clients were diagnosed with psychosis, in contrast to team G, 

in which a diagnosis of anxiety was almost as prevalent as psychosis.

Health economic costs 

Figure 7.5 gives a summary of costs 6 months into the period. Costs are derived as 

mean cost per client, and rounded to the nearest pound. Economic costs for in- 

patient days, outpatient appointments, day care sessions, and contact with 

practitioners were calculated using Unit Costs of Health & Social Care compiled by 

Ann Netten and Jane Dennett at the PSSRU University of Kent at Canterbury. We 

commissioned advice on the analysis and interpretation of these data from the 

Centre for Health Economics, University of York. 

The following assumptions were made when calculating costs: 

• In-patient days were calculated at £136 per day 

• Outpatient appointments were calculated at £97 per appointment 

• Day care costs were calculated at £32 per session. One session equates to 

half-a-day. All contacts reported were assumed to be one session. Day care 

included day hospitals, day centres, drop-ins and workshops 

• Calculations for contacts with practitioners were based on a generic cost for 

all members of the Community Mental Health Team. The unit cost used was 

face to face contact calculated at an hourly rate. All contacts were assumed 

to last one hour. Both a minimum cost of £26 per hour and a maximum of £50 

per hour were calculated 

• Medication costs were calculated using the British National Formulary. Costs 

of generics were used in all calculations except where these were not 

available 

• Contact costs have been computed using the minimum generic costing (£26 

per contact), so this is an underestimation of the cost of contacts, although 

consistent across all teams

Figure 7.5: Summary of health economic costs: first 6-month period 

Medication Contacts Day care OP Inpatient TOTAL 

appointments days 

Team A 247 2655 1156 120 1572 5750 

Team B 199 950 842 99 126 2216 

Team C 210 939 1043 119 162 2473 

Team D 100 2140 1304 213 1012 4769 

Team E 150 5001 1294 172 3515 10132 

Team F 169 1138 1003 136 382 2828 

Team G 193 2530 1197 77 1480 5477 

Team H 225 2727 1816 131 1496 6395 

Team I 180 3129 1092 246 1806 6453 

Team J 325 999 440 229 48 2041 

One way ANOVA was used to determine significant differences between 

teams. Significant differences were apparent in terms of outpatient (F = 3.94, 

p < .001), inpatient (F = 3.41, p < .001) and practitioner contact costs (F = 

3.01, p < .01). Using univariate analysis of covariance, controlling for 

caseload severity, differences between teams remained statistically 

significant, as shown in figures 7.6 to 7.8. 

Figure 7.6: Inpatient costs, first 6 months 

Source df F Sig. 

Corrected Model 10 3.785 .000 

Intercept 1 1.014 .315 

SEV 1 6.688 .010 

TEAM 9 2.854 .003 

Error 359 

Figure 7.7: Outpatient costs, first 6 months 



Intercept 1 .570 .451 

SEV 1 7.039 .009 

TEAM 9 2.972 .002 

Error 231

Figure 7.8: Contact costs, first 6 months 



Intercept 1 3.166 .076 

SEV 1 32.308 .000 

TEAM 9 2.648 .006 

Error 353 

Post hoc Bonferroni tests indicated that Team I had significantly higher outpatient 

costs than Teams B, C and G. Post hoc tests also indicated that Team E had 

significantly higher inpatient costs than teams B, C, F and J, and that Team E had 

significantly higher practitioner costs than teams A, C and J. 

Pearson’s R correlations were carried out on caseload severity with all health 

economic costs for the first 6-month period. Medication costs were not associated 

with other costs or caseload severity. Practitioner contact costs were associated with 

outpatient (Pearson’s R .14, p < .01) and inpatient costs (Pearson’s R .25, p < .01). 

Practitioner contact costs were also associated with caseload severity, Pearson’s R 

.30, p < .01. Outpatient costs were associated with inpatient costs, Pearson’s R .17, 

p < .01. Caseload severity was also associated with outpatient costs, Pearson’s R 

.12, p < .05, and inpatient costs, Pearson’s R .18, p < .01. 

Mental health status, second 6-month period 

Whereas in some CMHTs we were able to collect cost and clinical data for 

most of the sample of representative clients for the second 6-month period, in 

others there was high attrition. Figure 7.9 shows the attrition rate within each 

team. 

Figure 7.9: Summary of selected clients lost at second 6-month period 

First 6 months Second 6 months % lost 

Team A 34 21 38 

Team B 40 27 33 

Team C 36 17 53 

Team D 41 12 71 

Team E 40 32 20 

Team F 36 29 19 

Team G 35 31 11 

Team H 26 7 73

Team I 39 26 33 

Team J 45 39 13 

TOTAL 372 241 35 

Clients were divided into two independent groups, the first made up of clients for 

whom data were collected only in the first 6 months, the second consisted of clients 

for whom we collected data at both time points. Using independent sample t-tests, 

we found that over the first 6 months clients retained in the sample were marginally 

less severe (mean = 0.48) than those lost to the sample over the second 6 months 

(mean = 6.80; t = 1.70, p = .09). 

For those clients who were on CPA at the first time point, and remained in the 

sample, 116 remained at the same level, 25 moved to a lower level, and 63 moved to 

a higher level. 

Health economic costs, second 6-month period 

In Figure 7.10 below, costs are shown for the second 6-month period, based 

only on the clients still in the sample, and calculated as described above. 

Figure 7.10: Summary of health economic costs: second 6-month period 

Medication Contacts Day care OP 

appointments 

Inpatient 

days 

TOTAL 

Team A 136 433 4302 185 648 5704 

Team B 179 216 551 86 584 1616 

Team C 188 177 452 102 0 919 

Team D 136 295 891 162 533 2017 

Team E 258 597 747 173 1466 3241 

Team F 269 267 164 171 1913 2784 

Team G 440 265 364 122 715 1906 

Team H 436 505 1563 83 2273 4860 

Team I 310 307 411 224 675 1927 

Team J 258 223 340 259 883 1963 

One way ANOVA was used to determine differences between the teams in 

terms of costs. Significant differences were found in practitioner contacts and 

day care costs, but not for other costs. Post hoc Bonferroni tests indicated 

that practitioner contact costs were accounted for by Team E being 

significantly higher than all others except A, D, and H (F = 4.50, p < .001).

Day care costs were significantly higher for Team A than all other teams, 

except teams C and H (F = 2.75, p < .01). Pearson’s R correlations were 

carried out on client caseload severity with all health economic costs for the 

second 6-month period. There were clear associations between severity level 

and all costs except medication: with practitioner costs, R = .30, p < .001; with 

outpatient costs, R = .23, p < .001; with inpatient costs, R = .20, p < .01; and 

with day care costs, R = .13, p < .05. 

Clinical outcomes, first and second periods combined 

It was not until the end of the 12-month period that practitioners were asked to judge 

whether clinical targets for each selected client had not been met at all, had been 

partly met, had been fully met, or had been exceeded. Often, given the diagnosis 

and chronicity of many of these clients, the targets were simply that they should be 

stable or maintained in the community. Sometimes, though, there was a clear 

objective to discharge the client, and tests were carried out to see how many of the 

proposed discharges subsequently took place. 

At the team level, in order to determine team differences, client severity level 

and whether predicted targets were met were analysed using Oneway 

ANOVA. The analysis indicated that Team E clients continued to be 

significantly more severely ill (mean 7.19) than those of Teams B (mean 5.63) 

and G (mean 5.77), F = 2.97, p < .01. A marginally significant difference was 

found in the level of predicted targets met (F = 1.66, p = .10) and post hoc 

Bonferroni tests indicated that Team J’s perceived performance in meeting 

predicted targets was marginally better than Team C’s. 

Team-level tests were carried out to determine whether the costs incurred by 

different teams were related to the diagnostic profile of their clients. Univariate 

analyses of covariance were carried out, controlling for the effects of diagnosis and 

severity, as shown in Figure 7.11.

Figure 7.11: Costs and clinical targets met controlling for diagnosis and severity 

Dependent 

variable 

Inpatient costs 

Outpatient costs 

Df 11,227 

Medication costs 

Df 11,266 

Overall costs 

Df 11,352 

Clinical targets 

met 

Effects of diagnosis Effects of severity Team effects 

(controlling for diagnosis, 

severity) 

p 

p F (11,351) p 

F 

F 

< 1 ns 1.70 .19 3.06 < .01 

3.00 .08 6.24 < .05 3.39 < .01 

< 1 ns 1.56 ns 1.30 ns 

< 1 ns 6.65 .01 3.68 < .001 

3.94 < .05 < 1 ns 1.81 .07 

Taking into account variation across teams in diagnosis and severity of 

clients, teams were significantly different in terms of some health economic 

costs incurred, although not for medication costs. 

Inpatient costs (computed at £136 per day) 

In relation to inpatient costs, Team J (mean cost per client £48) made little 

use of inpatient facilities; teams B and C (means £125 and £167 respectively) 

also incurred low inpatient costs. Inpatient costs for Team E, some of whose 

clients were severely psychotic and at high risk, were higher than all others 

(mean £3515). 

Outpatient costs (computed at £97 per contact) 

Outpatient costs were considered only for those clients who attended appointments. 

As expected, both diagnosis and severity had an effect on outpatient costs, with 

more serious diagnoses and higher levels of severity positively associated with 

higher costs. At the team level, H and B (mean cost per client £97 and £161 

respectively) incurred lower costs than did teams I (mean £589) and J (mean £499). 

Medication costs

Medication costs were not influenced by diagnosis or severity, and teams did 

not differ significantly in terms of their outlay on medication.

Overall costs 

Overall cost per client was strongly influenced by severity, though not by 

diagnosis. Teams differed significantly in relation to overall costs, with Team 

E (mean £5001) higher than all other teams, a dimension partly accounted for 

by the high use of support workers visiting clients at home, sometimes daily, 

and high inpatient costs. Teams B, C and J (means £950, £964 and £999 

respectively) incurred lower overall costs than the other teams in the sample. 

We saw above that Teams B and C had relatively more moderate caseloads 

than other teams, but this did not apply to Team J. 

Clinical targets met 

Teams differed marginally in terms of practitioners’ judgements of whether 

clinical targets were met, although this was also influenced by client 

diagnosis. Teams B and J (mean per client 2.67 and 2.74 respectively) 

scored relatively high on this dimension, while Teams A, C and H scored low 

(means 2.25, 2.07 and 2.25 respectively). However, a score of over 2.00 

indicated that for the average client, clinical targets had been at least partly 

met. 

Psychiatry input 

A serious problem for this sample of CMHTs was their lack of effective input from 

psychiatrists. This was more of a problem for teams with a higher number of 

severely ill clients, for example, Teams E and I. How this problem manifested varied 

across the teams. One team reported that they had direct access to a psychiatrist for 

over 2 years. Other teams had negative views about access to medical input. Their 

clients had to visit outpatient departments for CPA reviews, rather than this being 

conducted at the team base. Some teams reported that although a psychiatrist was 

based within the team, and clients attended clinics at team premises for some CPA 

reviews, these reviews were not conducted as frequently as specified in the client’s 

care plan, because no medical input was available. It was difficult to find locum 

psychiatrists so long term absence or secondment also resulted in a lack of 

psychiatric cover for the team.

Team processes, team performance, team stress, clinical outcomes, 

user satisfaction and cost effectiveness 

At the team level, in order to determine how the different dimensions of 

effectiveness were related, correlation analyses were performed on relevant 

compositional (age, tenure, severity of caseload, number of linked GPs, 

MINI), process (team processes, clarity of leadership, ability to communicate 

across disciplines, relationships with GPs, Trust and Social Services, pooling 

of referrals, how quickly emergencies are seen), performance (overall self 

report and external evaluation, external evaluation of innovations) and 

outcome (targets met, overall costs, and user satisfaction variables). Some 

associations were apparent, as shown in Figure 7.12. These data must be 

viewed as exploratory and interpreted very cautiously, in view of the 

probability of both Type I and Type II errors: calculating such a large number 

of correlations invites Type I errors, whilst the small sample of teams incurs 

substantial risk of Type II errors. 

Figure 7.12: Summary of associations across composition, process and outcome 

Association Pearson’s R probability 

Caseload severity/annual costs .763 .010 

Caseload severity/self report effectiveness 

Teams feel ineffective when they have severe 

caseloads 

Clinical targets met/team stress level 

Teams whose members feel stressed also report 

disappointing clinical outcomes 

-.655 .040 

-.628 .052 

External evaluation of innovation/clarity of team 

leadership 

Good team leadership recognised by innovation 

raters 

.560 .091 

Team processes/self report effectiveness .890 .001 

User satisfaction/how quickly emergency referrals are 

seen .789 .011 

MINI/team uses integrated case notes 

Integrated case notes tend to be used in more 

deprived areas 

.766 .016

Referrals pooled in the team/number of linked GP’s 

A central referral system in response to larger N of 

GPs 

.708 .049 

CMHT relationship with Trust/CMHT relationship with 

Social Services .642 .045 

Tenure/external rating of effectiveness (n = 8) .699 .054

The survey results suggested that ‘good’ processes and outcomes are associated 

with: 

• small team size 

• few part-time workers 

• Health Service only commissioning 

• single, clear line of leadership or co-ordination 

• rapid response to emergency referrals 

• effective communication processes 

• external judgement about its effectiveness if the team itself rates its 

functioning highly 

When we looked in more depth at exemplar CMHTs, we found a wide variety in 

practice. During the researchers' visits to the 10 CMHTs in four NHS regions, the 

team numbers spent an average of around 20 hours with the research team, which 

yielded rich anecdotal evidence in support of the ‘hard’ findings at both survey and 

intensive stages of the study. 

Size We found that in one very large team CHMT where three smaller teams had 

been created, and separate meetings were held for nursing staff and social workers, 

co-ordination and communication were problematic. The wider team met only once 

every two months to debate and decide team policy and practice. 

Single, clear leader or co-ordinator Seven of the sub-sample teams had a clear 

leader or co-ordinator, but in three teams the lack of clarity about leadership was 

problematic. One team had been without a leader for over two years, which was felt 

to be an indicator of under-resourcing and lack of support from the local 

commissioners. Practitioners agreed that this situation also made team meetings 

difficult, not only in terms of process, but in terms of the struggle to implement and 

communicate decisions. 

Rapid response to emergency referrals One of the primary agenda items at 

CMHT meetings was the implementation of duty systems to cover emergency and 

urgent referrals. These clients often had to wait longer than practitioners felt was 

ideal. Such new systems were also described by many team members across the 

sample as one of the major innovations their teams had implemented in the previous

12 months. Of course, some of these teams had only been brought together within 

the previous 12 months. 

Effective communication processes Observation of team meetings indicated wide 

variation in quality of team communication. In general, meetings had an agenda, 

either formally written and circulated before the meeting or informally presented at 

the start of the meeting. Most teams kept to the agenda and covered all business. 

However, there were wide differences in process. In the most effective teams, 

interaction was quick, responsive and supportive, and participation was equal; in 

some teams though most people attending did not take part and merely ‘listened in’. 

The issue then arises that those people who do not participate in discussion or 

decisions do not feel they ‘own’ decisions and are slow to implement them. 

Inclusion of social workers At the statutory level, social workers must be involved 

in the care of the CMHT client group. Our survey findings indicated that social 

workers tended to rate their team’s effectiveness lower than other disciplines. What 

we discovered in carrying out the study was that the research process itself was not 

so thoroughly underwritten by Social Services employees as by Health personnel. At 

some site visits, we also observed the negative attitudes of health personnel towards 

social workers, and vice versa. In open-ended statements in the survey, this cross- 

disciplinary hostility was evidenced in many teams, partly because nurses were 

expected to take on the duties previously seen as only related to social work, for 

example, giving housing or benefits advice. However, in the most effective teams in 

the sub-sample, social workers were well integrated to provide the delivery of care for 

this client group. 

Discussion 

This intensive analysis of a sub sample CMHTs draws attention to some key issues 

in delivering mental health care, as well as providing a demonstration methodology 

for looking in detail at the effectiveness of services delivered in terms of participant 

evaluations in relation to health care costs. However, in view of the small number of 

teams we were able to study at this level of detail, our substantive findings cannot be 

interpreted as more than tentative. 

The intensively-analysed teams were selected on the basis of team member ratings 

of team effectiveness, team processes, and personal stress. The 3 teams whose

members perceived them as effective were seen as more innovative, but not as more 

effective, than the remaining teams in the sub sample. 

We found that teams varied in the perceived severity of their caseloads, in the 

proportion of their caseloads who were suffering from severe and enduring mental 

health problems, and in the health care utilisation costs incurred in the treatment of 

patients on their caseloads. Two of the 3 teams with relatively low overall costs per 

case had relatively high proportions of only moderately severe cases. Health care 

utilisation costs differed across teams even when controlling statistically for the 

variation in caseload severity across the 10 teams. The different categories of cost 

incurred (CMHT practitioner contacts, outpatient costs and inpatient costs) were 

positively inter correlated across teams. This suggests that teams differ in terms of 

their use of more or fewer services of all kinds, rather than differing in the priority or 

availability of the 3 types of service in the care packages delivered by each team. 

Only medication costs were unrelated to the other categories of cost. 

Further analyses controlled statistically for both diagnosis and caseload severity and 

showed that inpatient, outpatient, and overall costs all differed across the 10 teams. 

In terms of meeting the clinical targets set by keyworkers themselves, however, 

teams differed only marginally ( p = .07) when diagnosis and severity were 

controlled. The associations between severity and costs were well-illustrated by the 

team with the highest costs being the one that judged its patients to be most severely 

ill. 

In the course of collecting these data we made important supplementary 

observations concerning the targeting, integrity, and likely effectiveness of CMHT 

care. The most significant problem was the frequency of overdue Care Programme 

Approach reviews, suggesting that CPA is often not implemented effectively. This 

was attributed to the unavailability of psychiatric input. This echoes the finding from 

the larger survey sample that only 12% of CMHTs included all core disciplines. 

However, effective CPA requires availability of all relevant staff for review meetings, 

a requirement that goes beyond the mere inclusion of relevant disciplines in the 

membership of the team. A further problem was the threat to continuity of care 

arising from the staff turnover that accounted for most of the 35% attrition when we 

returned to collect data for the second 6-month period.

We were also forcibly reminded of the tension experienced by CMHTs between 

policy requirements to focus on severe and enduring mental health problems and the 

demands of GPs continuing to refer many adults with mental health problems. This 

was reflected in the finding that the 3 teams with relatively moderately ill caseloads 

all provided clinics in primary care, with inclusion of their primary care patients 

accounting for their lower overall caseload severity. Fulfilment of CMHTs’ remit 

under the National Service Framework will require primary care to shoulder its full 

burden in relation to the less severe but considerably more prevalent disorders with 

which it is tasked by the framework. 

Finally, this intensive analysis of clinical data lent some further validation to the 

measures used in the full sample of CMHTs: teams with relatively severe caseloads 

considered themselves less effective; teams whose members felt under stress also 

reported disappointing clinical outcomes; users of services provided by teams 

reporting rapid response to emergency referrals were more satisfied with their team’s 

service. 

Although not definitive, on account of the small sample, this intensive analysis 

highlights key issues in mental health service delivery.

Introduction 

Chapter 8 

Secondary Health Care Team - 

Research methods and Sample Details 

Three studies were conducted with secondary health care teams. The first examined 

the relationship between team processes and team member stress. The second 

explored whether team membership per se, was associated with stress, and if so, 

what factors in the team environment accounted for this association. The third was a 

longitudinal study of the relationship between team functioning and subsequent 

member turnover from the team. 

The Sample in Study 1 in Secondary Care 

The Association between Team Membership and Sress. 

The purpose of this study was to determine whether team membership conferred 

upon NHS employees better mental health than did membership of loose working 

groups or a work situation which did not involve working in a team or loose staff 

grouping. Four Trusts were selected from nineteen Trusts included in a larger study 

of stress in the National Health Service (Borrill et. al., 1998) and 4,500 names were 

selected from the Trusts’ staff lists. The next step involved selecting individuals from 

these hospitals for possible involvement in the study. For small occupational groups, 

where the number of possible respondents was a hundred or fewer, all those on the 

staff lists supplied by the hospitals were included. For larger occupational groups, 

individuals were randomly selected from staff lists, with a minimum proportion of 

20%. Hence, greater proportions were sampled from smaller occupational groups 

and from smaller hospitals. A total of 4,500 names was thus selected. Individually 

addressed questionnaires were distributed either by hand to the person’s area of 

work or through the internal post. 2,263 people returned completed questionnaires, 

representing a response rate of 50%. 

Questionnaires were sent to all those selected for the sample 

The questionnaire was in four sections:


Respondents were asked to give information about age, gender, marital status, 

number of children, number of other dependants, job title, length of service, hours of 

work. 

Section 2: Work Characteristics 

Scales were used to measure perceived job, work and hospital characteristics (e.g., 

work demands, autonomy, role conflict, influence in decision-making). Full details of 

these measures can be found in Haynes et al., (in press) and are available from the 

first author of this report. Measures of organisational climate were also included, 

which examined 12 dimensions of climate. 

The climate measure we employed is based on the Competing Values Model of 

organisational effectiveness (Quinn & Rohrbaugh, 1981; Hill, 1998). This model 

posits two fundamental organisational dimensions: internal versus external 

orientation and emphasis on control versus an emphasis on flexibility. These two 

orthogonal dimensions create four domains of organisational emphasis: 

Rational Goal Approach - external focus with tight internal control 

Open Systems Model - external focus and flexible relationships with the 

environment 

Internal Processes - internal focus with an emphasis on tight internal control 

Human Relations - emphasis on well-being, growth and commitment of 

employees. 

These approaches reflect the rich mix of competing views and perspectives within an 

organisation and Quinn (1988) argues that a balance of these competing 

organisational values is required for organisational effectiveness. 

The organisational climate questionnaire (Hill, 1998) was developed by selecting 

scales from an existing team processes measure considered appropriate to service 

organisations. Following extensive pilot work in four NHS Trusts, this Organisational 

Climate Questionnaire (OCQ) was used to survey 5,275 health service employees 

from 27 Trusts (Hill et. al., 1997). The results of this survey suggested seven core

dimensions: innovation, performance monitoring, autonomy, co-worker co-operation, 

training, communication and resources (Hill, 1998). 

Innovation 

This dimension measures the extent to which the Trust is seen to be responsive to 

change. More specifically the scale explored the extent to which senior staff were 

interested in suggestions and the development of new ideas. This was a six-item 

scale with five intervals and three stems ranging from strongly agree to strongly 

disagree. An example item from this scale is “New ideas are readily accepted in the 

Trust.” The coefficient alpha for the current sample was 0.91. 

Performance Monitoring 

This dimension addresses the perception of how adequately job performance is 

monitored within the Trust as a whole, and how well staff are informed about their 

work performance. The scale consisted of five items with five intervals and three 

stems ranging from strongly agree to strongly disagree. An example item from this 

scale is “Staff performance is measured on a regular basis.” The coefficient alpha for 

the current sample was 0.86. 

Autonomy 

This dimension measures the extent to which employees feel that they have the 

freedom to work in their own way and are given adequate scope and responsibility to 

work without constant upward consultation. The scale has six items with five intervals 

and three stems ranging from strongly agree to strongly disagree. An example item 

from this scale is “Management tightly control the work of those below them.” The 

coefficient alpha for the current sample was 0.87. 

Co-worker co-operation 

This factor measures the extent to which there is co-operation and conflict amongst 

staff in the Trust. The scale comprised of six items with five intervals and three 


scale is “People can rely on one another in the Trust.” The coefficient alpha for the 

current sample was 0.87. 


This dimension measures the employee’s perceptions of degree of emphasis within 

the Trust on skill development and the availability of training resources. The scale

comprised of six items with five intervals and three stems ranging from strongly agree 

to strongly disagree. An example item from this scale is “Staff are strongly 

encouraged to develop their skills in the Trust.” The coefficient alpha for the current 

sample was 0.86. 

Communication 

This dimension measures the employee’s perceptions of information sharing 

throughout the Trust, particularly top-down/vertical communication between 

management and workers. The scale comprised of five items with five intervals and 

three stems ranging from strongly agree to strongly disagree. An example item from 

this scale is “Communication between management and staff is excellent in the 

Trust.” The coefficient alpha for the current sample was 0.85. 

Resources 

This dimension measures employees' perceptions of resource allocation and usage 

within the Trust. The scale consisted of seven items with five intervals and three 


scale is “There is very little waste of financial resources in the Trust.” The coefficient 

alpha for the current sample was 0.77. 

Scale Structure and Reliability 

Factor analyses and other multivariate techniques demonstrated the empirical 

distinctiveness of the scales from each other (Hill, 1998). The scale reliabilities 

reported for this study compared well with the original work, which quotes a range of 

reliability coefficients from 0.69 to 0.89. 

The notion of teamness was operationalised by using the definitions of teams 

employed in the literature (e.g. Alderfer, 1977; Hackman, 1987; Guzzo & Shea, 

1992; Guzzo, 1996, p. 8; West, 1996b). The following characteristics are commonly 

used to define a team: 

a) The group is perceived as a social entity by others and has an organisational 

identity within a defined function.

) This is a real group with a task to perform in an organisation from which shared 

objectives are developed for the team. 

c) There is a degree of interdependence between members of the group and 

members interact together to achieve group objectives. 

d) There is a degree of differentiation of roles and duties in the group. 

e) There is collective responsibility for measurable outputs. 

f) Groups are not so large that they constitute an organisation, which has vertical and 

horizontal relationships and sub-groups. In practice this is usually a group of less 

than 20 members (although there may be some exceptions to this number). 

Distilling these characteristics suggests five components of teamness: 

• Distinct roles for members of the team, 

• Task interdependence - team members rely on each other to perform the task, 

• Outcome interdependence - team members' achievement of team goals is 

dependent on other members' knowledge, skill and task performance, 

• Team identity - team members and other organisational members regard the 

group as a team with a clear team level task to perform 

• Clear team objectives - there are clear team level objectives. 

Section 3: Stress 

The main measure of stress was the 12-item version of the General Health 

Questionnaire (GHQ-12; Goldberg, 1972; Goldberg & Williams, 1991). The GHQ-12 

was designed as a self-administered screening test for detecting minor psychiatric 

disorder in the general population. It covers feelings of strain, depression, inability to 

cope, anxiety based on insomnia, lack of confidence and other psychological 

problems. 


Respondents were asked to indicate, by ticking a ‘yes’ or a ‘no’ response option, 

whether they worked in a team. To differentiate between those who did and did not 

work in a clearly defined team according to our criteria of teamness, but who 

indicated in answer to the categorical question that they did work in a team, we 

summed responses to 4 questions:

• Does your team have relatively clear objectives? 

• Do you frequently work with other team members in order to achieve 

these team objectives? 

• Are there different roles for team members within this team? 

• Is your team recognised by others in the hospital as a clearly defined work 

team to perform a specific function? 

Those who did not answer, “yes” to all four questions were categorised as being in a 

‘quasi team’. Out of the total sample, 283 responded clearly that they did not work in 

a team. Of the 1,980 who answered “yes” to the question “Do you work as part of a 

clearly defined team?” 692 answered “no” to one or more of these questions and 

were therefore categorised as members of “quasi teams”. Thus 283 (12.5%) did not 

work in a team, 1,288 (56.9%) worked in a team, and 692 (30.6%) worked in a “quasi 

team”. 

The Sample in Study 2 

The Relationship between Team Processes and Team Member Stress 

Using data from official records and the expertise of members of the National Health 

Service Executive, ten Trusts were selected for inclusion in this part of the study 

Identifying a sample of teams in each Trust was a lengthy process. Discussions 

were held with senior managers, who identified teams in their organisations and 

suggested contact persons from each team. The researchers then telephoned the 

contact person, negotiated their collaboration in the study, and once agreement was 

reached, secured the names and location of team members. Contact persons were 

asked to distribute questionnaires to their team members. 

There was considerable variation in the types of team in Trusts, and it was not 

possible to identify a sufficiently large sample of a single type of team that was 

common across all Trusts. Six team types predominated: 

• nursing care 

• management 

• medical 

• multidisciplinary 

• support 

• quality improvement teams

Members of 225 teams were invited to take part in the study. Members of 14 teams 

declined this invitation. Over a period of 16 months, 193 teams in 10 NHS Trusts 

continued to collaborate in the research. Questionnaire responses were received 

from 1,237 team members. The numbers in each profession/occupation were: 752 

nurses, 114 doctors, 98 administrative staff, 78 managers, 125 professions allied to 

medicine (PAMs), 26 professional and technical staff, 26 ancillary staff and 18 of 

unknown occupational group. Team sizes ranged from 2 to 44 (mean 11.4, SD = 

6.93). 

Type Budget* 

Figure 8.1: Characteristics of NHS Trusts 

(in £ million) 


Staff* 

Year of 

Trust Status 

Teaching 100 3,000 1991 City 




District 78 3.250 1994 City 

Location 

District 56 2,500 1994 Rural 

District 38 1,200 1991 Rural 

Community 40 2,000 1992 City 

Community 57 1,200 1992 Rural 

Community 45 2,500 1993 Rural 

* Data available from 1996 

The ten NHS Trusts included four teaching hospitals, three community Trusts and 

three full District Trusts. Numbers of staff ranged from 1,200 to 5,500 (as shown in 

Figure 8.1). 

Women formed 86 % of the sample. Mean age of team members was 39.58 years 

(SD = 10.52, range 17 to 64 years). Mean team tenure was 4.3 years (SD = 4.65, 

range one month to 38 years). 5% of the sample had worked in their team for less 

than one year, 17% between 1 to 5 years, 25% between 6 and 11 years, 18% 

between 12 and 16 years, and 36% had over 16 years service.

The mean caseness of teams was 23.3% (SD = 0.25), with a mean GHQ Likert 

score of 0.95 (SD = 0.24). This level is comparable to a group of 71 primary health 

care teams (caseness = 21.8%, Borrill & West, 1998). 

At individual level this can be contrasted to 26.7% for a larger group of British 

health care employees (n = 22,298, SD = 3.09, Mullarkey et al., 1999) and 18.4% 

for the general working population (BHPS, Taylor, Brice, Buck, et al., 1995). 

NHS employees often belonged to three or more teams (48%), with only 14% 

belonging to one team. Teams either met infrequently (30% had not met in the last 

month, and 39% ha met once), or frequently (21% of team had met four or more time 

in the last month). Most people worked in permanent teams (90% of members). 

Questionnaire completed by individual team members 

Section 1: Biographical Information 

Participants were asked for their job title, age, gender, and duration of tenure in the 

NHS. 

Section 2: Team Composition 

Team members were asked to indicate the size of their teams (number of members), 

how frequently they interacted together, whether they were members simultaneously 

of other teams, team tenure, and the nature of the team‘s task. Teams were 

classified as coming from Teaching, District General Hospitals or Community Trusts. 

Section 3: Team Processes 

This contained eight measures of team working. Four of these were drawn from the 

Team Climate Inventory (Anderson & West, 1994,1998) that is based on a well- 


assess levels of: 

• team participation 

• clarity of and commitment to team objectives 

• emphasis on quality 

• support for innovation. 

Four other measures were included:

• Reflexivity – the extent to which team members reflect upon their team 

objectives, strategies and processes and make changes accordingly (West, 

1996; West, 2000) 

• Teamness – The extent to which the team functions as a team versus a loose 

grouping 

• Roles - Team members' understanding of the distinctiveness of their own role and 

the degree of differentiation of roles within the team. Team members are asked 

to consider their understanding of their job in the team and the appropriate use of 

skills and knowledge needed to carry out the work. Then they are asked to 

consider these themes in relation to other members’ roles. 

• Interdependence - Task interdependence is when group members interact and 

depend on one another in order to accomplish work. 

Section 4: Outcomes 

This section of the questionnaire elicited members’ perceptions of team performance 

and shared understanding of team goals. 

Section 5: Objectives 

A single item invited team members to describe their team objectives. 

Study 3: Do team inputs and processes predict team member retention? 

Research Design 

This was a longitudinal research design with data collected six months after 

participating teams had completed Study 2. 76 teams were selected from four NHS 

Trusts (two community, one teaching and one District General Hospital). 

Following Study 2 teams were sent feedback reports. This created opportunity for 

dialogue with the teams. A single sheet of questions and an introductory letter was 

sent to each team contact. Materials were clearly marked with the team name as 

some contacts were members of more than one team. A stamped, addressed 

envelope was included to return responses.

Response 

Fifty-seven teams participated in the survey (31 nursing care, 13 management, 5 

multi-disciplinary, 5 Quality Improvement, 2 medical and 1 administrative support 

team). Community Trusts gave the most enthusiastic response (17 of 19 teams, 

89%) and teaching Trusts the least (15 of 26 teams, 58%) (overall = 57%). Data 

from the Quality Improvement teams were removed from analyses as these teams 

are not permanent; and several teams had ceased to exist having completed their 

tasks. The final sample for analysis comprised 52 teams (mean size 11.8, SD 6.03, 

range 2 to 25). 

Nineteen teams did not respond to this survey (mean size 9.0, SD 4.9, range 2 to 

19). No information is available as to the turnover in these teams. A comparison of 

means was undertaken across study variables obtained at Time 1 to identify any 

differences between responders and non-responders. No significant differences 

emerged. 

Team size and type of Trust are associated with turnover. People are more likely to 

leave a team if they work in a teaching Trust (mean rank = 36.0 Kruskal-Wallis one 

way ANOVA; Chi-square 8.43, df 2, p < .05) and are members of a larger team 

(Pearson correlation: r = .23 between log percentage leaver and team size p < .05, 

one-tailed test). 

Regression analyses showed team size and Trust type account for between 15% to 

18% of the variance in turnover. 

There is no evidence to suggest that stress at Time 1 is associated with team 

viability at Time 2. 

Perceptions of clear team objectives and high levels of participation are significantly 

associated with low levels of turnover 

Regression analysis (controlling for team size and Trust type) reveals that TCI 

variables treated as a block (participation, support for innovation, team objectives 

and task orientation) explain 10% of the variance in team retention.

Team Tasks 

Secondary health care teams diagnose illnesses, plan and administer treatment for 

various conditions, conduct health screening, and provide maternity care. These are 

complex tasks that require co-ordination and management, both, in a professional 

sense to ensure the best outcomes for patient care, and, in an organisational sense 

to ensure that the work conforms to organisational objectives, budgets, and internal 

and external standards. There were seven main categories of team included in the 

sample and these are shown in Figure 8.2 below: 

Figure 8.2: Types of Secondary Health Care Team 

Classification Description 

Medical Teams These are teams of doctors. 

Nursing Care Teams This is a broader notion of team covering all nursing 

care to patients / clients. These teams included groups 

of staff in addition to nurses such as health care 

assistants, auxiliaries, ancillary staff, clerical staff, and 

professional staff. 

Management Teams These were teams which undertook the task of 

managing a department, group of wards, or 

specialty/directorate. Therefore, a senior nursing team 

that manages a number of wards would be described 

as a management team. 

Multi-Disciplinary Team These were teams, often of professional staff, which 

had the task of delivering care or a service to 

patients/clients often in a boundary spanning role 

across departments, wards and specialities. For 

example, an Endoscopy team would contain medical, 

nursing, and professional staff who may work in a 

medical, surgical, or investigative context. 

Support Teams: Administrative These were teams, often of administrative and clerical 

staff, which provided support to the four team types 

above. This support may be secretarial, administrative 

or record keeping in nature. For example, a medical 

records team would be responsible for the storage, 

retrieval, and distribution of patients’ hospital records. 

Support Teams: Ancillary These were teams of ancillary staff such as porters, 

domestics, and catering staff who provided support 

services for both patients and staff. For example, a 

portering team would provide support to the whole Trust 

to transfer patients and goods between locations, 

provide access to restricted areas and other duties such 

as security and staff protection. 

Quality Improvement Team These were temporary teams assigned discrete tasks in 

order to improve quality of services provided in various

health care areas. For example, a bed hire team would 

be monitoring in-patient admission activities and 

ensuring appropriate mechanisms were created to 

facilitate the provision of hospital beds in the 

appropriate locations depending upon demand. 

The frequency of each type of team in the sample is shown in figure 8.3.

Figure 8.3: Frequency of Team Types in Study 2 

f 

r 

e 

q 

u 

e 

n 

c 

y 

100 

80 

60 

40 

20 

0 

86 

29 

10 

NUR MAN MED MD SUPP QI 

51 

Type of team 

In order to portray the variety of work that takes place within secondary health care 

we offer a few examples from each task category and describe the team 

composition, accountability, and work undertaken. 

Nursing Care Teams 

The Paediatric Nursing Team 

This team is part of an urban community Trust. Team members provide for the 

nursing care needs of acutely or chronically sick children at home, or, in other 

community settings. There are 12 members of this team: a nurse manager, 2 

paediatric community nurse sisters, 4 paediatric community nurses, 2 staff nurses, 2 

district nurses, and a paediatric diabetes nurse specialist. The nurse manager is the 

team leader. Organisationally this team is part of the Child Health Care Group and is 

accountable to the Child Health Management Team. This team can be described as 

a complex decision making team which performs multiple tasks using both basic and 

specialised equipment. This team interfaces with many other specialised teams in 

hospital and community organisations. 

11 

6 

Key to Task Type 

NUR = Nursing care 45% 

MAN = Management teams 15% 

MED = Medical teams 5% 

MD = Multidisciplinary teams 25% 

SUPP = Support teams 6% 

QI = Quality improvement teams 3%

The Coronary Care Unit 

This team is part of a busy urban teaching Trust. This team provides care for patients 

with heart disease and problems associated with acute and chronic capacity. There 

are 23 team members: 2 nursing sisters, 15 staff nurses, 2 enrolled nurses, one 

domestic, and 3 doctors (a consultant, a senior house officer, and a house officer). 

This is a complex decision making team that provides specialised care delivered 

using highly specialised and technical equipment. Team members are involved with 

patients and their families and take an essential role in rehabilitation. In addition, this 

unit undertakes training and education of staff. The team leader is the medical 

consultant who is responsible, at Trust Board level, to the Clinical Director of 

Medicine. 

Ward One 

Ward One 7 is a busy surgical ward that is part of an urban teaching hospital Trust. 

The ward practices team nursing and divides patient care between four teams. Team 

members provide care for patients in conjunction with other professional staff such as 

occupational therapists and physiotherapists during patients’ post-operative 

rehabilitation. Ward One has four members: two health care assistants, one primary 

nurse (nursing sister), and one associate nurse (staff nurse). The primary nurse is 

the team leader and will co-ordinate with the other three team leaders on the ward. 

This team is responsible to the ward manager who is part of the Medical Directorate 

Management Team. 

Management Teams 

The Child Health Management Team 

This team is part of an urban community Trust. The team co-ordinates the Children’s 

Service in the community. There are 10 members of this team: a general manager, 

an assistant general manager, a primary care manager, a district dental officer, 

manager of speech and language therapy, finance manager, care group planner, 

consultant paediatrician, personnel manager, and a nurse manager. The general 

manager is the team leader and is accountable for this team at Trust Board level. 

This is a complex decision making team which can be considered the top 

management team for the Child Health Care Group. 

7 Team names are fictitious in order to maintain confidentiality.

The Clinical Management Team 

This team is part of a busy district general hospital. The function of the team is to 

manage the General Medicine Directorate and they are responsible to the Trust 

Board. There are seven team members: one clinical head of service and a deputy 

clinical head (both doctors), a speciality manager, two nurse managers, a bed 

manager, and a secretary. The clinical head of service is the team leader. This team 

can be described as a top management team. 

Multi-disciplinary Teams 

The Surgical Oncology Team 

This team provides treatment for patients with breast cancer in a busy urban teaching 

hospital Trust. There are 14 team members: two consultant surgeons, two ward 

sisters, two medical secretaries, two senior house officers, four surgical house 

officers, and two breast care nurses. This is a complex decision making team which 

provides diagnostic services, treatment and follow-up care for breast cancer patients 

using in-patient and out-patient resources. The team leader is the senior consultant 

and he is responsible, at Trust Board level, to the clinical director of surgery. 

The Medical Practice Team 

The team is part of an urban community Trust providing a comprehensive health care 

service to a practice population that involves working across the boundaries of local 

and community care. There are nine members of this team: two district nursing 

sisters, a community staff nurse, a district staff nurse, a community nursing auxiliary, 

and four health visitors. A district nursing sister is the team leader responsible to the 

Locality Management Team. This is a complex decision making team that works 

across the boundaries of primary and secondary health care. 

Medical Teams 

The Transplant Team 

This team is part of a busy teaching hospital Trust. The team provides bone marrow 

transplants for adults and children and carers for patients before, during and after 

their transplant. This specialist team is involved in the development of new 

techniques, training, and research at an international level within the medical 

community. There are five members of this team who are all doctors: one acts as 

programme co-ordinator, and two other consultants take responsibility for adult and 

paediatric patient care. The team leader is the specialty director. This is a complex 

decision making team which operates across the boundaries of several medical

specialities. The clinicians are involved in highly complex work that requires the use 

and understanding of complex medical and surgical techniques, drug therapies, and 

highly technical equipment. 

The General Medical Team 

This team has a broad remit providing treatment for any medical or social problem 

and is part of a large district Trust. This team has four members: a consultant 

physician, a registrar, a senior house officer, and a pre-registration house officer. 

The consultant physician is the team leader and there is a strict medical hierarchy 

within this team. This is a complex decision making team which provides care for 

patients within the hospital and the community for a wide variety of acute and chronic 

conditions. 

Administrative Support Teams 

The Clinic Notes Team 

This small team provides medical records for patients with outpatient clinic 

appointments. This team is part of a busy rural whole district Trust. The team is 

composed of three administrative staff. This team will undertake tasks that require 

co-ordination across many departments within the Trust and will undertake many 

problem-solving tasks. Information technology skills are well developed within this 

team. This is a non-hierarchical team, which is responsible to the medical records 

manager. 

Ancillary Support Teams 

St. Jane's Domestics 

St. Jane’s is a small community hospital in a busy urban Trust. The hospital is due to 

close in the next two years and services will be moved elsewhere. St. Jane’s 

domestics are a team of 14 ancillary staff who provides domestic services throughout 

the hospital over a twenty-four hour period. The team is lead by a supervisor who is 

responsible to the domestic services manager. Each domestic assistant will have a 

designated geographic area of work but will be required to work in other areas as the 

need arises. The team performs domestic duties and assists ward staff in providing 

food and beverages, keeping the ward clean, feeding patients, and helping visitors. 

It is likely that the team members will feel more part of the ward team than the 

domestic team. Although this type of work would appear to be of low complexity, 

domestics need to be able to carry out their work in harmony with the health care 

environment of the ward. This requires understanding of the health care process in

order to communicate appropriately with patients and visitors and to adequately 

clean highly complex equipment. These tasks are of medium complexity. 

Quality Improvement Teams 

The Outpatients Quality Improvement Team 

This is a temporary team, which is part of a busy whole district Trust. The aim of this 

team is to improve the quality of patient care within the Outpatients’ Department, 

which covers a broad range of care across medical and surgical specialities. There 

are six team members: two outpatients' service managers, a quality assurance co- 

ordinator, a senior midwife, an outpatient senior sister, and a medical records 

manager. This is a complex decision making team which is involved in generating 

many problem solving strategies in order to achieve standards set by the Trust and 

the external Patients’ Charter standards. This is not the principal team for most of its 

members and has many similarities to a quality circle. 

In summary, a majority of these teams are complex decision making groups, which 

undertake multiple health care tasks. With the exception of the quality improvement 

teams, all are permanent teams with an on-going work remit. The composition of a 

majority of these teams is made up of a variety of different occupational groups. In 

addition, there are differences of status, pay, conditions of service and hours of work 

across these teams. 

Conclusion 

The diversity of team types, tasks, composition and organisational contexts in 

secondary care argues against the use of research designs we employed in primary 

care and community mental health. There are no unitary measures of effectiveness 

common across these diverse types of teams. Moreover, the nature of their tasks 

varies across organisational settings as well as across team types. Consequently, 

we focused on three questions: 

• Does membership of teams buffer NHS employees in secondary care from the 

negative effects of stress at work and, if so, why? 

• To what extent and in what ways are team inputs and processes related to team 

member mental health in secondary care? 

• Do team processes predict team member retention in secondary care? 

We provide the answers to these questions in Chapter 9.


Chapter 9 

Secondary Care Teams 

Results from Surveys 

• Those working in clearly defined teams in secondary care have lower levels 

of stress than those not working in teams or working in loose groupings (quasi 

teams). 

• Differences between team membership types in stress could be accounted for 

by the higher levels of social support and role clarity experienced by those 

working in clearly defined teams. 

• Those working in teams also perceive greater co-operation amongst all staff 

and clearer feedback from the organisation on staff performance than those 

not working in clearly defined teams. 

• This finding suggests that team membership somehow buffers individuals 

from the vagaries of organisational climate. Poor training; resistance to 

innovation, low levels of resources, co-operation, feedback on performance, 

autonomy, communication and training, appear to affect stress levels 

deleteriously much less among those working in clearly defined teams, than 

among those not working in teams or working in looser groupings. 

• It implies that teams can somehow compensate for the limitations and 

frustrations of organisational factors in the work experience of their members, 

and that this can significantly influence the level of stress experienced by 

organisational members. 

• Team processes are significantly associated with stress – better team 

functioning is associated with lower team member stress.

• The more frequently team members interact and meet, the better does the 

team function. 

• The longer team members work together, the clearer their understanding 

about each other’s roles. 

• The more teams people were members of, the less clear they were about the 

teams’ objectives. However, they reported higher levels of emphasis on 

quality of care and understanding of others’ roles. 

• Those working in larger teams reported lower levels of participation in team 

decision making and less clear understanding of team objectives. 

• Around 10% of teams in the sample ceased to exist in the six-month study 

period and there is an average 6% turnover of team members in the 

remaining teams. 

• Clear team objectives and high levels of team participation positively predict 

member retention. 

• Data from our recently completed study at the Aston Centre for Health Service 

Organisation Research 8 show that the percentage of people working in teams 

in acute trusts is associated with lower levels of patient mortality. The more 

people who work in teams in Trusts, the lower the number of patient deaths 

measured by the Sunday Times (Dr Foster) Mortality Index, deaths within 30 

days of emergency surgery and deaths after admission for hip fracture. 

Is team membership associated with lower stress? 

The data from this study revealed that 283 (12.5%) respondents did not work in a 

team, 692 (30.6%) were members of “quasi teams” and 1,288 (56.9%) worked in a 

clearly defined team (i.e. they conformed to the criteria of teams specified in the 

research design – see chapter 8).

Analysis of variance within and between the three groups (team, non-team, quasi- 

team) in relation to stress scores on the GHQ-12 revealed significant differences 

between those who worked in teams (mean = .95), those who did not work in teams 

(mean = 1.09) and those who worked in quasi teams (mean = 1.03) (f = 15.68; df = 

2,2250; p = > 0.001). Using the GHQ “caseness” method of scoring, 98 of those who 

definitely did not work in a team were categorised as cases (equivalent to 34.9%). 

275 of those who worked in a team were categorised as cases (21.8%) and 203 of 

those who worked in a quasi team were categorised as cases (29.7%). Caseness 

implies the individual is suffering from a sufficiently high level of stress that they 

require and would benefit from some professional help. 

The next step in the analysis addressed the question of what could explain these 

differences in GHQ scores between the teamworking types. We examined, in turn, 

demographic, work role and organisational climate factors. 

Demographic factors 

To determine the extent to which demographic factors accounted for GHQ 

differences between those not working in teams, those working in teams and those 

working in quasi teams, we conducted Chi-Squared tests of these groups by 

demographic factors. 

These included occupational group, gender, whether they had children, marital 

status (single/married/living with a partner/separated/widowed/divorced), the 

organisation, (i.e., membership of which of the four Trusts that participated in the 

study), time employed in the National Health Service, time employed in current post, 

and age. There was a significant Chi-Square value only in the case of occupational 

group (Chi-Square of 47.73; df =12; p =

Next we conducted analyses of variance to determine whether work role factors 

varied between team membership types (those not working in teams, those working 

in teams and those working in quasi teams). There were significant differences 

between these types in role clarity, supervisory leadership, social support, feedback, 

autonomy and control, and influence over decision-making, with those working in 

teams reporting higher levels that those in quasi teams, who in turn report higher 

levels than those not working in teams. A directly opposite pattern was found in 

relation to role conflict and role ambiguity. There were no differences between the 

groups in perceived work demands and hours worked. 

Which of those clear differences in work role factors between the groups might 

therefore account for the variation between team membership types in GHQ scores? 

To answer this question we conducted separate analyses of covariance to examine 

the variation between team groups in GHQ scores controlling for each of the work 

role factors in turn. Figure 9.1 shows the results, which reveal that none of these 

work role factors alone accounts for the difference between the team membership 

types in GHQ scores. However, the effect is most reduced by using role clarity and 

social support as covariates. Indeed, when these two variables are entered as 

covariates together, the difference between team membership types in GHQ scores 

is no longer significant (F= 0.955; df = 2,221; P = 0.385). Thus it appears to be the 

differences in social support and role clarity between those who work in teams (high 

social support and role clarity) and those who do not work in teams or work only in 

quasi teams, which account for variations in stress levels between these team 

membership types. 

Figure 9.1: Analysis of variance of GHQ scores by team membership type (team, 

quasi team, non-team) controlling for work role factors 

Covariate F DF Significance 

of F 

Main 

Effect (F) 

DF Significance 

of F 

Role Clarity 213.03 1,2231

Role Conflict 148.16 1,2147

Finally, we checked the data to determine whether there were any significant 

interactions between perceptions of organisational climate factors and team 

membership types that predicted GHQ scores. There were significant interactions 

between team membership type, innovation, feedback on performance, co-operation 

between staff, communication, autonomy, and training and organisational resources 

when predicting GHQ levels. They show that those working in clearly defined teams 

seem less strained than those not working in teams, or working in ‘quasi teams’, by 

perceptions of low levels of these organisational climate factors. It is as though, by 

working in a team, team members achieve a shared level of self-sufficiency that 

buffers team members from the inadequacies of their organisations. Those who are 

not members of clearly defined teams seem more affected both positively and 

negatively respectively, by the relative presence or absence of those organisational 

factors. 

Discussion 

The results suggest that being part of a team in the high-strain setting of the NHS is 

associated with lower levels of stress than if one is not a member of a team or 

belongs to only a loosely defined and weakly interdependent team (what we have 

called a ‘quasi team’). The results could not be accounted for by demographic 

factors, or by individual work role and organisational climate factors. However, the 

results clearly suggested that differences between team membership types in stress 

could be accounted for by the higher levels of social support and role clarity 

experienced by those working in clearly defined teams. This finding is consistent 

with theoretical explanations of some of the beneficial effects of teamworking that 

propose that teams contribute to a greater and shared sense of role clarity and social 

support (Cohen & Bailey, 1997; West, Borrill & Unsworth, 1998; Mohrman, Cohen & 

Mohrman, 1995). Roles are socially negotiated sets of mutual expectations and, by 

working closely with those in one’s role set, role clarity results. Moreover, since 

teamworking, by definition, involves interdependent working with close social contact 

and communication, it is likely that team members will experience more support from 

colleagues than those whose working relationships are less tightly linked. 

Similarly, in relation to organisational climate perceptions, those working in teams 

derive a sense of greater co-operation amongst all staff and clearer feedback from 

the organisation on staff performance, as a consequence of their team membership 

than those not working in clearly defined teams, and this accounts for the differences

etween team membership types in stress levels. It is easy to appreciate how 

membership of a team (whose members co-operate to achieve shared goals) might 

lead to the illusory sense of high levels of co-operation among staff more generally in 

the organisation. Another possibility is that staff do co-operate more with those who 

are members of teams, perhaps because of their clearer roles and goals, or because 

of the greater power conferred by their membership of a group, or as a result of their 

more clearly defined social and functional identity - "This person is a member of the 

Accident and Emergency Resuscitation Team and I know about their functional 

significance and understand what information or resources they require" 

Similar explanations can be offered for the effect of the relatively high level of 

organisational feedback perceived by team members which accounts (in concert with 

perceptions of staff co-operation) for the differences between team membership 

types in stress levels These may be illusory perceptions with team members 

mistakenly assuming that the higher level of feedback on their performance that they 

experience (as a consequence of their team members' feedback to them), can be 

attributed also to organisational feedback to staff on performance. It could also be 

that as a result of the clear functional identity of the team in the organisation, the 

team does get clearer feedback on performance. 

Particularly intriguing is our finding of significant interactions between team 

membership types and organisational climate perceptions as predictors of stress. 

This finding suggests that team membership somehow buffers individuals from the 

vagaries of organisational climate. Poor training, resistance to innovation, low levels 

of resources, co-operation, feedback on performance, autonomy, communication and 

training, appear to affect stress levels deleteriously much less among those working 

in clearly defined teams, than among those not working in teams or working in poorly 

defined teams. The consistency of these interactions and the fact that they are 

largely absent when we examine interactions between work role factors and team 

membership types, suggest their robustness. It implies that teams can somehow 

compensate for the limitations and frustrations of organisational factors in the work 

experience of their members, and that this can significantly influence the level of 

stress experienced by organisational members 

We can speculate about a number of possible explanations for our findings First, it 

may be that those who have lower levels of stress, self select into teams People who 

are relatively well-adjusted socially and have lower levels of anxiety may be attracted

to work closely with others since the challenges of teamworking are more 

manageable for them than they are for those who experience high levels of anxiety 

and uncertainty. Alternatively, it may be that those who are more relaxed and cope 

with stress better are selected into teams by existing team members as they offer 

less of a threat to the effective social functioning of the team. Finally, of course, it 

may be that those who have relatively low levels of stress are less likely to leave 

teams, than those with high levels of stress. 

Thus those who experience high levels of stress may find teamworking too 

demanding and challenging and their stress may also create social dysfunction that 

leads to their attrition from the team. These attraction-selection-attrition explanations 

for our findings are credible alternatives to the suggestion that it is the effect of 

working in teams upon stress that we have discovered in this first study. 

Study 2 

Do the composition of and the way secondary health care team members work 

together affect member stress? 

• Team processes are significantly associated with stress – better team 

functioning is associated with lower team member stress. 

• The more frequently team members interact and meet the better does the 

team function. 

• The longer team members work together the clearer their understanding 

about each other’s roles. 

• The more teams people belonged to, the less clear they were about the 

teams’ objectives. However, they reported higher levels of emphasis on 

quality of care and understanding of others’ roles. 

• Those working in larger teams reported lower levels of participation in team 

decision making and less clear understanding of team objectives. 

Questionnaires were distributed to team members as described in the previous 

chapter. 193 teams from 10 NHS Trusts responded. The responses consisted of 1,

237 team members (752 nurses, 114 doctors, 98 administrative staff, 78 managers, 

125 professions allied to medicine (PAMs), 26 professional and technical staff, 26 

ancillary staff and 18 of unknown occupational group). Team sizes ranged from 2 to 

44 (mean 11.4, SD = 6.93). 

The overall response rate to this survey was 54%. There were variations in 

response across organisational type (from teaching 42% to community 72%) and 

across team task type (Support team 30% to Management team 65%). Women 

formed 86 % of the sample. Mean age of team members was 39.58 years (SD = 

10.52, range 17 to 64 years). Mean team tenure was 4.3 years (SD = 4.65, range 

one month to 38 years). 5% of the sample had worked in their team for less than 

one year, 17% between 1 to 5 years, 25% between 6 and 11 years, 18% between 

12 and 16 years, and 36% had over 16 years’ service in their teams. 

Nearly a quarter of those working in teams scored above the cut-off point on the 

GHQ, indicating a high levels of stress. The mean caseness of teams was 23.3% 

(SD = 0.25), with a mean GHQ Likert score of 0.95 (SD = 0.24). This level is 

comparable to the primary health care and community mental health teams 

(caseness = 21.8%) but somewhat lower than the 26.8% recorded amongst a 

larger group of NHS employees (n = 22,298, SD = 3.09, Borrill et al., 1998) though 

higher than the figure of 18.4% for the general working population (BHPS, Taylor, 

et al., 1995). 

Team Interaction 

Teams either met infrequently (30% had not met in the previous month, and 

39% had met once), or frequently (21% of teams had met four or more times in 

the previous month). Team interaction frequency was significantly related to all 

team process variables (with eight of the ten possible relationships being 

significant). All relationships were in a positive direction suggesting that 

higher frequency of team interaction facilitates team processes. 

Team Task 

A simple classification of six team task types was used (see previous chapter). 

Quality improvement teams rated support for innovation higher than did medical and 

ancillary support teams. Managerial teams described their team objectives in greater 

detail than support and multidisciplinary teams. Administrative support teams report

greater understanding of each other’s roles compared to teams undertaking medical 

and managerial tasks.

Multiple Team Membership 

Most people worked in permanent teams (90% of members). Nearly half of this 

sample belonged to three or more teams (48%). Multiple team membership was 

negatively associated with clarity of and commitment to team objectives and 

positively associated with emphasis on quality of care, interdependence, and role 

understanding. This suggests a lack of clarity about team objectives may be 

counterbalanced by a more vigorous emphasis on quality of care: working in other 

teams may enable members to be more vigilant about and aware of quality issues. 

Team Size 

Team size is positively related to interdependence and negatively related to 

participation and clarity of and commitment to team objectives. Many of the larger 

teams are ward or department teams, which administer care or undertake 

investigations over a 24-hour period. Dependency on other team members is critical 

for the safe and efficient delivery of these services. However, membership of larger 

teams is also associated with low levels of information sharing and influence over 

decision making, and less clear understanding of the team’sobjectives. These 

findings are consistent with previous studies (Blau, 1970; Shaw, 1981; Stahelski & 

Tsukuda, 1990; Sundstrom et. al., 1990) that demonstrate that as group size 

increases there are increased difficulties in communication, co-ordination and 

interpersonal relationships. 

Team Tenure 

Team tenure was not related to stress but was related to mutual role understanding. 

Relationships between Team Processes and Stress 

Partial Pearson product moment correlations were undertaken with pair-wise 

deletion, controlling for team size. Eight of the ten-team processes variables 

examined were significantly and negatively associated with stress. This suggests that 

good team processes are associated with lower stress. Five process variables 

predicted stress: participation, support for innovation, emphasis on quality, team 

objectives, and role understanding.

Team Processes and Stress 

Regression analysis at team level revealed team processes accounted for 22.8% of 

between team variance in stress. These results are summarised below. After 

controlling for team size, three process variables negatively predicted stress (task 

reflexivity, p < .01; emphasis on quality; p < .05; interdependence, p < .01). 

Figure 9.2: Hierarchical Regression Analysis for Team Processes Predicting Stress 

(n=193) 

Variable B SE 

B 

Step 1 

Team Size .0043 .002 

.5 

β 

.13 

R 2 .016 df 1 p

higher level unit (organisation, the NHS Trust). Strategies that examine 

relationships at one level of analysis ignore the influence events at another level 

may have on the data. In this case events may occur in the team that might 

influence individual stress as well as individual events influencing team morale 

(such as team members leaving). 

Hierarchical Linear Modelling (HLM; Bryk & Raudenbush, 1992) is a strategy that 

investigates data at more than one level of analysis. This analysis takes into 

account both individual and team level variance. To explore the relationships in 

this study the following research questions were examined. How much does 

stress vary across teams? Do team process variables influence stress? 

Data from 136 teams (n = 1,121) were analysed using HLM (teams with 4 or less 

members were removed from analysis to improve reliability). Variables were 

chosen that significantly correlated with stress: participation, support for 

innovation, team objectives, emphasis on quality, reflexivity, social relations, role 

understanding, knowledge of team outcomes and teamness (a composite of the 

four criteria variables to identify team membership). Team tenure, age and gender 

were used as control variables. 

HLM demonstrates that 3.4% of the total variance in stress is explained by team 

factors (this is significant, given that the GHQ measures general life stress rather 

than work-related stress in particular). More than75% of this variance can be 

explained by team processes (as measured by the TCI scales – clarity of team 

objectives, emphasis on quality, participation and support for innovation). 

Study 3: 

Do Team Inputs and Processes Predict Team Member Retention? 

• Around 10% of teams in the sample ceased to exist in the six-month study 

period and there is an average of 16% turnover of team members in the 

remaining teams. 

• Larger teams have lower levels of retention. 

• Clear team objectives and high levels of team participation predict 

member retention.

Results 

57 teams from 4 NHS trusts (75% of those originally participating) participated in the 

survey (31 nursing care, 13 management, 5 multi-disciplinary, 5 quality improvement 

teams, 2 medical teams and 1 administrative support team). Data from the quality 

improvement teams were removed from the data set as these teams were not 

permanent and several had ceased to exist having completed their tasks. The final 

sample for analysis comprised 52 teams (mean size 11.8, SD 6.03, range 2 to 25). 

Nineteen teams did not respond to the survey (mean size 9.0, SD 4.9, range 2 to 19. 

No information is available as to the turnover in these teams. A comparison of means 

was undertaken across study variables obtained at Time 1 to identify any differences 

between responders and non-responders. No significant differences emerged. 

A high rate of turnover was reported amongst the teams surveyed. 10% (5) of the 

teams ceased to exist and only 12% (6) of teams reported no change in membership 

(either joiners or leavers) over the six months period of the study. On average, there 

were two leavers per team (mean = 1.90; SD = 1.94; range 0 to 8), and an average 

16% turnover during the study period (mean = 16.1; SD = 15.8; range 0 to 71.4%). 

26.3% of teams reported no leavers.

Team size and type of Trust are associated with turnover. People are more likely to 

leave a team if they work in a teaching Trust (Chi-square 8.43, df 2, p < .05) and are 

members of a larger team (Pearson correlation: r = .23 between log percentage 

leaver and team size p < .05, one-tailed test). Regression analyses revealed that 

team size and Trust type accounted for 15% and 18% of the variance in turnover 

respectively. There was no evidence to suggest that stress at Time 1 was 

associated with team turnover at Time 2. 

Perceptions of clear team objectives and high levels of participation were significantly 

associated with low levels of turnover, such that in teams whose members were clear 

about and committed to the team objectives, and who reported high levels of team 

participation at Time 1, there were lower levels of turnover between the two 

measurement points. (See Figure 9.3). 

Regression analysis (controlling for team size and Trust type) revealed that team 

process variables treated as a block (participation, support for innovation, team 

objectives and emphasis on quality) explained 10% of the variance in team turnover 

or team member retention. 

Conclusions 

Overall these three studies suggest the value to NHS employees in secondary care 

of working in teams, and particularly in teams that are characterised by clear 

objectives, high levels of participation, emphasis on quality and support for 

innovation. Taken together with the findings reported in earlier chapters, it 

suggests teamworking is a means for promoting effectiveness in the NHS and the 

well-being of employees. Perhaps most striking is the finding from a recently 

completed study by the Aston research team (West, Borrill and colleagues) 

revealing that the percentage of Trust staff working in teams in acute trusts is 

associated with lower levels of patient mortality. The more people who work in 

teams in Trusts, the lower the number of patient deaths measured by the Sunday

Times (Dr Foster) Mortality Index, deaths within 30 days of emergency surgery and 

deaths after admission for hip fracture. 

We now turn to examine the results of the intensive analysis of team meetings and 

communication amongst primary health care and community mental health teams, 

carried out by the Human Communications Research Centre at the Universities of 

Glasgow and Edinburgh in collaboration with the Leeds and Aston research groups.

Introduction 

Chapter 10 

Meetings and Communication 

Research Methods 

Meetings are important for effective teamworking, providing teams with their main 

opportunity for communicating. They are particularly important in health care teams 

where the team members often work in different locations and therefore have little 

opportunity for communication. For this part of the work, we have compiled two 

different sources of information about team meetings. The first source details the 

range of meetings held within the team and who is invited or expected to attend 

them. This information was derived from the practice manager interviews in PHCTs 

and the CMHT. This allows us to assess how much communication took place in a 

team, especially across different disciplines, where links are usually the poorest. 

However, even within teams which hold many meetings, with good links across 

disciplines, communication can be good or poor, depending on how those meetings 

are conducted. Therefore our second source of information is recordings of team 

meetings, from which we draw both quantitative measures and observations about 

meeting practice. 

Communication and decision making in teams 

Communication in meetings is important in teams for two different reasons. First, 

effective teamworking requires everyone to be both well-informed and to be invested 

in the team's overall goals and plans. Although there are other methods for keeping 

team members informed, such as newsletters, bulletin boards, and informal 

conversations, meetings are a common way of doing it. Meetings are the most 

effective method of involving a group of people in activities which require discussion. 

Team members who have been involved in the discussions of the team's goals or 

plans, or in the decision-making process itself, are more likely to feel that they "own" 

those goals and plans and to work actively to bring them about (Weldon & Weingart, 

1993). Second, the plans which a team develops are likely to be better, the wider the 

pool of views they take into consideration. Each individual in a team will have their 

own unique perspective on how health care can best be provided in that team's 

circumstances; in particular, team members from different disciplines encounter very

different situations in their daily working lives and therefore will have different ideas 

about what should be done. Providing the best care means synthesising this 

diversity of views into a co-ordinated plan which is understood and accepted by 

everyone on the team. Therefore two important properties of team communication 

are that everyone participates and especially that every discipline is involved in 

discussion. 

Barriers to effective communication 

One of the classic problems for all teams, and not just ones from the health care 

sector, is that when there are status differences between team members, higher 

status members are more likely to attend the most important meetings. Even within a 

single meeting, higher status members are likely to make the contributions which 

drive the meeting, such as giving information, asking questions, and making 

suggestions; lower status members are usually restricted to relatively short, 

responsive contributions such as answering questions or expressing agreement with 

something that has been said (Berger, Rosenholtz, & Zelditch Jr., 1980; Berger, 

Fisek, Norman, & Zelditch Jr, 1977). This tends to make lower status members less 

invested in the team's plans and to limit the range of ideas about potential changes to 

increase effectiveness that the team actively discusses. In manufacturing industry, 

for instance, it has been argued that strictly hierarchical management structures are 

insufficient to deal with the rate of change in the modern business world because 

they promote the flow of information downward but not upward, making it difficult to 

adapt using information gained "on the ground." (Burns & Stalker, 1966) 

Another classic problem, again universal, is that the larger a group discussion, the 

more one person will come to dominate that discussion and the more people will sit 

silently rather than contributing actively (Bales, Strodtbeck, Mills, & Roseborough, 

1951). In fact, the optimal group size for free discussion is five people, and in any 

group larger than around eight, no more than eight people say virtually anything 

which is said. In status-differentiated groups, it tends to be the high status individuals 

who speak and the low status ones who remain quiet (Berger et. al., 1980); where 

one person has authority for decision-making, they tend to control the interaction 

(Carletta, Garrod, & Fraser-Krauss, 1998). This can create difficulties for larger 

teams unless they can find a way to discuss freely issues in small, cross-disciplinary 

groups and then pass ideas forward from them. Finally, there are differences in the 

properties of very small groups which make them more suitable for free discussion.

Even in relatively small groups, active discussion in a meeting tends to involve just a 

few people at a time, but there is evidence that people who participate actively in a 

discussion understand and react to it differently from those who simply overhear it 

(Schober & Clark, 1989). In non-status-differentiated groups of five people, 

discussions are highly interactive, with people's opinions influenced by whoever they 

interacted with the most. Even in groups of just ten people, speakers make longer 

utterances as if lecturing to the whole group, and whoever speaks the most has the 

most influence (Fay, Garrod, & Carletta, 2000). This means that for good discussion 

across disciplines, it is important to keep the groups small and make sure that status 

is not an issue as far as that is possible, so that everyone has at least some chance 

to interact with everyone else. Because people are more likely to have informal 

conversations outside meetings with people they encounter and see as similar to 

themselves — i.e., staff from the same discipline — this makes cross-disciplinary 

discussion in meetings all the more important. 

Methods 

Our general interview methods have already been detailed in chapter 3; interviews 

were held with the practice manager for primary health care teams and the team 

leader in the community mental health care teams answered a questionnaire. 

Information was collected about the set of meetings held within the team, who was 

invited or expected to attend them, how long the meetings were, the purpose of the 

meetings, and how frequently they were held. The sample sizes for primary health 

care teams and community mental health teams are 67 and 92, respectively. The 

rest of this section describes the methods used in order to obtain a corpus of 

recorded meetings. 

Team Selection 

Within the primary health care sector, all teams undertaking the questionnaire and 

interview section of the Health Care Team Effectiveness study were invited to 

participate in recording of meetings for further study; selection was first-come first- 

served, with no additional selection criteria. In particular, we did not select teams 

based on meeting size or on the results of the effectiveness questionnaires. Twelve 

teams volunteered for this part of the study. Meeting size ranged from three people 

to twenty-five. The teams recorded were reasonably representative of the larger 

sample of primary health care teams. 

Meeting Selection 

Recordings were made of multi-disciplinary decision-making meetings as it was 

expected that these meetings would best reflect effective teamworking. Multi- 

disciplinary meetings were defined as those attended by a range of disciplines.

Decision-making meetings were defined as those where in addition to exchanging 

information decisions were made during them, again with active participation from the 

different disciplines. Primary health care teams provided access to the team’s 

business meetings, in which the day-to-day running of the practice was discussed. In 

one team, all decisions affecting the practice were made solely by the partners, all of 

whom were doctors, and therefore there were no multi-disciplinary decision-making 

meetings to record. In this case the partners’ meeting was recorded. For community 

mental health teams, the meetings again were multi-disciplinary business meetings in 

which decisions were made about the running of the team. Wherever possible, two 

meetings of the same type were recorded for each team. Dates for meeting 

recording were at the discretion of the practice; therefore the two meetings recorded 

were not always in sequence. 

Before each meeting was recorded, the primary contact for the team, usually the 

meeting chairman, was briefed that the meeting was to be kept as naturalistic as 

possible. It was requested that recorded meetings should be held in their usual 

locations, with their usual meeting protocols (agendas, minutes, chairing procedures, 

etc.), and that attendance should be the same as if the meeting were not being 

recorded. The researcher who tended the recording equipment made herself as 

unobtrusive as possible. 

Equipment used 

Audio recording was conducted with two omni-directional PZM tabletop microphones 

linked to different channels of a high quality audiotape recorder; the microphones 

were set up so as to maximise channel differentiation but to be unobtrusive enough 

that participants would not move them. A single static video camera on a tripod was 

trained to record the gross movements of as many of the participants as possible; 

this record was used only to aid speaker identification during transcription. 

Transcription 

Before each meeting was opened all participants introduced themselves and their 

occupation and on the basis of this was allocated a speaker number. Therefore the 

first person to introduce him/herself became speaker 1, the second speaker 2 and so 

on. Each participant was referred to by the same speaker number for the transcripts 

of both meetings regardless of when they spoke during the second meeting. 

Meetings were transcribed from the audiotapes by an audio typist who had not 

attended the meeting. Audio typists transcribed complete contributions in order 

according to when they began, labelling each contribution by speaker number, but

did not code finer timing information. Speaker identification was facilitated both by 

the video recording and by a seating plan drawn up during the meeting by the person 

recording the meeting. In previous work using these methods on four to twelve 

person meetings, transcribers were able to agree very reliably who made any one 

contribution; using the kappa statistic, K=.93, k = 2, N = 230, with an average of 2% 

and a maximum of 6% non-backchannel contributions left as unidentified (Carletta et 

al., 1998). A contribution was defined as a period of speech from one individual in 

which the only major pauses coincided with silence from the other speakers, so that 

the pause was likely to be caused by the speaker thinking and not by the speaker 

listening to someone else's contribution. Under this definition, speakers cannot follow 

themselves in the speaking order. Overlapped speech was transcribed, with the 

extent of the overlap roughly marked. Infrequently, parts of the meetings were 

omitted because they were so badly overlapped that we could not track individual 

contributions. After transcription, the transcripts were completely anonymised taking 

out all staff, patient, place names, place and local authority names or possible team 

or person identifiers. 

An example transcription excerpt is given in Figure 10.1. Transcription proceeds one 

contribution per row. Column one contains the speaker number. Column two 

contains the words said, combined with some coding information, and column three 

contains any notes which the transcriber wished to make (for instance, about people 

entering or leaving the room). Column two codes include /num for the approximate 

location of the start of another contribution during overlap, italics for anonymised 

text, @ for words from the tape which could not be heard clearly, and some common 

descriptions of non-linguistic behaviour such as general laughter within the group. 

To make the example clear, everything but transcribed speech is indicated in red. 

Figure 10.1: An example of the format used for meeting transcription 

1 Shall I open /4 the meeting 

4 Yep, let’s get on with it. phone 

rings

3 My apologies I am going to have to leave before the end. I have 

an appointment in Place 1. 

1 Are you skiving off? 

Group laughter 

Analytical techniques 

The primary interest is in how well teams communicate not just overall but also 

across disciplines. The analysis therefore relies on a classification of meeting 

participants by occupation. For ease of reference, categories are identified by colour 

as well as number. For primary health care teams, we have used the following 

categories. 

1 GPs 

2 practice managers 

3 practice nursing staff, including nurse practitioners 

4 attached staff (mostly health visitors and district nurses) 

5 administrative staff (mostly secretaries and receptionists) 

6 Miscellaneous 

For community mental health teams, the categories are instead: 

1 Psychiatrists 

2 nursing staff 

3 occupational therapists 

4 psychologists, psychotherapists, and other therapists 

5 Managers 

6 staff from social services 

7 Miscellaneous 

Both kinds of teams rarely had miscellaneous staff or miscellaneous meeting 

attenders who were not included in the analysis. In most cases, these were visitors, 

students, or staff associated with the physical location such as caretakers and 

security staff; for community health care teams, there were also sometimes 

representatives of user, carer, or voluntary groups and liaisons to local GPs. 

For both the entire range of meetings described in interview and for the recorded 

meetings, descriptions were produced of which staff categories interact with each 

other. These descriptions are best explained in terms of diagrams. For instance, 

consider the following diagrammatic representation of one of the recorded primary 

health care team meetings:

Figure 10.2: Communication in a primary health care team meeting 

9 

1 0 

1 1 

8 

1 2 

7 

1 3 

6 

1 4 

5 

1 5 

4 

1 6 

3 

1 7 

2 

1 8 

1 

1 9 

70 minutes 

68% of team present 

heavy: > 2 1 

medi um: > 1 4 

l i ght: > 7 

In the diagram, each person is represented by a coloured circle, where the colour 

represents their occupational category. How often each person spoke immediately 

before or after each other person is represented by the line between their two circles. 

Heavy lines mean the people took adjacent turns relatively often; light or no lines 

means that they took adjacent turns relatively rarely. When people take adjacent 

turns in meetings of this type, they are usually (but not always) communicating 

directly with each other and addressing the same topic. The actual line darknesses 

are determined by the maximum number of times anyone followed anyone in the 

meeting and using that to construct quartiles; no line is shown when the number of 

adjacent turns the two people took is less than a fourth of this maximum, a light line 

when it is less than half, and so on. For instance, in the diagram shown, nineteen 

people attended the meeting, of which seven were doctors (indicated in red), and the 

heaviest interaction was between participants 3 and 6, 3 and 8, and 8 and 1. Despite 

the fact that no pairs were able to interact very many times (as indicated by the 

numbers in the legend) this was a quite long meeting. Although the numbers in the 

legend are affected by meeting length, smaller meetings are more likely to have high 

numbers because there are fewer possible pairs to interact, and therefore the 

potential for any given pair to interact is greater. High numbers in the legend of a 

large meeting, unless it is unusually long, indicate that most of the possible pairs of

people do not interact with each other at all, and usually means that many of the 

people attending the meeting say little or nothing. 

In the diagram just observed, quite a few pairs of people interact, showing that, at 

least among those who participate actively, the interaction is quite free. However, 

although there are many people present at the meeting and they represent all of the 

occupational categories, the interaction is almost exclusively among the GPs and 

practice manager. It is also possible for interaction to occur primarily between one 

person and others within the meeting (see Figure 10.3). 

Figure 10.3: Communication in a primary health care team meeting 

9 

1 0 

1 1 

8 

1 2 

7 

1 3 

6 

1 4 

5 

1 5 

4 

1 6 

3 

1 7 

2 

1 8 

1 

1 9 

30 minutes 

40% of team present 

heavy: > 7 

medi um: > 4 

l i ght: > 2 

This usually indicates strong chairing of the meeting, although the chair may only be 

choosing who will speak next rather than actively controlling the topic of the 

discussion or making contributions to the topic him or herself. Alternatively, it may 

indicate that the purpose of the meeting was for the dominant person to give a report, 

with others asking clarification questions as needed. Whether the diagrams indicate 

interaction among many pairs or interaction through one central person, the 

interaction which exists can be more or less cross-disciplinary, depending on the mix 

of people who actively contribute to the meeting. 

The same sort of diagram serves for the interview data. Consider the following 

depiction of the set of meetings in a community mental health team:

Figure 10.4: Communication in a community mental health team 

3 

4 

Here, instead of representing individuals, the coloured circles represent staff 

categories. Instead of representing the number of times people took adjacent turns, 

the lines show the number of minutes per month which representatives of the two 

categories spend in the same meetings. Lines around a circle show all meetings 

which someone from that staff discipline attended. For instance, this diagram shows 

a team in which psychiatrists never attended meetings, not even ones only with other 

psychiatrists. As in the diagrams for the recorded meetings, the darker the line, the 

more communication occurred. 

2 

5 

1 

6 

v er y l i gh t: < 2 1 3 

l i gh t: < 4 2 7 

m edi u m : < 6 4 1 

h eav y : < 8 5 5 

As well as providing a descriptive account of meeting practice in health care teams, 

we also derive quantitative measures of communication from what we observed. 

Recall that good communication among the pairs of individuals in a team and among 

the pairs of disciplines is theoretically important for effective teamworking. To 

measure this, we have devised a score for freedom of interaction (Carletta et. al., 

1998). For a recorded meeting, the freer the interaction, the more pairs of 

participants take adjacent turns. This is reflected in the diagrams by how "starry" 

they appear. Similarly, starriness in the diagram for a set of meetings reflects how 

free the interaction is in general among the different staff disciplines. Freedom of 

interaction is scored based on either the meeting transcripts or the interview data. 

The scores vary between 0 and 1, with high scores reflecting high freedom of 

interaction. Similarly, for the individual meetings, since it is important to know 

whether high status individuals are over-represented in the communication, we score

equality of participation from 0 to 1. Meetings with equal participation have the same 

darkness of lines coming from each of the participants if they are added together, but 

do not necessarily link all the pairs and therefore do not necessarily have very free 

interaction. Other measures for both individual meetings and the set of meetings for 

a team as a whole consider the amount of communication which occurs, sometimes 

divided by individual or discipline, and who attends meetings.


Chapter 11 

Analysis of Communication in PHCT teams 

� Meetings in primary health care are often badly managed and dysfunctional 

� Attached staff (i.e. health visitors and district nurses) often miss team meetings, 

yet support for innovation is higher in teams where they attend. 

� Better meeting attendance in PCHTs is associated with care that is more patient 

centred. 

� In primary health care, team meetings are often re-arranged, cancelled or start 

late. 

� When teams do meet many PHCT team members remain silent throughout the 

meetings. 

� In over half the meetings we recorded no group decisions are taken. 


"A meeting" is defined as a set of people, who meet usually at some regular interval, 

for a particular purpose. Adding together the time devoted to the different meetings 

reported - all the meetings which involved any part of the team - shows that primary 

health care team members spend relatively little of their time in meetings. On 

average, there was a meeting involving some part of the team for 325 minutes per 

month (range 22 - 1190, S.D. 240); that is team members spent about 3% of their 

time in meetings. The primary health care teams in the sample had between 1 and 6 

meetings. The frequency of these meetings ranged from weekly to yearly. Primary 

health care meetings tended to fall into the following categories, divided by who 

attended them:

Figure 11.1: Primary health care meetings 

3 

3 

3 

3 

3 

3 

2 

2 

2 

2 

2 

2 

4 

4 

4 

4 

4 

4 

1 

1 

1 

1 

1 

1 

5 

5 

5 

5 

5 

5 

Whole team meetings, usually held monthly and attended by 

either the whole team or at least by representatives of each of 

the disciplines (22% of sample). 

Single discipline meetings for doctors or for administrative 

staff, sometimes with practice management also attending (28% 

and 3% of sample, respectively). Doctors meetings were 

typically weekly or monthly; administrative meetings were 

usually monthly or every two months. 

Practice clinical meetings attended only by those clinicians 

based in the practice, and sometimes by the practice 

management (43% of sample). These meetings were usually 

monthly but some practices held them weekly. 

Full practice meetings, usually held monthly and attended by 

all staff based at the practice: management, doctors, practice 

nurses, and administrative staff (7% of sample). 

Clinical staff meetings, usually held monthly and attended by 

all clinicians included attached ones, and sometimes by the 

practice management (16% of sample). 

Nursing meetings attended by the practice nurses and 

attached staff such as health visitors and district nurses (6% of 

sample). 

Diagrams shown are representative of the types, but not all meetings in the category 

conform completely to the diagram. Nursing meetings were the only ones which were 

never attended by the practice management. For each meeting type, there was no 

relationship between whether or not a team held a meeting of that type and the

team's size (unrelated t-tests, allowing for unequal sample sizes). The set of 

meetings which a team held divided teams into the following categories, with the 

following typical diagrams. For each category, we give the mean, minimum, and 

maximum size of team with that meeting practice. 

• Unitary: Teams with whole team meetings and nothing else (mean team size 

14, min. 8, max. 26). 

• Multiplex: Teams with both a clinical staff meeting which included attached staff 

and either a full practice, practice clinical, or single discipline doctors meeting. 

One-quarter of these teams also held a whole team meeting (mean team size 23, 

min. 10, max. 51). 

• Unitary-plus: Teams which hold whole team meetings plus either a separate 

doctors meeting or a separate practice clinical meeting (mean team size 23, min. 

10, max. 45). 

• Practice-based: Teams whose most inclusive meetings were full practice clinical 

ones. These teams sometimes had additional single discipline meetings. In this 

category, attached staff such as health visitors never attended any meetings and 

administrative staff never met with anyone outside of their single discipline 

meeting (mean team size 21, min. 8, max. 64). 

• Isolated: Teams which had nothing which could be categorised as a team 

meeting. In these cases, the only cross-disciplinary meetings might mix practice 

nurses and health visitors. These teams tended to report some single discipline 

meetings (mean team size 24, min. 17, max. 37). 

Of these types, multiplex, unitary-plus, and practice-based were the most common, 

with relatively few teams having just a whole team meeting (the unitary category) or 

no true cross-disciplinary meetings (isolated). (See Figure 11.2).

Figure 11.2: Proportions of multiplex, unitary-plus, unitary, practice-based, and 

isolated Teams 

27% 

7% 

9% 

28% 

29% 

Multiplex 

Unitary-plus 

Unitary 

Practice-based 

Isolated 

In practice-based and isolated teams, communications with attached staff could be 

insufficient, causing inefficiencies and lack of direction. Unitary teams might require 

a great deal of informal communication to supplement meetings; this is more likely to 

be a successful strategy for fairly small teams, which is in fact where the meeting 

practice tends to occur. 

One might expect teams which have more inclusive meetings - those with whole 

team, full practice, or clinical staff meetings - to have higher self-reported 

team-working effectiveness scores, because these teams tend to have more chances 

for cross-disciplinary communication. Although the occurrence of a whole team 

meeting is unrelated to self-reported teamworking effectiveness (unrelated t-test, 

t = -1.32, NS), the occurrence of full practice and clinical staff meetings is (for full 

practice meetings, t = -2.44, df = 6S, p

meetings, we will return to why this might be the case after we have considered what 

form they take. 

Processes within meetings 

Meeting practice in PHCTs varies considerably. In this section we describe the 

meetings recorded in terms of who attended, how long they were, meeting practice, 

and interactional characteristics. 

Interpreting date relating to the relationships between communication in the recorded 

sample and other variables such as effectiveness and team processes, is 

challenging. Primary health care teams are highly variable, not just in terms of input 

factors, involving team context. For instance, one of the recorded teams, identified as 

Team A, was made up half of new staff who had been brought in with the explicit aim 

of changing the ethos of the practice. We observed that the atmosphere in this 

practice was quite tense, and, they were one of only three teams in the wider sample 

not to hold a Christmas party. This team had very low self-report effectiveness 

scores compared to the rest of the recorded sub sample for all but the sub scale 

reflecting professional delivery of care. They also declined to have a second meeting 

recorded. For this reason, the team was omitted from analyses involving 

effectiveness and team processes variables, but shown in graphs. In addition, 

differences in meeting practice made it necessary to omit further teams for certain 

parts of the analysis. 

Because of the small sample size, it is not always possible to test whether 

assumptions of normality and linearity are warranted for our statistical analysis. In 

order to make the analysis more robust, we categorise teams into two sets, high and 

low, for each of the properties of communication which we investigate, and employ 

tests. Where these show a difference, we then go on to show the relationship 

graphically and to characterise it using correlations. 

In most cases, the teams held one meeting which they considered to be for the whole 

team. These meetings were open, with all team members expected to attend. 

Although the meeting remit was not always clear, the teams used these meetings as 

their opportunity to discuss matters affecting the practice. There were three obvious 

exceptions. One of the teams, identified as Team B, was strictly controlled by the 

partners and never held multi-disciplinary meetings. Their team meetings were

attended by the partners and practice manager only, and even took place away from 

the practice, in one of the partners' kitchens. This team had very low effectiveness 

and team processes scores compared to the other teams in the sub sample. Like 

Team A, they also declined to have a second meeting recorded. Another team, 

identified as Team C, did not hold one whole team meeting, but had two highly multi- 

disciplinary sub-teams with specific remits which were meant to improve the working 

of the practice. One sub-team discussed how to make the best use of the nursing 

staff within the practice, while the other discussed initiatives to improve preventative 

care (for instance, an anti-smoking campaign). A third team reported that they held 

team meetings and gave us permission to record them. However when we 

attempted to arrange to record meetings, the team claimed that they were not holding 

any meetings which would be appropriate. This team had average self-reported 

effectiveness scores. 

Figure 11.3: Length of recorded PHCT meetings 

meeting length (minutes) 

The recorded sample is larger than the set of analysed meetings due to recording difficulties. 

PHCTs had regular time set aside for weekly or monthly team meeting. However they 

were quite often rearranged or cancelled completely. Meetings often started late, 

with people coming in late and leaving early in order to complete their other duties. 

Many of those attending were silent throughout and appeared bored: many 

commented informally to the researcher that the issues discussed in meetings were 

irrelevant to them. Meeting agendas were quite vague. Early business in the 

meetings, tabled on the agenda, tended to consist of items which the practice 

manager felt it was important to discuss. However, most of the meeting time was

taken up by "any other business" raised by other people present. In many cases, 

items which the practice manager were put off in order to accommodate unscheduled 

discussion. We observed that for many teams, items raised at the beginning of the 

first meeting we recorded had not been dealt with by the end of the second meeting. 

Only one team kept rigidly to the agenda, with no unscheduled discussion. Meeting 

chairs were usually practice managers, GPs, or practice nurses. (See Figure 11.4). 

However, the degree of control which chairs exerted over the meetings varied 

considerably, with some chairs, particularly those who were nursery and 

administrative staff, merely announced the next step on the agenda as prior 

discussion came to a close. 

Figure 11.4: Who chaired the recorded PHCT meetings, by occupational class 

Who cha ir ed t he r ecor ded PHCT meet ings, 

by occupa t iona l cla ss. 

In the meetings we recorded the decisions made which affected the entire team. 

Often the issues discussed were logistical; financial or business issues were 

discussed in different meetings. The official agenda in individual meetings tended to 

focus on one or two large issues, such as auditing team performance or clinic 

management. However, the majority of meeting time was spent discussing less 

weighty, more social issues such as what to do on practice nights out, whether to 

have a fish tank in the waiting room, and where to go for a Christmas party. These 

discussions rarely remained focused therefore they tended to take up more time than 

the critical issues. 

ATTACHED 

PN 

ADMIN 

MISC 

PM 

GP

Although the meetings we recorded had been identified by teams as decision- 

making, we found that decisions were not made in the meetings. Where decisions 

were made, they were often about how to proceed with the issues discussed; for 

instance, in these meetings, the team might decide to call another, often smaller, 

meeting for more discussion. Major decisions affecting the team members, such as 

changing a clinic date or recruiting more staff, were taken in a different forum and 

reported back to the 'decision making' meetings. Thus these meetings were largely 

for exchanging information and a forum so that there would be a place where team 

members could express their opinions. Some of the individual participants 

complained informally to the researcher carrying out the recordings that the meetings 

were boring and that the issues which they addressed were completely irrelevant to 

them. 

Figure 11.5: Primary health care meetings vary considerably in size 

M 

e 

e 

ti 

n 

g 

s 

i 

z 

e 

Number of People attending PHCT meetings 

20 75 100 125 200 225 300 

Number of People 

To score general attendance, one can use the average proportion of team members 

who attended recorded meetings. All of the recorded teams considered their 

meetings to be open to all team members except for Team B, which openly restricted 

. 

. 

.

attendance to GPs and the practice manager, and Team C, which was organised into 

sub-teams. Omitting these two teams, there is a relationship between team size and 

the proportion of members attending recorded meetings (see Figure 11.60 (dividing 

teams into two sets, small and large, (t = -3.64, df = 7, p = .01 two-tailed; small teams 

have the higher proportions). 

Figure 11.6: The relationship between team size and meeting attendance for 

whole team meetings 

.9 

.8 

.7 

.6 

.5 

.4 

.3 

.2 

.1 

10 

The relationship between team size 

and 

meeting attendance for whole team 


20 

30 

team size 

Team B is omitted from the graph because team size is 

unavailable. Fit 

shown without Team 

C. 

40 

50 

Team C 

Other teams 

One likely reason for this is the workload of health care team members. The bigger 

the team, the harder it is to schedule meetings at times that are suitable for 

everyone, and the more likely is that members will be unable to attend. This needs to 

be taken into account when interpreting results based on this general attendance 

score. Team A was omitted from the analysis because it had disproportionately low 

effectiveness and Teams B and C because they did not hold whole team meetings. 

When the average attendance was divided into two sets, low and high, a relationship 

was found with one of the self- reported effectiveness sub scales, patient- 

centredness of care (see Figure 11.7) (t = 2.42, df=6, p= 0.5 two tailed). Among the 

teams that have a higher proportion of team members attending meetings, the 

effectiveness score is higher. If a linear correlation between general attendance and

this effectiveness sub scale is assumed, the same result emerged (r = .73, df = 8, p = 

.04). This is the case despite the fact that there is no relationship between team size 

and patient-centredness of care, either in the sample of teams we recorded or in the 

wider sample. 

Figure 11.7: The relationship between general attendance and patient-centredness 

of care 

6.5 

6.0 

5.5 

5.0 

4.5 

4.0 

.1 

The relationship between general attendance 

.2 

and patient-centredness of care. 

average proportion of team members attending meetings 

Teams B and C have been omitted because their meetings are not open to 

the whole team. Fit shown without Team A. 

.3 

.4 

.5 

.6 

.7 

.8 

.9 

Team A 

Other Teams 

These results show that higher levels of attendance at meetings is associated with 

effectiveness with respect to quality of patient care. The explanation for this, even 

though there are no relationships with the other effective variable, can be found if we 

consider how the team use meetings. Even during the meetings, agenda items were 

often delayed while team members passed on information about individual patients to 

other members who were also involved in their care. Team members also used the 

time just before and after meetings to have such discussions, although there the 

opportunities were less certain because people often came late or left early. 

Although these discussions were only useful to a few of the people present and 

therefore might be seen as wasting team time, this was the only opportunity many 

had to exchange information. 

Team members from the differing occupational groups were not equally likely to go to 

the meetings recorded; whereas GPs and practice managers nearly always attended.

(See Figure 11.8). The graph includes team members whether they work full or part- 

time with the team. Although some categories are more likely to be part-time than 

others, and therefore have difficulty attending meetings, all team members still need 

some opportunity to communicate with each other. 

Figure 11.8: Who attended at least one meeting (in solid), by occupational class, 

versus total team membership (complete bars) 

nu 

m 

be 

r 

in 

sa 

m 

pl 

e 

90 

80 

70 

60 

50 

40 

30 

20 

10 

0 

In addition, not all meetings recorded had at least one representative from each 

of the constituent disciplines; whereas all meetings had at least one GP and one 

practice manager present, nearly half the recorded meetings did not involve any 

attached staff. 

Who attended at least one meeting (in solid), 

by occupational class, versus total team 

membership (complete bars). 

GP PM PN ATTACHED ADMIN MISC 

occupational class

Figure 11.9: For each occupational class, percentage of meetings recorded which 

had someone from that class attending 

1 2 0 % 

1 0 0 % 

8 0 % 

6 0 % 

4 0 % 

2 0 % 

0 % 

F o r e a c h o c c u p a t io n a l c la s s , p e r c e n t a g e 

o f m e e t in g s r e c o r d e d wh ic h h a d s o m e o n e 

Team B deliberately excluded all members except GPs and the practice manager. 

Two teams where we were able to record two meetings did not have any attached 

staff present at either one. Some practice managers remarked informally that for 

some individuals, failure to attend was quite regular and tended to cause resentment 

among the other team members. 

f r o m t h a t c la s s a t t e n d in g . 

GP P M P N A T T A DM IN M IS C 

o c c u p a t i o n a l c l a s s 

The meetings which we recorded were in all cases the largest and most 

multi-disciplinary meetings which the teams held. As a result, we can use who 

attended the recorded meetings as a measure of integration in between the different 

disciplines. Although team meetings were only one of many ways in which a team 

communicated internally, it is likely that team members and disciplines that had poor 

attendance at meetings would be less well-informed and less involved in decision- 

making. This was most likely to apply to attached staff such as health visitors and 

district nurses. Not only were they least likely to attend team meetings, as the 

interview data shows, in most team these were the only meetings they were 

expected to attend. Much of the work of attached staff was carried out away from the 

practice premises, therefore they were least able to communicate with other team

members in other ways. From the content of the meetings it was clear that because 

attached staff do most of the home visits for the practice more than other team 

members, they were more in touch with both the circumstances of individual patients 

and patient needs in general. The recordings of team meetings also suggested that 

detached staff were the most aware of inefficiencies within the practice arising from 

GP's performing tasks that other team members could do (for instance/GPs making 

home visits on the same day as an attached team member). Thus for this analysis, 

we use two measures to reflect the discipline mix of meeting attendance. The first, a 

score for multi-disciplinarity of meetings, is the average number of occupational 

categories present at a team's recorded meetings, out of our list of five. The second 

is simply whether or not at least one attached staff member was present at one of the 

meetings we recorded. These scores are highly related, since no teams ever had an 

attached staff member present unless all of the other disciplines were represented as 

well; that is, for teams that ever had an attached staff member present, the multi- 

disciplinarity rating was over 4. 

There is no relationship between self-reported effectiveness and either of these 

measures. However, the data suggest a relationship between self-reported support 

for innovation and multi-disciplinarity of team meetings, if we omit Team A on the 

grounds of its disproportionately poor team processes. If Team A is omitted, support 

for innovation is higher when attached staff are present for at least one of the team's 

recorded meetings (t = -3.76, df = 8, p = .006 two-tailed). 

Dividing the multi-disciplinarity score into two sets, low and high, more multi- 

disciplinary teams have higher support for innovation (t = -2.8, df = 8, p = .02 two- 

tailed; r = .8347, df = 10, p = .003 two-tailed).

Figure 11.10: Fit shown with (solid) and without (dotted) Team A 

4.0 

3.8 

3.6 

3.4 

3.2 

3.0 

2.8 

* 

1 .5 

This result suggests that team members viewed these meetings as their chance to 

raise new ideas within the team. For this sample, as for the wider study, only around 

a quarter of the team members providing self-reports for team processes were 

attached staff (in this sample, mean 22.56%, min 8.33%~ max 38.46%). Therefore it 

is unlikely that the differences were a result of attached staff themselves reporting 

that they feel the team supports innovation; a more likely explanation is that their 

presence affects the entire team. 

it shown w ith (solid) and without (dotted) Team 

A. 

A 

2 .0 

2.5 

3.0 

3.5 

A t least o ne attached mem ber w as p resen t fo r at least o n e 

m eetin g if nu mb er o f catego ries presen t ex ceed s 4. 

4.0 

number of occupational categories present 

We used the 'freedom of interaction' and 'equality of participation' scores previously 

to study interactions during meetings in small to medium-sized manufacturing firms. 

In that study we confirmed that the scores differentiate groups which operate as 

teams, with equal responsibility among the members, from groups in which one 

person has overall authority. Equality of participation and freedom of interaction 

were higher for the teams, showing that they engage in freer discussion. Primary 

health care teams behave like equal responsibility teams and not like the managed 

groups. Restricting consideration to teams in the same size range (fewer than 

thirteen members), PHCT scores are higher and less varied than the industry scores 

as a complete set (for equality of participation, F = 6.725, p = .014 two-tailed; 

t = 3.76, df = 3l.53, p = .001 two-tailed; for freedom of interaction, F = 5.028, p = .032 

two-tailed; t = 2.50, df = 33.05, p = .017 two-tailed), but indistinguishable from the 

4 .5 

5.0 

5 .5 

T e a m A 

O th er te am s

equal responsibility subset (for equality of participation, F = .72l, NS; t = l.57, df = 22, 

NS; for freedom of interaction, F = 3.582, NS; t = .60, df = 22, NS). Although the 

teams have nominal chairs, for the most part the meetings are not strictly led. This is 

surprising because it is generally difficult to have free discussions in such large 

groups. In addition, status differences tend to make interaction less free, and GPs 

are both traditionally high status and the employers of many of the team members. 

Under the circumstances, if free discussion is what is required, these teams are 

doing better at allowing them to occur than one would ordinarily expect. 

Conclusion 

In primary health care teams, good general attendance at team meetings was linked 

to self-reported patient-centredness of care. An explanation for this seems to be that 

meetings gave individuals the opportunity to have conversations and exchange 

information about patients. However, whole team meetings do not appear to make 

the team believe they are more effective in other ways. In particular, teams that have 

whole team meetings do not believe they are any better at teamworking than teams 

that do not, even though full practice meetings and clinical staff meetings do improve 

a team's impression of their teamworking skills. These differences may arise from a 

sense of the purpose of a meeting. Team members may have felt that it was 

important to meet, but have been unsure about who should go to the meeting and 

what should be discussed. Being aware that a meeting is necessary requires that 

team members know that people need to communicate, but knowing how to 

communicate requires more preparation. Where there is uncertainty about the 

purpose of the meeting, the practice was to suggest that everyone (or at least 

representatives from each staff group) attended just in case something important was 

discussed. It was only possible to know which staff could be excluded when the 

remit of the meeting was clear. Although whole team meetings could be useful if 

they had a clear purpose that included everyone who attended, the meetings that we 

observed often did not have this character. Instead, because of the lack of direction, 

many staff members saw the meetings as irrelevant and a waste of their time. 

Attending meetings that are seen as irrelevant may have a demoralising effect on 

staff with further ramifications for the team's work. Therefore it is important for teams 

to consider their meeting practice and to make sure it is designed to best fit their 

circumstances.

Chapter 12 

Analysis of Communication in CMHT's 

_____________________________________________________________________ 


• CMHT members spent three times more time in meetings than PHCT members 

• The more cross-disciplinary meetings held in a CMHT the lower the stress levels 

in the team 

• CMHT meetings were generally well organised and multi-disciplinary 

• In 90% of CMHT meetings effective group decisions were taken 

• The prototypical CMHT meeting combined operational and clinical decision 

making and contained about 9-13 members 

• CPNs and Social workers were the best represented in the meetings but there 

was also regular attendance of occupational therapists, psychologists and 

psychiatrists

Types of Meetings 

The number of different meetings was larger and more varied in community mental 

health teams than in primary health care teams (range 1 to 11, mean 4.36, SD 1.77). 

(See Figure 12.1). 

Figure 12.1: Number of meetings 

30 

20 

10 

0 

1 

2 

3 

4 

5 

Number of meetings in total 

6 

Teams identified over 20 types of meeting, which we considered to fall within four 

categories: 

• Clinical, including audit/quality; day care meetings; ward rounds; representation 

at PHCT meetings; CPA reviews; allocation; referrals 

• Operational, including MDT meetings; business; locality, sector or patch 

meetings; team leader meetings; management; communication 

• Strategy, including planning meetings, away days, and team building 

• Professional development, including education or training meetings; 

professional group meetings; supervision; support 

Some of the meetings described, for example, PHCT, ward rounds, locality, sector, 

patch, or team leader meetings, were not strictly team meetings, although the CMHT 

was represented and received clinical, operational or strategic input from such 

7 

8 

10 

11

meetings. There is some confusion between clinical and operational meetings in the 

data set because teams tended to mix these two functions, for instance, by calling 

one meeting which first performed case allocation and then handled business issues. 

81% of teams reported having clinical meetings and 97% reported having operational 

meetings; these two types of meetings are probably ubiquitous, with the teams 

reporting no meetings of a type performing that function as part of another meeting. 

Strategy and professional development meetings were reported by 16% and 48% of 

the teams, respectively. Probably because they held so many different meetings, 

counting up the number of minutes per month that at least part of the team is in a 

meeting gives an average of around 1000 minutes per month (range 140-2940, S.D. 

608). This means that on average, there was a meeting happening a tenth of the 

time involving at least part of the team. 

Because of the variety of meeting types, it is less useful to characterise team practice 

as a whole in terms of the set of meetings which a team holds than to consider which 

disciplines engage in meetings with each other. In these teams, communication was 

usually very strong across the constituent disciplines. Teams generally fell into one 

of four categories of practice. (See Figure 12.2).

Figure 12.2: Four Categories of Practice 

3 

3 

3 

3 

4 

4 

4 

4 

2 

2 

2 

2 

5 

5 

5 

5 

1 

1 

1 

1 

6 

6 

6 

6 

Teams exhibiting complete connectivity might have some 

direct links missing --- for instance, in the example shown, 

managers never met directly with occupational therapists --- but 

all disciplines were involved in some cross-disciplinary meetings. 

In just under half of these teams, all disciplines encountered all 

others in meetings. 

Team with one isolate exhibited complete connectivity for five of 

the six disciplines, but one discipline was never involved in 

cross-disciplinary meetings. In two-thirds of these cases, the 

isolated discipline was management; the remaining cases were 

distributed evenly among psychiatry, occupational therapy, and 

psychology. 

Teams with a psychiatry + nursing + social services axis 

showed good connectivity for these three disciplines. Just over 

half of these cases only ever had these three disciplines 

communicate together in meetings. In the remaining cases, 

these three disciplines were included, but so was one other, with 

all the others equally likely to be the additional inclusion. 

Teams with a nursing + social services axis showed good 

connectivity between these two disciplines, and also usually 

included cross-disciplinary meetings with one or two other 

disciplines, but never with psychiatry. In over half of these 

cases, occupational therapists were involved in meetings, but 

there were also examples with management and psychology 

involvement. 

All of these categories were reasonably common in the sample, but the categories 

showing better overall connections were more prevalent:

Figure 12.3: Cross-disciplinary communication in CMHT meetings 

23% 

Cross-disciplinary communication in 

CMHT Meetings 

12% 

Processes in Meetings 

32% 

33% 

Complete connectivity 

One isolate 

Psychiatry+nursing+social 

services axis 

Nursing+social services axis 

What we can see from this analysis is that in terms of communication in meetings, 

nursing and social services staff tend to form the core of the team, with psychiatry in 

close contact and management most likely to be isolated. Although what happens in 

meetings is not necessarily indicative of communications in the team as a whole, 

meetings provide opportunities to discuss work and develop good relationships not 

just during the meetings themselves, but also beforehand and afterwards. Therefore 

we would expect this pattern to hold for the teams overall, even outside their 


Which meeting communication pattern a team has is not completely arbitrary. 

Omitting three teams with more than 35 members and six teams which were 

strangely constituted (usually nursing-only teams rather than cross-disciplinary 

teams), freedom of interaction is related to commissioning (one-way ANOVA F (2,79) 

= 3.41, p

Teams which are commissioned by health service and social services separately are 

more likely to have psychiatrists meet with social services than teams which are 

commissioned jointly or by the health service only. Whether managers were 

involved in meetings at all was also related to commissioning (X 2 = 6.45, df = 2, p

probably complex, since communication with colleagues should, by and large, reduce 

work stress and allow team members to express ideas which eventually turn into 

team innovations, but innovative teams undergo more changes than non-innovative 

teams, and change increases stress. 

Results derived from CMHT recorded meetings 

Meeting practice in CMHTs followed a more consistent pattern than with the PHCTs. 

Overall we found the communication in these meetings to be extremely effective. The 

meetings were used to make important group decisions and the content of the 

meetings was appropriate to their stated purpose. In this section we describe the 

recorded meetings in terms of their purpose, meeting practice, multidisciplinary 

representation, and the general interactional characteristics. We then use the 

analysis to identify good practice in such meetings and highlight what we believe to 

be important contributory factors toward good practice. 

As in the case of the recorded PHCT meetings we did not think it appropriate to try 

and draw strong conclusions about the relationships between communication in the 

recorded sample and other variables such as effectiveness or team processes. The 

sample is not sufficiently large or diverse to do this. Instead we describe the results in 

more qualitative terms and use them to identify prototypical meeting practices in a 

CMHT. On the basis of the purpose, content and general interactional characteristics 

of the meetings we then define a good practice prototype for CMHT meetings of the 

kind recorded. 

The purpose of the recorded CMHT meetings 

Teams were asked to select for recording routine meetings with strong 

multidisciplinary membership. Generally, they chose meetings that fell into the 

operational category described earlier. So the meetings were typically weekly team 

business meetings, but frequently they also had a clinical component. We recorded 

18 meetings from 9 teams and where possible ensured that they were two 

consecutive meetings of the same type from each team in the sample. Unfortunately, 

for one of the meetings there was a technical problem in recording so it had to be 

dropped from the sample. Hence, the analysis was based on a sample of 17 

meetings in 9 CMHTs.

Although the meetings fell into the operational category, as business meetings, they 

did vary in terms of purpose and this affected their style. In one case the team 

selected for recording two special meetings designed to respond to and influence 

health department policy on CMHTs. Membership was much larger than for other 

meetings in the sample and was quite different. For example, it included health care 

managers and a ward manager. The content and communicative style of these 

meetings was also quite different from others in the sample. We refer to these as 

High Level Policy (HLP) meetings to differentiate them from the others. 

A second kind of meeting associated with two of the teams involved dissemination of 

policies imposed from above. The purpose of these meetings was to ensure a 

detailed understanding of Trust or DoH policy initiatives. In many respects 

communication in these particular meetings was less effective than in others. For one 

of the teams much of the meeting time was spent reading documents that would 

have been better dealt with outside the meetings and decisions about how to deal 

with the policy initiatives were regularly put off to subsequent meetings. However, 

this team had adopted a rotating chair practice for their meetings and this limited the 

ability of the team leader to control the team’s decision making. It could well have 

been this factor which led to the apparent ineffectiveness of the decision making. We 

take up this issue in the section on meeting practice. We refer to this kind of meeting 

as a Policy Dissemination (PD) meeting. 

The most frequent kind of meeting in the sample was the weekly team meeting in 

which both clinical issues, such as deferrals, and team policy were formulated. 

Typically, teams split the meeting into a section on clinical reporting and case 

allocation and a subsequent business section. In most cases the business section of 

the meeting dealt with team operational issues rather than high-level policy issues. 

We shall refer to these as Mixed Purpose (MP) meetings.

Running meetings in CMHTs 

Members of CMHTs spend much more time at meetings than do members of 

PHCTs. This greater experience is reflected in a generally high standard of meeting 

management. In the majority of recorded cases, team meetings were held regularly, 

they were well organised and chaired, and had clear agendas. However, there was 

some variation in the organisation and style of chairing that did affect the quality of 

the decision making at the meetings. 

Three important factors in the running of meetings are their regularity, their size and 

their duration. In all cases except the rather anomalous HLP type, the team meetings 

took place on a weekly basis. The HLP meetings only occurred every two months. 

Twenty-one people attended the HLP meetings, but this was also not representative 

of the sample. For the meetings as a whole the average size was 11 and it varied 

between 5 and 21. (See Figure 12.4). The average duration of the meetings was 71 

minutes and it ranged from 38 to 140 minutes. (See Figure 12.5). In most cases the 

meetings were scheduled for no more than an hour, but there were a few occasions 

when this was extended to two hours for both clinical and business meetings. 

Figure 12.4: Size of meetings in terms of number of people present 

Number of people 

21 

18 

15 

12 

9 

6 

3 

0 

People present 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 

Meeting

Figure 12.5: Duration of meetings in minutes 

Length of Meeting 

140 

120 

100 

80 

60 

40 

20 

0 

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 

For multidisciplinary decision making teams choosing the right size of meetings is 

always going to be difficult. On the one hand, groups of more than about 8 or 9 tend 

to fall into a non-interactive mode of communication in which each speaker 

broadcasts information to the rest of the group. This hinders the process of finding a 

true consensus in the group. On the other hand, it is important to have a sufficient 

number of people present to ensure effective representation of the different 

disciplinary interests. In this situation meetings should be restricted to no more than 

about 12 or 13 members and there needs to be an experienced chair. The chair can 

then ensure that all relevant voices are heard and promote interactive discussion 

when it is needed. This was the practice in a large proportion of the MP type 

meetings that we recorded. 

Meeting 

For example, in one of the MP meetings the team was confronted with a crucial 

decision about how to respond as a team to a change in the sectors they were to 

cover. This change, which had been introduced without consultation, meant that 

there would be a reduced overlap between the areas covered by team members. The 

question was whether they should respond by splitting into two separate groups for 

their meetings or remain as a single group. The meeting contained 13 members and 

up until this point was characterised by a non-interactive broadcast style of 

discussion. So the team leader and chair of the meeting first promoted an extensive 

discussion of this issue in which he did not intervene. Then, when everyone had had

their say, he went round the whole group and allowed each member to indicate their 

feelings on the issue before confirming the decision. So although the group contained 

13 members it was possible to establish a clear consensual decision about this 

important matter. Interestingly, this meeting also managed to get through as much 

business as most of the others. Yet, this was all achieved in 40minutes; it was one of 

the shortest meetings in our sample. 

By contrast, one of the much larger HLP meetings (21 members) faced a situation in 

which a group decision should have been made, but it was left up in the air. A young 

CNP raised a problem of risk management and safety in the light of a recent 

traumatic experience. She had been on a routine visit and on arrival confronted a 

suspected suicide. Because she had no portable ‘phone and was in a poorly 

provisioned area of the City, she had to return to base before being able to call for 

support. The question confronting the meeting was whether to push for provision of 

portable phones to all staff engaged in domiciliary visits. This item received 

considerable discussion, but because the group was so large the discussion 

amounted to a series of long broadcasts where different members expressed their 

opinions on everything to do with risk management. After nearly 10 minutes 

discussion the problem had not been resolved and was not deferred for subsequent 

decision. This does not reflect on the will of the people at the meeting or the ability of 

the chair, but rather on the extreme difficulty of making effective group decisions in 

meetings of 21 members. In a smaller MP meeting, when confronted with a less 

dramatic example of the same problem, the team managed to come up with a co- 

ordinated policy, including the provision of portable phones, for just such cases as 

this one. 

The point illustrated here is that meeting size is crucial to effective group decision 

making and that even with relatively small groups of around 12 or 13 members the 

process relies on skilful chairing. In relation to this point, two of the teams in our 

sample adopted a practice of rotating chairs for meetings. Both had relatively small 

meetings (between 6 and 9 members at each). However, it was apparent that the 

quality of the group decision making was affected by the practice. For instance, in 

one case there was real confusion about who was to monitor and control the 

decision; whether it should be the team manager or the chair. In another case at 

least 5 minutes was wasted establishing who was to chair the meeting and who to 

take the minutes. Although it may seem helpful to give members experience of

chairing meetings, such cases illustrate that ineffective chairing will certainly reduce 

the effectiveness of the team’s decision making processes. 

For about half of the teams in this sample meeting size was restricted to less than 9 

members, which is quite an appropriate size for effective interactive discussion and 

group decision. 

The content of CMHT meetings and decision making 

The content of the recorded meetings fit in with the goals of the meetings. There 

were three main areas of discussion: policy, team operations and clinical allocations. 

The proportion of meetings in the sample that covered each of these topics is shown 

in the Figure 12.6. 

The three broad categories of meetings HLP, PD and MPD discussed the three kinds 

of issue according to their goals. The HLP meeting predominantly discussed a “green 

paper” on mental health care provision in their city. This was quite appropriate to the 

meeting because the team had been chosen to elicit feedback from relevant 

community groups on the content of the paper. The PD type meetings also discussed 

policy, but more in the context of detailed policy documents that had been sent to 

their team leader. In MP type meetings there was often also reference to policy, but 

only in so far as it was pertinent to particular issues arising from either clinical cases 

or team operation. 

The second main topic of discussion was what we have called team operation: by 

this we mean practices or policies to be adopted by the team that affect the way the 

team works. Not surprisingly this topic arose in most of the meetings we recorded. It 

was also the source of most team decision making that occurred in the meetings. 

Finally, the MP teams also discussed clinical matters. In the meetings we recorded 

most clinical (i.e., patient oriented) discussion concerned allocation of cases. 

However, there was also discussion of particular problems associated with difficult 

cases. For example, in one such case a sectioned patient had been on leave in her 

hometown in India. She had written to indicate that she was being held by the family 

against her will and was requesting repatriation as a British subject. The team had to 

work out an appropriate response to this situation.

Figure 12.6: Content and decision making in CMHT team meetings in terms of % 

meetings discussing these topics and making group decisions 

% of meetings 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

Policy Team 

operation 

The figure also shows the proportion of meetings which resulted in 1 or more group 

decisions. As can be seen such decisions were made in 88% of the recorded 

meetings. These decisions varied from straightforward matters of how to co-ordinate 

reports between the nurses, social workers and occupational therapists to more 

complicated matters such as formulating an effective security policy for staff on 

domiciliary visits. Interestingly these two issues arose in a number of the meetings 

and the teams tended to come up with slightly different solutions. The diversity of 

decision in operational matters reflected the different circumstances of the teams and 

seemed perfectly appropriate. 

Type of decision 

Clinical Group 

Decision

Attendance at meetings 

The CMHT meetings were attended by a broad range of different categories of staff 

representing different professional groups. The figure shows percentages of 

meetings attended by each of the major staff categories (see Figure 12.7). 

Figure 12.7: Percentage of meetings with a representative from each staff category 

All the meetings had representation of both the nursing staff and the social services. 

In fact, community psychiatric nurses and social workers were nearly always in the 

majority at the meetings. Across all meetings 37% of attendees were CPNs and 24% 

were social workers. In more than half of the meetings there were also occupational 

therapists, but they only represented 9% of the membership across all meetings. The 

two other staff categories of psychiatrists and psychologists were less well 

represented. Psychiatrists represented 6% of the attendees and psychologists only 

4%. 

% of meetings 

100% 

90% 

80% 

70% 

60% 

50% 

40% 

30% 

20% 

10% 

0% 

psychiatrists 

nursing staff 

occupational therapists 

psychologists, psychotherap... 

managers 

staff from social services 

miscellaneous staff 

In a situation where different disciplines are associated with marked differences in 

status (e.g., between consultant psychiatrists and CPNs) multidisciplinary 

representation at meetings can become a barrier to group decision making. On the 

one hand, it is important to have representation from as many groups as possible; 

but on the other hand, it is also important to minimise any major disparities in the

status of the group members. This is especially true for larger groups in which high 

status dominant speakers exert a disproportionate influence on the discussion. This 

means that notional group decisions tend to become individual decisions that do not 

reflect the broader interests of the group. 

So it is interesting that there were psychiatrists at only 1 in 10 of the meetings. 

Furthermore, we had the strong impression that the meetings in which they were 

present were not so effective at making group decisions. They tended to be longer 

(average 91 minutes compared to 72 minutes for the others) and generally the 

communication was less interactive. 

One strategy adopted by CMHTs was to have nursing staff from the hospitals 

represent the consultant’s cases at the meeting. This seemed to be a very effective 

way of ensuring broader representation without introducing marked disparities of 

status within the meeting itself. 

Communication dynamics in CMHT 

Unfortunately, we encountered some problems with the quality of the video recording 

for CMHT meetings. This made it difficult to establish quantitative measures of the 

degree of interaction of the kind made with the PHCT meetings. Also the mixed 

nature of many meetings with a clinical reporting section followed by a business 

section would have made it difficult to interpret overall measures of interactivity and 

participation. 

From other sources of information, such as the relative length of contributions it is 

possible to draw general conclusions about the interactivity of the discussion in the 

meetings in the sample. The major contributory factor to interactivity was simply the 

size of the meeting. In general, the larger the discussion group the lower the 

interactivity in the discussion and this was reflected in the CMHT meetings. 

The prototypical CMHT meeting: recommendations on good practice 

On the basis of this sample, which represents around 20 hours of discussion in 

CMHTs, it is possible to define a prototypical meeting. This can be used both to

describe the overall nature of CMHT team meetings as they occur in our sample and 

as a framework for giving recommendations about good practice. 

Within our sample of meetings a clear pattern of practice emerged that corresponded 

to the results from the interview data. The most common type of meeting was an 

operational meeting, which included both a clinical component and a separate 

business component. This was the case for more than half of the recorded meetings. 

In terms of size this prototypical type of meeting ranged from 5 to 13 members. In 

terms of multi-disciplinary representation it fit into the one isolate style of meeting. In 

other words, the meeting always contained representatives from nursing and social 

work but had either psychiatrists or occupation therapists or psychologists not 

represented. We feel that this is probably quite satisfactory in terms of group decision 

making because it allows for a sufficiently broad representation without 

compromising the size of the group or producing disparities in status. 

In relation to this prototype, meetings with around 9-13 members were generally the 

most satisfactory for both routine reporting and case management as well as more 

general group decision making. However, for the larger meetings to be effective there 

had to be skilled chairing of the meetings. We would strongly recommend that 

meetings be chaired by team leaders where possible and that they be given some 

training in effective meeting management. 

In contrast, the three meetings with membership of 15 or more were noticeably less 

effective in terms of decision making. It seemed that the very small team meetings 

with 5 or 6 members were also less effective. Despite often being very interactive in 

terms of the discussion they seemed to have more trouble making group decisions 

and on one occasion ended in conflict between two of the groups being represented. 

This was the only occasion in all the recorded meetings where such a conflict arose. 

Conclusions 

The prototypical CMHT meeting contains between 9 and 13 members, it combines 

clinical discussion with team business and is used to make team decisions. 

Communication in community mental health care teams was much more effective 

than in the primary health care teams. On average team members spent three times 

as much time at meetings as members of PCHTs. Also, there was strong cross- 

disciplinary interaction over the range of meetings that they held. Interestingly, the

freedom of cross-disciplinary interaction was associated with reductions in team 

stress levels (as derived from the interview data). Furthermore, the meetings we 

recorded showed evidence of high quality chairing and were generally well 

organised. Unlike many of the PHCT meetings group decisions were made in 90% of 

the meetings and many teams came up with effective ways of ensuring 

multidisciplinary representation without introducing too much disparity in the status of 

the members. 

General Conclusions 

In Chapters 11 and 12 we have looked at communication in both primary and 

community mental health care teams. The analysis was based both on the interview 

data from a large sample of teams in the two health sectors and the detailed analysis 

of recorded team meetings from a sub-sample of teams. The findings highlight major 

differences in the quality of communication and group decision making between 

PHCTs and CMHTs. In PHCTs there are few occasions where the whole team gets 

together in a recognized forum to discuss their activities as a team. When they do so 

in team meetings the communication and decision making is not particularly effective. 

In less than half the meetings we recorded not group decisions were taken. Team 

members who are attached to a practice regular do not attend the team meetings. 

Yet, there was evidence that teams were they do attend have stronger support for 

innovation. To the extent that the team meetings are effective, they enable pairs of 

members to sort out bilateral problems, such as coordination of patient visits. 

In contrast, meetings play an important role in the day-to-day operation of CMHTs. 

On the basis of the interview data it seems that members spend about 3 times as 

much of their time at meetings as do members of PHCTs. Most of the meetings that 

they attend are multidisciplinary and there is generally good connectivity across the 

different disciplines in teams at these meetings. Overall, the recorded meetings were 

well managed and spent most of their time discussing topics on their agendas. In 

about 90% of meetings appropriate group decisions were made and there was 

evidence in some meetings of skilled management of this process by the chair. 

In relation to the primary health care teams we would recommend that some 

attention is given to training in the management of multidisciplinary meetings. We feel 

that PHCTs should recognize the importance of group decision-making processes in 

supporting an effective team. For CMHTs the communication and meeting practices 

are in general more professionally organized and on occasion match the highest 

standards observed in industrial team meetings in which the members have had 

training in communication and decision making. However, we would also like to 

underline how important it is for these meetings to be chaired effectively. This was 

one of the most striking observations from the CMHT meetings.

Chapter 13 

Conclusions and Recommendations 

We began this research programme by asking whether team working in healthcare 

was associated with better quality patient care. We also asked what factors were 

associated with effective teamwork in healthcare organisations. Using a model that 

related team inputs and team processes to healthcare outcomes we were able to 

conduct research which has directly addressed these questions. The results paint a 

clear picture and provide firm answers to the questions we addressed. 

� Inputs such as team composition and organisational factors have a strong 

influence upon innovation and effectiveness in healthcare teams. 

� Team processes are directly related to the innovation and effectiveness of health 

care teams across sectors. 

� The quality of teamwork is directly and positively related to quality of patient care 

and innovation in healthcare. 

• There is a significant and negative relationship 

between the percentage of staff working in teams 

in acute hospitals and the mortality rate in those 

hospitals, taking account of local health care 

needs and hospital size 1 . Where more 

employees work in teams the death rate among 

patients is significantly lower (calculated on the 

basis of the Sunday Times Mortality Index Dr. 

Foster; deaths within 30 days of emergency

surgery and deaths after admission for hip 

fracture) 9 . 

� Effective teamwork in primary healthcare teams is associated with lower stress 

among team members. 

� In those teams characterised by clear leadership, high levels of integration, good 

communication and effective team processes, team members have good mental 

health and low stress levels. In secondary health care settings the retention rates 

of staff are higher in those teams characterised by good team processes. 

� In this setting also, the research demonstrated that team membership itself 

confers role clarity and social support on team members, helping them to achieve 

better mental health or lower stress than their counterparts not working in clearly 

defined teams. 

� Good team processes means clear, shared objectives amongst team members; 

high levels of participation including frequency of interaction, quality of 

information sharing and shared influence over decision making; emphasis on 

high quality patient care within teams and a preparedness to encourage 

constructive controversy but to discourage interpersonal conflict; and practical 

support for ideas for new and improved ways for providing healthcare. 

� Effective and innovative teams are characterised by a pattern of reflexivity. Team 

members collectively and individually take time out to review the objectives, 

strategies and processes of the team; they prepare plans for making changes 

accordingly; and they implement those plans in action. 

� Such reflexivity leads to both better quality healthcare and higher levels of 

innovation. 

9 This finding is based on separately funded research recently completed by the research 

team at the Aston Centre for Health Services Organisation Research (further details available 

from West or Borrill).

� Leadership also emerges as critical in healthcare teams but is often absent. A 

single clear leader in highly complex large teams is associated with higher levels 

of effectiveness and innovations 

� As teams develop and become more sophisticated in their ability to work 

effectively, distributed leadership or shared leadership amongst different 

functions is associated with higher levels of effectiveness, innovation and better 

quality teamwork 

� Clear shared leadership is associated also with better team processes - clear 

objectives, participation, emphasis on quality, support for innovation and 

reflexivity. 

� But conflict over leadership is disastrous for teams. Where conflict over 

leadership exists, teams are ineffective, not innovative and team processes tend 

to be very poor. 

The implications of our research are clear. First it is important that teamwork is 

encouraged in healthcare organisations and second that leaders are trained and 

encouraged to work effectively in teams. Leadership should be group-centred rather 

than traditional. 

The traditional approach to leadership of healthcare teams is that the leader 

is responsible for the group and has control over final decisions. He or she 

guards their position power and perceives the group as individuals to be 

managed by the leader. The leader shapes the task for the team and 

ignores the socio-emotional processes within the teams. He or she 

discourages expression of needs or feelings during team meetings. 

Our research suggests that healthcare teams needs group centred leaders 

who see responsibility as shared by both the leader and the team; where 

control over final decisions is vested in the team; where leader position 

power is de-emphasised; where the leader perceives the team as a 

collective entity and shares responsibility for shaping the tasks of the team. 

Moreover, the team leader should emphasise and share with the group the 

responsibility for maintaining the group as a social entity. He or she should

closely observe socio-emotional processes in the group and encourages 

discussion in meetings of team members' needs and feelings. 

� The research reveals that multi-professional working is associated with high 

levels of innovation in healthcare. Where a variety of professional groups are 

involved in healthcare teams it is much more likely that innovation will be a 

consequence. This is particularly so when the team processes are healthy. 

� Larger teams are seen as more innovative and effective, partly because they 

have the resources, organisational structures and processes in place which 

enable radical changes in the delivery of healthcare to be accomplished. 

Policy makers should be cautious about how they respond to these findings. 

Teams cease to exist above around twelve to 14 members. They become 

small organisations. Primary health care "teams" consisting of around 40 

members are in effect medium sized enterprises. As these teams transform 

at around 15 to 20 members into organisations it is likely that they will divide 

into sub-teams. This is a normal structural process in organisations. 

Leaders and managers then have to make decisions about the appropriate 

sub-teams to be formed. These should be formed taking account of the 

team's context and tasks. The purpose of these sub-teams should be to 

manage uncertainties in relation to particular patient groups, particular 

stakeholder groups and particular illness categories. 

A wise differentiation within healthcare teams is necessary as they develop 

into organisations. This differentiation or specialisation of activities is 

necessary for the team to cope effectively with its environment. But at the 

same time it creates new pressures upon the organisation. The sub-groups 

must learn to integrate effectively with one another to communicate, liase 

and co-operate. The danger is that sub-teams, particularly if they are 

composed of like professional groups, end up competing rather than 

collaborating and co-operating for the greater good of patients. Therefore, 

managers and leaders must ensure that these groups and sub-teams liase 

and collaborate together. It is harder to work as a single team as the 

organisation grows in size and the required differentiation and integration 

processes necessary require sophisticated leadership. Leaders of health

care teams must therefore be trained in appropriate leadership knowledge, 

skills and attitudes. 

These observations are reinforced by our finding that higher levels of integration in 

healthcare teams are associated with innovation and effectiveness. Communication, 

quality of meetings and information sharing activities to increase integration are all 

associated with innovation and effectiveness in healthcare teams. However, our 

research also reveals that quality of communication and meetings varies 

considerably. In general meetings are very poorly managed in primary health care 

and professionals in this domain have much to learn from their colleagues in 

community mental health teams. Indeed, another important conclusion which can be 

drawn from the research is the importance of training for those working in primary 

health care to better plan and manage their meetings. 

Recommendations 

There are a number of key elements to effective teamwork (Guzzo and Shea, 1992). 

1. Conditions for effective teamwork 

• First, Individuals should feel that they are important to the success of the team. 

When individuals feel that their work is not essential in a team, they are less likely 

to work effectively with others or to make strong efforts towards achieving team 

effectiveness. Roles should be developed in ways which make them 

indispensable and essential. 

• Individuals' roles in the team should be meaningful and intrinsically rewarding. 

Individuals tend to be more committed and creative if the tasks they are 

performing are engaging and challenging. 

• Teams should also have intrinsically interesting tasks to perform. Just as people 

work hard if the tasks they are asked to perform are intrinsically engaging and 

challenging, when teams have important and interesting tasks to perform, they 

are committed, motivated and co-operative (Hackman, 1990).

• Individual contributions should be identifiable and subject to evaluation. People 

have to feel not only that their work is indispensable, but also that their 

performance is visible to other team members. 

• Above all there should be clear, shared team goals with built-in performance 

feedback. Research evidence shows that where teams are set clear targets at 

which to aim and they receive feedback on their performance, their performance 

is generally improved. 

2. Selecting team members 

Regardless of their task specialism, there are certain attributes that all team 

members need to demonstrate if the team is to achieve its goal. Selection should 

focus not just on professional skills but also on knowledge skills and attitudes (KSAs) 

for teamworking. (See Figure 13). 

Figure 13: Knowledge, Skills and Abilities for Teamworking 

A Conflict resolution KSAs 

e.g. 

Fostering useful conflict, while 

eliminating dysfunctional conflict. 

Using integrative (win−win) strategies 

rather than distributive (win−lose) 

strategies. 

B Collaborative problem solving KSAs 

Having the right level of participation 

e.g. for any given problem. 

Avoiding obstacles to team problem 

solving (e.g. domination by some team 

members). 

C Communication KSAs e.g. Employing communication patterns 

that maximise an open flow. 

Using an open and supportive style of 

communication. 

Using active listening techniques. 

Paying attention to non-verbal 

messages. 

D Goal-setting and performance 

Management KSAs 

E Planning and task co-ordination KSAs 

. e.g. Setting specific, challenging and 

attainable team goals. 

Monitoring, evaluating and providing 

e.g. 

Source: Stevens & Campion, 1999 (Reprinted with permission). 

feedback on performance. 

Co-ordinating and synchronising tasks, 

activities and information. 

Establishing fair and balanced roles 

and workloads among team members.

3. Team composition 

Today’s health care teams are being formed to respond to increased complexity and 

demands in the environment; and they bring together people from diverse 

professional backgrounds. Such diverse teams therefore embody different attitudes 

and working practices as a result of differences in age, gender, educational 

background, nationality, organisational culture, etc. 

There is growing evidence, supported by the results from our research, that teams 

that are diverse in terms of skill and educational specialisation produce high levels of 

innovation and clear strategic thinking. 

To date however it seems that other forms of diversity produce less positive effects 

on team performance. Teams whose members have diverse cultural backgrounds 

initially tend to perform more poorly than culturally homogenous teams, although this 

effect diminishes over time. Turnover rates are higher in teams which are diverse in 

terms of demographic features such as age, educational level, status and non- 

industry work experience. 

Diverse teams are not only advantageous if team performance is to be maximised: in 

current health care settings, it is simply not practical to select teams that are highly 

homogeneous. The challenge is to achieve the positive effects of diversity whilst 

building stable teams that will grow and develop together. It is essential therefore to 

provide induction and training for individual team members which will minimise the 

impact of differences that can be disruptive. 

Susan Jackson (1996) has drawn a distinction between team-member differences 

that are task related (for example, educational level, work specialisation, 

organisational function) and those that are relations-oriented (e.g. gender, age, 

nationality, political views). It would seem that difficulties in teams are more often, in 

the short term at least, related to relations oriented-differences. In these areas, 

individuals will tend to make shallow or stereotyped decisions about others. Both 

awareness training and opportunities for social or informal contact between team 

members therefore play an important part in breaking down stereotypical reactions 

and developing more appropriate judgements.

4. Team Leadership 

• Leadership is creating alignment around shared objectives and strategies to 

attain them. 

• Leadership is increasing enthusiasm and excitement about the work and 

maintaining a sense of optimism and confidence. 

• Leadership is helping people appreciate each other and helping them to learn 

how to confront and resolve differences constructively. 

• Leadership is helping people to co-ordinate activities, continuously improve, 

develop their capabilities, encourage flexibility, encourage an objective analysis 

of processes, and foster collective learning about better ways to work together. 

• Leadership is representing the interests of the group or organisation, protecting 

its reputation, helping to establish trust with external stakeholders and helping to 

resolve conflicts between internal and external partners. 

• Leadership is creating a unique group or organisational identity. 

Organisations that introduce team based working stress the importance of selecting 

the right people to lead teams at the very beginning. Leaders who find it difficult to 

move from a directive/controlling supervisory role to one of participative leadership 

can cause lasting problems. Those organisations which have successfully overcome 

this difficulty actively encourage all members of staff to apply for team leader 

positions. This begins the process of breaking down stereotypical thinking about who 

can lead teams, the criteria for application, etc. In addition, these organisations 

provided considerable training and support for new team leaders in the initial months 

of their appointment. 

In the early stages of a team’s development, training should be made available for 

team leaders to enable them to design and implement appropriate team processes 

and to develop the skills needed for effective team leading. 

Team leaders need to be skilled in responding appropriately to meet the needs of 

their teams, i.e. to be more or less directive in supporting a team. Their aim should

always be to move as quickly as possible away from being directive and towards 

allowing the team to be autonomous. When supported by a team leader who 

provides an autonomous environment, a team can achieve more highly by becoming 

self-directing in its development and its work. 

5. Organisational Support for Teams 

Hackman and his colleagues at Harvard University have concluded that there are six 

principal areas within which teams need organisational support: targets, resources, 

information, education, feedback and technical/ process assistance in functioning. 

Examining the extent to which organisations provide team support in these areas can 

help in discovering the underlying causes of team difficulties. 

Targets 

Teams need support from an organisation in determining targets or objectives. 

Surprisingly few health care teams are given clear targets by their organisations often 

because organisational targets and aims have not been clarified sufficiently. It is 

striking, when team members are asked to outline their objectives and team targets, 

how few have clear notions of what is required of them. There is an implication that 

teams should derive their targets and objectives by scrutinising the organisational 

objectives or mission statements. However, these are often such vague good 

intentions or positive but abstract sentiments that it is almost impossible for a team to 

derive clear targets and objectives. Where, through a process of negotiation, teams 

are able to determine their targets in consultation and collaboration with those 

hierarchically above them, there is usually a better level of performance. 

Resources 

The organisation is required to provide adequate resources to enable the team to 

achieve its targets or objectives. 

Resources include: having the right number and skill mix of people; adequate 

financial resources to enable effective functioning; secretarial or administrative 

support; adequate accommodation; adequate technical assistance and support (such 

as computers, blood pressure testing equipment, or appropriate equipment for testing 

infants' hearing, etc).

Information 

Teams need information from the organisation which will enable them to achieve 

their targets and objectives. Changes in strategy or policy which are not 

communicated to teams can hamper their effective functioning. Ensuring that 

relevant information reaches a team to enable it to perform effectively is an essential 

component of an organisation's management. For example, GPs need to provide 

health visitors with ready access to age/ sex registers, medical records and other 

information about the practice population, in order for the health visitors to function 

effectively within the teams. 

Education 

Part of an organisation's responsibilities for effective team functioning is to provide 

the appropriate levels and content of education for staff within teams. The purpose of 

such training and education is to enable team members to contribute most effectively 

to team functioning and to develop as individuals. This includes on-the- job training, 

coaching via supervisor, training courses, residential training courses or distance 

learning courses. There should be adequate access to training which is relevant to 

the team's work and of a sufficient quality and quantity to enable them to perform to 

maximum effectiveness. And, as indicated above, team members should be trained 

in the knowledge, skills and abilities, for team working. 

Feedback 

Teams require timely and appropriate organisational feedback on their performance if 

they are to function effectively. Timely feedback means that it occurs as soon as 

possible after the team has performed its task, or occurs sufficiently regularly to 

enable the team to correct inappropriate practices or procedures. Appropriate 

feedback means that it is accurate and gives a clear picture of team performance. 

For some teams it is difficult to gain accurate feedback. For example, primary health 

care teams have almost no feedback at all. For a team responsible for providing 

training in one division of, say, a major oil company, organisational feedback might 

take the form of senior managers' satisfaction with improved performance. This could 

include measuring the results from technical training courses in customer service in 

retail outlets (i.e. filling stations). Such information could come from surveys of

customer satisfaction with retail operators' services. Clearly there are large 

differences in the extent to which organisations can and do provide feedback to 

teams, but the aim should be for the organisation to improve continuously in the 

extent to which it provides useful, accurate and timely feedback to teams. 

Technical and process assistance 

Organisations have to provide the specialised knowledge and support which will 

enable teams to perform their work effectively. A primary health care team engaged 

in developing its practice objectives, by identifying the health needs of the practice 

population, might need the health authority to deploy a community medical officer to 

advise the team on patterns in local health and ill-health. For a training team in an oil 

company, technical assistance might take the form of specialist computing experts 

and marketing strategists, advising the company on how to communicate most 

effectively to managers throughout Europe, in order to market their training courses 

to managers in different functions. 

Process assistance refers to the organisational help available when team process 

problems are encountered. Are consultants and facilitators available to help the team 

identify, diagnose and overcome problems of team functioning from time to time? 

But the implication of this work is that NHS organisations should not simply create 

teams. They should recreate themselves as team-based. We now turn to address 

this important issue. 

6. Developing team-based organisations 

Teams working within team-based organisations have more discretion and scope 

than those working within traditionally managed organisations. In practice, team- 

based organisations reflect a management philosophy that incorporates certain 

fundamental principles. 

In team-based organisations, most employees are clear about and committed to the 

objectives of the organisation as a whole. Senior management take time to 

communicate information to all employees about organisational objectives and also 

encourage team members and teams to influence the development of organisational 

objectives.

In team-based organisations employees are more fully involved. They are 

encouraged to contribute ideas, opinions and information to decision-making 

processes, and their teams have influence over decisions that are made. The 

organisation as a whole promotes acceptance of and commitment to processes of 

debate about how to perform work most effectively. 

Managers within team-based organisations are committed to encouraging 

constructive debate within the organisation. They listen carefully to the views of team 

members and take time to explore diverse views and differences of opinion. They 

also encourage the expression of minority points of view and value opportunities for 

careful discussion about the best ways of delivering products and services. 

In team-based organisations there must necessarily be a climate supportive of 

creativity and innovation. Teams are hothouses for creative ideas, and the 

organisation must encourage the expression and implementation of ideas for new 

and improved health care processes and ways of working. If it fails to do this, both 

the impetus for and the value of team-based working are lost. 

To ensure the achievement of these aims, team-based organisations must reflect the 

belief that organisational goals will largely be achieved not by individuals working 

separately but by groups of people who share responsibility for outcomes and who 

work in efficient and effective teams. 

In traditional organisations, there tend to be individual command structures with 

various status levels representing particular points in the hierarchy. There are 

supervisors, managers, senior managers, assistant chief executives and so on. In 

team-based organisations, the structures are collective. Teams orbit around the top 

management team or other senior teams, both influencing and being influenced 

rather than being directed or directive. The gravitational force of different teams 

affects the performance of the teams around them. This is a flexible, fluid structure in 

contrast to the mechanical, hierarchical structure of traditional organisations. 

In traditional organisations, the manager monitors the performance of employees. In 

team-based organisations, the team monitors the performance of members within the 

team and the team as a whole is appraised by those it provides services and 

products for. Thus the Human Resource Management team may be appraised by all 

of the teams within the organisation for which it provides services.

In traditional organisations, power is invested in the hierarchy. The further up the 

hierarchy you go, the more power you find located there. In team-based 

organisations, the emphasis is on integration between teams and on reducing the 

number of levels in the organisation so that there is less vertical difference between 

different teams and groups. Whereas in traditional organisations the emphasis is on 

maintaining power and control through the use of a clear hierarchy of command 

(which may be important for example in an organisation dealing with crises), in team- 

based organisations the emphasis is on achieving shared purpose across teams and 

achieving shared understanding and integration across teams. 

In traditional organisations the emphasis is on stability and keeping things the same. 

Rules and regulations, formalisation and bureaucracy encourage uniformity and 

control. In team-based organisations the emphasis is on encouraging innovation, 

change and flexibility in order that the organisation can adapt appropriately to its 

changing environment and be innovative health care services. 

Traditional organisations tend to adopt ‘one best way’ and to seek for universal 

models of effective organisational functioning. The team-based organisation 

emphasises its uniqueness, adopts ways of working that are appropriate to the 

organisation in its current circumstances, environment and economic context, and 

adapts as the environment changes. 

In traditional organisations, managers manage and control; whereas in team-based 

organisations, the teams are self managing and take responsibility for setting their 

(perhaps in consultation with senior managers) and monitoring the effectiveness of 

their strategies and processes. Changes in the process of achieving the team-based 

organisation are therefore deep, wide and pervasive. 

In the face of the inevitable complexities within organisational environments, within 

teams themselves and between the people who constitute those teams, there are no 

simple prescriptions for implementing effective team based working. In order to be 

effective, team members must therefore learn to reflect upon, and intelligently adapt 

to, their constantly changing circumstances as the team develops. 

There are however certain areas where problems can be predicted and where 

effective initial design greatly improves the chances of success. Many of the

common problems in the introduction of team-based working (TBW) result from 

impatience: effective TBW takes time to implement and requires multiple changes 

that create almost inevitable difficulties. Long-term benefits can only be achieved 

through persistent and consistent action in each of these three key areas: 

• organisational context 

• team structure 

• team processes 

Organisational context 

The top management team’s level of commitment towards TBW is a key factor in an 

organisation's introduction of TBW. But the attitude towards TBW amongst 

employees generally is another powerful issue under this heading. Reward systems 

that focus on competition between individual employees for bonuses undermine the 

introduction of TBW. Similarly, information systems that are characterised by secrecy 

rather than openness will impede the implementation of TBW. The training and 

education priorities of the organisation must also be geared towards developing the 

knowledge, skills and abilities required for TBW, including leadership skills and 

teamworking skills. The organisation will also need access to coaching expertise to 

support teams both during their development and when they experience difficulties in 

the course of their work (such as conflicts between team members), either provided 

by someone within the organisation or an outside consultant. 

Team structure 

Teams structure refers to the composition of the teams, i.e. who will be the team 

members. This is not simply a matter of the skills required to perform the task, but 

also raises questions of variety in functional background and balance in demographic 

characteristics such as background culture, gender, age and even personality. 

A key aspect of team structure is the nature of the task that the team is required to 

do. The goals should be clear, the task should be motivating and team members 

should have clear feedback on how effective their performance has been. It also 

refers to effective team leadership, as we have emphasised above, and the need to 

appoint team leaders who know how to lead teams and are not hierarchical, 

traditional supervisors.


When TBW is introduced, most organisations focus initially on team processes and 

send prospective team members on team-building workshops. Though the motive 

behind this is valid, i.e. to build cohesion, the first step in building effective teams is to 

ensure that team members: 

• make sufficient effort (that they are motivated to perform the task). 

• have adequate knowledge and skill within the team both to perform the task and 

to work in a team. 

• have developed appropriate ways of performing their task, i.e. task performance 

strategies. 

As organisations implement TBW, there are major pitfalls in each of these three key 

areas that must be avoided, any of which could considerably delay or impede the 

process. 

• the creation of teams throughout the organisation, regardless of the need or the 

nature of the tasks. 

• setting up teams but continuing only to appraise, reward and manage individuals. 

• creating teams but neglecting to train people to function effectively within and 

across teams. 

• introducing TBW while leaving teams without expert assistance when problems 

such as major conflicts arise. 

• creating well functioning teams but ignoring the vital need to ensure these teams 

communicate with each other, integrate their work and otherwise liaise 

effectively. 

• failing to negotiate with the teams clear and challenging team-level objectives. 

• giving the teams challenging objectives but not the training, skills and resources 

to meet those objectives.

Conclusion 

The following quotation illustrates just how fundamental team working is to our 

species and we include this to remind the reader of the importance of groups and 

teams to human societies throughout their development. There is little new about 

teamwork. 

"He makes tools (and does so within more than one technical tradition), 

builds shelters, takes over natural refuges by exploiting fire, and sallies out 

of them to hunt and gather his food. He does this in groups with a 

discipline that can sustain complicated operations; he therefore has some 

ability to exchange ideas by speech. The basic biological units of his 

hunting groups probably prefigure the nuclear family of man, being founded 

on the institutions of the home base and a sexual differentiation of activity. 

There may even be some complexity of social organization in so far as fire- 

bearers and gatherers or old creatures whose memories made them the 

data banks of their 'societies' could be supported by the labour of others. 

There has to be some social organization to permit the sharing of co- 

operatively obtained food, too. There has to be some social organization to 

permit the sharing of co-operatively obtained food, too. There is nothing to 

be usefully added to an account such as this by pretending to say where 

exactly can be found a prehistoricial point or dividing line at which such 

things had come to be, but subsequent human history is unimaginable 

without them." 

[Extract from J.M. Roberts (1995), The History of the World, page 18]. 

The activity of a group of people working co-operatively to achieve shared goals via 

differentiation of roles and using elaborate systems of communication is basic to our 

species. The current enthusiasm for team working in and in health care reflects a 

deeper, perhaps unconscious, recognition that this way of working offers the promise 

of greater progress than can be achieved through individual endeavour or through 

mechanistic approaches to work. That is what this report has demonstrated in 

relation to health care teams to and quality and innovation in patient care.

Appendix I 

Measures Used 

Primary Health Care Team Questionnaire 

Section 1 Team working. This contained seven measures of team working. Five of 

these form the Team Climate Inventory (Anderson and West, 19xx): participation, a 

15 item scale covering information sharing (α = ); innovation, an eight item scale 

covering support from new ideas (α = ); team objectives, covering clarity and 

relevance of objectives (α = ); task style, covering the monitoring and appraising of 

work in the team (α =). Three other measurers were included: reflexivity, covering 

the reviewing process in the team (α = ) and XXX was measured using XX (xx 

19xx) (α = ); and team innovation measured using (West?) (α = ). Respondents 

were also asked to list the major changes introduced by the team in the previous 12 

months. 

Section 2 included measures of team effectiveness adapted from Poulton and West 

(199x). This includes three dimensions: team working (α = ); , patient orientation (α 

= ); and organisational efficiency (α = ). 

Section 3 included a measure of psychological stress, the GHQ-12 (Goldberg, 1991) 

(α = .88 ). 

Section 4 included questions eliciting biographical and team information (e.g. age, 

gender, ethnic origin, job title, employer, team composition, team leader). 

Initial construction of the effectiveness measure 

Effectiveness criteria were generated using an iterative process within the 

constituency model approach (Connally et al., 1980). After consultation with the local 

Health Authority and Community Mental Health Trust, the Department of Health, and 

local community mental health teams, representatives of the range of stakeholders in 

the provision of mental health care were invited to a one-day workshop. A total of 13

interest groups were approached: users, carers, advocacy agencies, mental health 

charities, consultant psychiatrists, community mental health nurses, occupational 

therapists, psychologists, social workers, managers, policy makers, researchers in 

mental health, and general practitioners. All groups were represented by the 50 

people attending the workshop. 

The aim of the workshop was to provide the basis for an agreed set of definitions of 

effectiveness in CMHTs. Stakeholders sharing a perspective were grouped together, 

so that consensus could be achieved more easily within each working group. 

Participants were asked to generate a set of criteria which they agreed would 

measure CMHT effectiveness, with the proviso that any criterion must be supported 

by concrete examples of how good practice could be audited. Groups then 

reconsidered their criteria in order to prioritise aspects of practice. 

Output from the workshop was analysed and categorised by the research team. 

Duplication and ambiguity were removed. The 76 remaining criteria, grouped into the 

three broad categories of user and carer issues, team development and viability, and 

organisational issues, were re-circulated to all workshop participants. They were 

invited to comment on wording and clarity, to suggest modifications, indicate 

significant omissions, and approve priority ratings. Items rated as less important by a 

majority of respondents were removed, and any items rated down in the final 

consultation were respositioned. Remaining ambiguities and duplication were 

removed, together with items already covered in other sections of the proposed 

survey questionnaire. 

The reduced set of CMHT effectiveness criteria, together with supporting measures 

of good practice, were piloted amongst local community mental health nurses, a 

CMHT, psychologists and other mental health professionals. Practitioners agreed 

that they captured the complexity of the work and the diversity of environments in 

which CMHTs operate. The final set of 27 criteria was incorporated into the main 

survey questionnaire, along with the Team Climate Inventory (Anderson & West, 

1994) and the 12-item General Health Questionnaire (Goldberg, 1970.) 

Each statement was clarified by additional concrete examples of elements of practice 

which individuals could use to aid their rating. A 5-point Likert-type scale was used 

to rate how effective the team was on each criterion. Thus, to illustrate, the content 

of the first criterion was

Accessibility of the service to users and carers has 

been identified as a measure of CMHT effectiveness. 

[For example: identification and contactability of a key worker; 

clear referral procedures; time taken to respond to users and 

or carers; a clear point of access.] 

Not at all To a great extent 

Overall, to what extent does your CMHT make 

services accissible to users and carers? 1 2 3 4 5

Appendix I I 

Knowing the Way: 

Effectiveness in Primary Health Care 

A description of national workshops aimed at defining 

effectiveness criteria for primary health care

Introduction 

The World Health Organisation define primary health as: 

“..essential care based on practical, scientifically sound and acceptable methods and tehcnology made 

universally accessible to individuals and families in the community through their full participation and 

at a cost that the community and the country can afford to maintain at every stage of their development 

in the spirit of self reliance and self determination. It forms an integral part of the countries health 

care system, of which it is a central function and main focus, and of overall social and economic 

development of the country. It is the first level of contact of individuals, the family and community with 

the national health system, bringing health care as close as possible to where people live and work”. 

World Health Organization, 1978. 

In order to enable primary health care professionals and the populations they serve to develop the 

health and stress of those populations, it is important that clear objectives for primary health care are 

established. Moreover, what constitutes effectiveness in primary health care also has to be determined 

by each primary health care team or organization. Indicators of effectiveness, once established, 

provide professionals with clear guidelines over how best to allocate resources in order to achieve 

effective primary health care. This consultative document represents the endeavours of 63 

professionals working in the area of primary care who spent four days in workshops designed to help 

achieve this overall aim. 10 

The vision of this exercise is to promote health care for the population nationally, by providing primary 

health care professionals and others concerned with the health and stress of the population with clear 

indicators of effectiveness. These can be used as a basis for discussion and development in primary 

health care teams across the country, taking into account their local circumstances, philosophies of 

primary care and the needs and views of their local populations. 

Effectiveness in Primary Health Care 

In an important analysis of the evaluation of health services’ effectiveness, St Leger, Schneiden & 

Walsworth-Bell (1992) observe that “Surprisingly, routine data [sources relating to primary care] are 

relatively sparse, especially when one considers that the majority of contacts that the general public 

have with the health service are with general practice.” (p.41). Indeed, it is striking how little research 

has focused on developing theoretically grounded or practically useful indices of effectiveness of 

primary health care services. In a rare exception, Pearson & Spencer (1995) employed a two-stage 

Delphi questionnaire to determine agreed indicators of effective teamwork in primary care. Using 

responses from 137 people involved in primary care teamwork - primarily from FHSAs - they rated the 

importance of twenty indicators. Four emerged as particularly significant: 

10 Within primary health care, terminology is a source of concern and conflict. For example, some 

prefer the term ‘primary care’. There are sensitivities around the terms ‘general practice’ and ‘primary 

health care’ being used interchangeably; and a distinction between medical and nursing care is also 

sensitive. Those who attend for treatment or advice are called ‘patients’ by some and ‘clients’ by 

others. We have preferred the terms ‘primary health care’ and ‘clients’ in this document.

• Agreed aims, goals and objectives 

• Effective communication 

• Patients receiving the best possible care 

• Individual roles defined and understood 

What is effectiveness? 

How can the effectiveness of primary health care teams therefore be judged? At the simplest level, 

effectiveness might be viewed as the influence the primary health care team has in improving health 

and ameliorating ill health within the practice population. Such a criterion of effectiveness begs a 

number of questions, however. Examples include: 

• Is the population in an area of social deprivation? 

• Does the team have unusually good resources, in terms of number of staff or technical equipment? 

• Will the effects be long-term? 

In the literature on organizational effectiveness, a distinction is made between efficiency (doing things 

right) and effectiveness (doing the right things) (Sundstrom, DeMeuse & Futrell, 1990). Efficiency 

may be defined as the output for a given input and how a team compares with other similar teams in 

this regard. Effectiveness can also be seen as the team’s capacity to perform, adapt, maintain itself and 

grow (where growth may refer to size, innovation or skill development) (Goodman, 1986). 

Clearly, teams can be seen as more or less effective depending upon the criteria adopted. 

Consequently, the assessment of team effectiveness has come to be seen as much a political as an 

empirical process. Below we consider (briefly three examples of approaches to managing this problem. 

The constituency approach 

Recognition that effectiveness is a political concept has led to the use of the ‘constituency approach’ 

(Connally et al, 1980; Bedeian, 1986) which seeks to incorporate all significant views in the judgement 

of team effectiveness. Each of the major constituents is identified (e.g. clients, carers, staff health 

authorities, professional organizations) and the effectiveness criteria they would use are adopted as 

indicators. Effectiveness is then measured using multiple indicators rather than an aggregate, since, in 

many cases, effectiveness in one area will necessarily imply ineffectiveness in another (consumer 

satisfaction may not always coincide with quality of care if consumers require prescriptions for drugs, 

the use of which is not in their best interest).

From this conceptual, background Poulton & West (1994) developed a set of 23 effectiveness criteria 

for primary health care teams using a focus group methodology involving multiple stakeholders in 

primary care. In a study involving more than 500 practice nurses (Poulton, 1995) the criteria were then 

factor analysed revealing four underlying factors: good teamwork, task excellence, organizational 

effectiveness and patient-centred care. More recent analyses with larger samples suggest only three: 

quality of health care, organizational efficiency, and teamworking. 

Poulton and West (1997) employed these outcome measures in a six month longitudinal study of the 

impact of teamworking on effectiveness. The research demonstrated that clarity of and commitment to 

objectives was the most important and statistically significant predictor of effectiveness in all four 

areas. 

Multidisciplinary audit 

Another important approach to measuring effectiveness is multidisciplinary audit. A major centre for 

research and advice is the Eli Lilley National Clinical Audit Centre (Hearnshaw, Baker & Robinson, 

1994; Baker, et al 1995). In a study conducted by this Centre of three practices, those supported in the 

development of multidisciplinary audit showed a significant improvement in specific areas of 

functioning. The procedure involves teams identifying particular problems (in a diagnostic area or an 

area of team functioning) and a priority is identified. The team then sets standards in the specific area, 

observes current practice and achievements, and compares these with the standards. Discrepancies 

prompt changes in practice and the results are then regularly reviewed. Such an approach clearly 

enables teams to assess and improve performance in specific areas, although the approach is somewhat 

atomistic and relies on the effective identification of priorities. An excellent overview of this approach 

is provided by Crombie, Davies, Abraham & Florey (1993). 

ProMES 

In the broader organizational literatures on team effectiveness, a widely adopted approach is the 

Productivity Measurement and Enhancement System (ProMES) based on research by Naylor, Pritchard 

& Ilgen (1980). Effectiveness criteria are established in group discussions with team members and 

supervisors. The variables are then “psychologically scaled” to a common effectiveness scale. Based 

on group consensus about expected levels of effectiveness, which are given a zero value, maximum 

effectiveness levels (set at +100), and minimum levels (-100) are set. Each variable is also weighted in 

terms of its perceived contribution to the overall effectiveness of the team or organization. The system 

is then used to set objectives, develop indicators monitor and improve performance and give feedback 

to the team (Pritchard, 1990). This is promising for primary health care, because of the sophistication 

of the approach, its theoretical robustness and practical utility in complex contexts. It was therefore 

used as a basis for developing effectiveness measures by the Health care Team Effectiveness project. 

Overall, however, it is clear that conceptual and empirical development in evaluating the effectiveness 

of primary health care is urgently required, if cost, clinical and community value are to be convincingly

demonstrated. In order to take this forward a series of four workshops on primary health care team 

effectiveness was sponsored by the Institute of Work Psychology. The methods are described below. 

Prior to detailing these we consider the need for a manageable set of objectives or effectiveness 

indicators; and the need for a theoretical framework within which to locate any set of dimension. 

(i) The need for relative simplicity 

It is apparent from any analysis of research in the domain of effectiveness that the development of 

indicators and effectiveness dimensions for primary health care is a complex task (West, 1996). A 

major problem is that many measures of effectiveness and many indicators can be developed. Trying 

to use this large number of measures within an organization as an effective means of targeting 

resources simply becomes overwhelming for the practitioners concerned. The sheer multiplicity of 

potential indicators is cognitively too complex for people within the organization to cope with the task 

effectively. Indeed, some research suggests we can only cope with 7 plus or minus 2 categories, 

whereas other organizational researchers specifies to more than 8 to 12 key dimensions. Consequently, 

we sought a parsimonious theoretical model which would provide guidance for researchers and 

practitioners. 

(ii) The Competing Values Model 

The most useful model appears to be the Competing Values Model. This model incorporates two 

fundamental dimensions; 

• flexibility of the organization versus control within the organization; 

• external orientation versus internal orientation (see figure 2).

Com peting Values M odel 

Internal 

Hum an Relations Model Open System s Model 

Orientation 

Figure A.1 


Team developm ent 

Learning organisation 

Team m em ber m ental 

health 

Commitm ent & 

satisfaction 

Efficient control of 

resources 

Clinical audit 

Reviewing & evaluating 

effectiveness 

Budget m anagem ent 

Internal Process Model 

Flexibility 

Control 

Combining these dimensions identifies 4 domains of effectiveness: 

• Human relations model 

human relations, 

open systems, 

rational goal, 

internal process 

Scanning of the 

environm ent 

Resource acquisition & co- 

ordination 

Innovation 

Collaboration with other 

organisations 

M eeting targets 

Em phasis on perform ance 

‘Custom er’ satisfaction 

External 

Rational Goal Model 

The primary emphasis is on norms and values associated with belonging, trust, respect, skill 

development, growth and stress. Motivational factors are attachment, cohesiveness and 

organization membership. Areas of effectiveness include: 

• development of skills 

• team development 

• learning organization skills 

• team member mental health 

• commitment and satisfaction 

Orientation

• Open systems model 

The primary emphasis is on change and innovation and appropriate scanning of the environment. 

Norms and values are associated with knowledge of the environment, resource acquisition, 

innovation and adaptation. Motivating factors are: 

• Rational goal model 

• development of services 

• resource acquisition and co-ordination 

• innovation 

• collaboration with other organizations 

The primary emphasis in this model is on the pursuit and attainment of well-defined objectives. Norms 

and values are associated with good performance, goal-fulfilment and achievement. Motivators 

are: successful achievement in pre-determined areas. Effectiveness dimensions include: 

• Internal process model 

• meeting ‘production’ targets 

• ensuring high quality 

• high client or customer satisfaction 

The emphasis here is on stability, internal organization and adherence to rules and protocols, 

where norms and values are associated with efficiency, co-ordination and uniformity. Motivating 

factors are needs for order, rules, regulations and efficiency. Effectiveness dimensions include: 

• efficient control of resources 

• reviewing and evaluating effectiveness 

• good budget management 

The model of competing values stresses how the allocation of resources to any one area, for example 

the open systems model, is likely to lead to a restriction of resources in the opposite domain (internal 

process). Similarly a focus on external control (rational goals) may well lead to a neglect of the area of 

human relations (internal flexibility). Effectiveness in organizations, is likely to be maximised when 

emphasis is placed equally in each of the four domains of effectiveness. Using this framework as a 

guide we embarked on a series of 4 workshops to clarify our thinking about effectiveness in primary 

care. 

The Workshops 

Method 

The methodology used to develop effectiveness measures for primary health care was developed taking 

account of the following: the importance of including the complexity and diversity in primary health

care and of taking into consideration the wide range of views and perspectives held by the professional 

groups who contribute to meeting patient needs; the need to develop a method which would most cost- 

effectively use the time of primary health care professionals; and the importance of developing 

measures which were generalisable across primary health care. 

The measures were therefore developed in two stages: 

i) Indentifying objectives for primary health care and developing indicators for these objectives, was 

carried out in four workshops with domain relevant experts from primary health care, based on an 

approach developed by Connolly et al, 1990. Such an approach enabled the views of a range of 

professionals to be taken into account. Working intensively with an expert group enabled considerable 

knowledge and insight to be gained in a short space of time. In addition, these professionals, who had 

a background in primary care but were mainly working in an advisory, policy or research role, 

provided a broader, more generalisable perspective on effectiveness in primary health care. 

ii) The measures developed were used by primary health care teams teams and feedback provided on 

effectiveness. 

Workshops 

Objectives 

There were three principle overall objectives for the workshops: 

♦ to identify the important issues relating to developing effectiveness measures for primary health 

care, 

♦ to develop a set of effectiveness measures acceptable to all perspectives in primary health care, 

♦ for participation in the workshops to be a valuable experience for the participants. 

Participants 

An initial stakeholder analysis identified 13 stakeholders in primary health care. Advise was sought 

from contacts in primary health care about key experts who could represent the views of each 

stakeholder group, and about whether the initial list of stakeholder was sufficiently comprehensive. 

The experts suggested by the contacts were sent information about the research programme, invited to 

attend the four workshops, and asked to suggest additional or alternative key experts who could also 

make a contribution. In addition, representatives from primary health care teams were invited, that is, 

professionals who were currently engaged in clinical practice. The majority of those contacted were 

keen to attend the workshops, and were able to commit themselves to attending two or three. X were 

able to attend all four. Each workshop was planned so that the participants covered the main 

stakeholder views. 

Workshop process

A focus group methodology was used. 

The delegates were divided into three working groups. These were designed so that (a) a range of 

stakeholder views were represented, and (b) one or two or group members had attended most or all of 

the workshops and so could share with new members the learning and experience from previous 

workshops. Each group worked with a facilitator, trained in ProMES, and a notetaker who recorded 

the group discussion and the decisions made. 

Workshop 1 

Objective: to develop objectives for primary health care. 

After an initial introduction to the Health Care Team Effectiveness project and a presentation on 

ProMES, the delegates were presented with a set of objectives for primary health care developed by the 

researchers. Each group worked on (a) refining the objectives, (b) critically evaluating the objectives 

in relation to the criteria for objectives (see appendix xx). 

The outputs from each group were presented at the end of the workshop in a plenary session. After the 

workshop the outputs were discussed with members of four primary health care teams (who endorsed 

their relevance and value), combined into a single list and then circulated to delegates. 

Workshops 2 and 3 

Objective: to develop indicators for the objectives for primary health care. 

Both workshops started with a presentation on team working in primary health care and issues relating 

to the development of effectiveness measures. 

Delegates were presented with the final version of the objectives for primary health care. Each group 

worked on (a) developing indicators for an objective, (b) critically evaluating the indicators in relation 

to the criteria for indicators (see appendix xx). 

In Workshop 2 the working groups selected the objective to discuss. The objectives - Quality of Care 

and Client Satisfaction were selected. In Workshop 3 groups were assigned an objective so that each 

was discussed at least once. The objectives - Effective Management of Resources, Development and 

Satisfaction of Primary Health Care Team Members and Quality of Care, were discussed. In the third 

workshop the output from each working group was given to another group in the afternoon session for 

discussion and refinement. 

The output from each group were presented at a plenary session at the end of both workshops. 

After Workshop 2 and 3 the outputs were amended and the circulated to delegates. In addition, after 

the third workshop the outputs from all three workshops was written-up in the document ‘Knowing the 

Way: Effectiveness in Primary Health Care’ and circulated to delegates. 

Workshop 4 

In the fourth Workshop, those attending critically analysed the objectives and indicators developed, and 

considered how they could be applied in practice by PHC teams and others. A review of the data

derived from 100 teams, examining their definitions of effectiveness was also presented. The focus 

groups commented on the next steps in taking forward the work completed to date. 

1. Objectives were identified in the first of the four workshops and after an additional three 

workshops with somewhat differing attendees who worked with them, they remained unchanged. 

(The point is they have been tested and found acceptable by lots of different people.) 

2. In addition, they were shown to a number of primary health care teams. These teams found the 

objectives useful and accurate. 

3. The themes in these objectives are similar in principle to the themes of objectives that other types 

of professional organizations and in other settings have developed. Thus, there is some consensual 

validation. 

Bearing in mind the problems of deluging primary health care teams/organizations with long and 

unmanageable lists of objectives and indicators of effectiveness, we endeavoured to produce a core list 

of key objectives 

Below we describe each and suggest possible indicators. 

Effectiveness measures are a guide not stone tablets 

The key objectives identified and the indicators developed for each are a synthasis of the outputs from 

the four workshops. Some of the contributions made by the working groups have been modified by the 

researchers, and the Competing Values Model used to provide a conceptual structure. The majority of 

objectives and indicators described below, however, were suggested and critically reviewed by the 

Primary Health Care professionals who attended the workshops. The objectives and indicators are not 

definitive, nor are they comprehensive and applicable to every primary health care team. They are 

meant to be used as an aid for teams which wish to measure and enhance their effectiveness. In 

relation to each objective, the focus groups developed a set of indicators by which progress towards 

objectives could be measured. Again, these indicators are meant as examples. If they fit and make 

sense to individual primary health care teams, fine; but they may well not fit. Primary health care 

teams have different missions and the measurement must be tailored to that mission. Moreover, the 

focus groups produced many more possible objectives and measures of them are described below. 

These can be used as a resource for teams wishing to explore areas beyond those we have designated as 

likely to be core. 

Objectives and Indicators for Primary Health 

The core key objectives developed in the workshops are showh in Figure A2, mapped 

in to the competing value model.

Internal 

Competing Values Model 

in Primary Health 

Care 

Human Relations Model 

Orientation 

Figure A.1 

Good Team working 

Continuing 


development 


commitment & 

satisfaction 


resources 

Health care reviewing & 

improving effectiveness 

Internal Process Model 

Flexibility 

Control 

Open Systems Model 

Accurate identification of 

health needs 

Responsiveness to clients 

and community 

Effective collaboration with 

other organisations 

*Improving health 

*High quality of health care 

Client satisfaction 

External 

Rational Goal Model 

*Indicators may depend on the health care philosophy of the primary health 

care teams e.g. holistic, preventive, biomedical 

The indicators developed in the workshops for each of the objectives are listed below. 

♦ Improving health 

♦ High quality of health care 

♦ Improving client satisfaction 

♦ Efficient use of resources 

♦ Reviewing and improving health care effectiveness 

♦ Good teamworking 

♦ Continuing professional development 

♦ High team member commitment, stress and satisfaction 

♦ Accurate identification of health needs 

♦ Responsiveness to clients and community 

♦ Effective collaboration with other relevant organizations 

Orientation

Rational Goal 

Objectives Example Indicators 

Improving health ⇒ Improvement in the health of the practice poulation including 

reductions in e.g. coronary heart disease, smoking, mental health 

problems. 

⇒ Percentage of clients improving at the expected rate after treatment. 

⇒ Effectiveness of preventive practice in reducing specific treatment 

requirements. 

High quality of health care ⇒ Effective knowledge of and management of chronic diseases (e.g. 

diabetes, epilepsy, asthma) measured by conformance with evidence- 

based good practice. 

⇒ Effective health education and preventive health care programmes. 

⇒ The PHCT holds regular meeting to review a sample of cases. This 

review would include the appropriateness of who saw the client, 

procedures, and outcomes. Percentage of cases managed entirely 

appropriately, based on all staff’s views. 

Improving client satisfaction ⇒ Measures of client complaints and adequacy of procedures for 

* See Appendix III for examples 

complaints. 

⇒ Questionnaire or telephone surveys using standardised measures*. 

⇒ Measures of waiting times, satisfaction with consultations, 

appropriateness of appointments.

Internal Process 


Efficient use of resources ⇒ Percent client contact time as a percentage of total time (there is an 

Reviewing and improving health 

care effectiveness 

optimal level between extremes). Assesment of DNA’s. 

⇒ Number and effectiveness of initiatives developed to help team 

members use time better. 

⇒ Review and evaluate budget allocation and improvements in resource 

utilisation. 

⇒ Review and use of evidence-based treatment protocols (all staff). 

⇒ Planned clinical audit (all staff). 

⇒ Intra-team referral practices regularly reviewed and adapted (all staff).

Human Relations 


Good teamworking ⇒ Clear, shared objectives (partly related to health needs analysis) set 

Continuing professional 

development 

High team member commitment, 

stress and satisfaction 

*See Appendix III for examples 

Open Systems 

annually by the team. 

⇒ Regular (at least monthly) meetings to review team objectives, 

strategies, processes and procedures to coordinate sub-groups and 

whole team. 

⇒ Positive team/organizational climate assessed annually. 

⇒ Clear and specific written annual training and development plans 

agreed for each staff member (percentage of staff covered; percentage 

of development plan items completed.) 

⇒ Research and development budget and plans agreed by team annually. 

⇒ Access for all team members to training/development resources. 

⇒ Annual review of staff commitment, stress and satisfaction using 

standardized measures*. 

⇒ Mechanisms to deal with and review staff dissatisfaction, conflicts and 

complaints. 

⇒ Low absenteeism and staff turnover. 


Accurate identification of 

population health needs 

⇒ Collection of practice level data (demographics, disease patters, socio- 

economic patterns, activity levels); and local, regional and national 

data. 

⇒ Involvement of clients, community groups and other relevant

Responsiveness to clients and 

community 

Effective collaboration with other 

relevant organizations 

*See Appendix III for example 

organizations in health needs analysis. 

⇒ Data used to inform daily planning, and longer term strategy and 

direction; setting annual objectives; identifying gaps in provision and 

skill mix. 

Application of the effectiveness measures 

General Principles 

⇒ Involvement of clients and community in team/organization decisions 

concerning team objectives, strategies and processes. 

⇒ Frequency, quality and usefulness of contacts between team members 

and representatives of community stakeholder groups. 

⇒ Extent of planning within team/organization to seek feedback from 

clients and community stakeholders/opinion leaders/groups. 

⇒ Appropriate admissions to hospital (and referral rate) 

⇒ Number of effective and appropriate contacts with agencies (e.g. 

palliative care, social services, education). 

⇒ High ratings of team/organizations on salient dimensions*. 

There are three levels of application of these effectiveness measures, ranging from simple through to 

comprehensive. 

• Simple. The simplest way of using the effectiveness measures is to use them as a basis for group 

discussions in the primary health care team; for members of the team to consider the areas of 

effectiveness described and how they can make use of the measures in facilitating of the 

effectiveness of the primary health care team. They may also consider what other measures they 

may wish to add, given their local circumstances and which of the measures are not applicable. In 

other words, the simple approach is to use the effectiveness measures as a basis for ongoing 

discussions about monitoring and improving the effectiveness of the primary health care team. 

• Moderate. The primary health care team can use the effectiveness dimensions and indicators to 

develop measures of effectiveness within their primary health care organization in relation to each 

effectiveness measure (as appropriate). The team can develop measures and make action plans in 

terms of how they can improve their performance in this area. Again they may wish to consider 

which of the measures are applicable in their organization and which are not, and what measures 

which are relevant to them are missing from document. 

• Comprehensive. This application involves the use of full productivity measurement and 

enhancement system, which has the following steps: (a) a design team, which includes 

representatives from all groups of staff in the primary health care team, is formed; (b) in a series of 

meetings the design team works with a facilitator identifying objectives and indicators for these, 

where necessary consulting with other members of the team; (c) the design team develops

contingencies for each indicator, that is, determines the relative contribution that improvements on 

a indicator will make to overall effectiveness; (d) the team uses the indicators and receives 

feedback on performance. 

Quality of Health Care 

Quality of Health Care 

• The PHCT would have a monthly (or more frequent) staff meeting where a sample of cases was 

reviewed. This review would include the appropriateness of who saw the client, what procedures 

were done, and whether that client was handled appropriately in all aspect. The measure would be 

the percentage of cases which were considered as being handled appropriately. This would also be 

the basis for discussion of what improvements need to be made for those specific clients and for 

clients in general. 

• Some PHCTs will feel a health needs analysis is valuable but do not know how to do one or how 

to use it. For such a PHCT, the task of developing such an analysis could be broken down into 

definable steps. E.g. get information on how to do such an analysis, decide on a plan for doing the 

analysis for that particular PHCT, gather the information, put the information together into a form 

that the PHCT can use to make decisions. Each of these steps would be given a time for 

completion. The indicator would be the percentage of the analysis completed compared to the 

anticipated time for completion. 

Survey on client perceptions of health improvement after treatment. For example, each client is 

given a questionnaire or a sample of clients are called by phone and asked about improvements. 

Measure is the percentage of clients improving. For the various specific targets given by agencies 

outside the PHCT such as immunisation rates, develop a scoring system whereby each level of 

meeting the objective gets a certain number of points. E.g. if the target immunisation rate was 

80%, actually doing 80% would give 100 points, 60% immunised would be 20 points, 70% 80 

points, 90% 130 points, etc. The number of points would be based in the importance of that 

target. The index would be the percentage of actual points earned compared to the maximum 

possible points received if all targets were met. (Note, this assumes there are lots of such targets. 

If this is not true, a composite measure such as this is probably not necessary. 

• The percentage of required reports completed on time. 

• The number of required reports returned by agencies requesting corrections or additional 

information. (This would be an index of the quality of the reports.) 

Client Satisfaction 

Establish a formal procedure where clients can make complaints including a process for following up 

on these complaints. Measure is the number of such complaints which were not concluded to the 

client’s satisfaction within one week.

Effective Management of Resources 

• Number of new initiatives developed that are designed to help team members use their time better. 

These initiatives should also be reviewed on a regular basis to ensure they are still effective. 

• Percent client related time as a percentage of total time. This measure gets at how much time is 

devoted to clients. It does not measure how well that time is being spent. Other indicators are 

needed to address this issue. (RDP: Note that this indicator is one where there is probably an 

optimal level between the extremes. To little time with clients may suggest too much 

administration time. Too much time with clients may suggest too little administration time.) 

• Percentage of staff turnover over time. High staff turnover leads to inefficient resource utilisation 

because it takes time to teach procedures to new staff and work is lost as a departing staff member 

leaves. This measure would also be an indicator for the satisfaction of team members. 

• Percentage of appointments which are unfilled or where the client did not come. 

Development and Satisfaction of Primary Health Group/Team Members 

• Training and development. A list of training and development experiences for each person on the 

team would be developed each year. For example, attendance at a certain type of conference, 

training on a piece of office equipment, learning a new procedure, etc. This list would be the 

development plan for that person for that year. There would be two measures for training and 

development. The first would be the percentage of team members who had the written plan. The 

second measure would be the percentage of the development plan items actually completed. 

• Who are reviewed, given feedback, and have a formal, jointly developed action plan for making 

improvements. 

• Satisfaction. Measure overall satisfaction on a monthly or bi-weekly basis with a very brief 

questionnaire that would take no more than 2 minutes to compete. Measure would be the 

percentage of staff indicating Satisfied or Very Satisfied with their jobs. 

• Staff turnover is also a satisfaction measure. Note this measure under Effective Management of 

Resources. 

Figure A.2 List of participants 

NAME JOB TITLE PLACE OF EMPLOYMENT 

John Horder President CAIPE 

Debbie Mellor Section Head of Workforce 

Non-Medical Planning 

NHS Executive 

Thelma Sackman Nursing Officer NHS Executive 

Kate Andrews Clinical Research Fellow Dept. General Practice 

Rosemary Field To Be Advised To Be Advised 

Nicki Meade Research Associate The National Primary Care 

Research & Development

Centre 

Steven Campbell Research Associate The National Primary Care 

Research & Development 

Centre 

Brenda Leese * Research Fellow The National Primary Care 


Centre 

Bonnie Sibbald Research Associate The National Primary Care 


Centre 

Ann Richards Research Fellow Psychological Therapies 

Malcolm McCoubrie Senior Lecturer in Community 

Based Medical Education 

Standards - Medical Director 

Research Centre 

Wandsworth Community 

Health 

Sheelagh Richards * Occupational Therapy Officer London 

Jane Cannon* Practice Nurse Larwood Surgery 

Sue Jenkins-Clarke Research Fellow University of York 

Peter Bundred Senior Lecturer in Primary 


University of Liverpool 

Judy Mead * Physiotherapist Chartered Society of 

Physiotherapists 

Richard Brown * To Be Advised To Be Advised 

Alan Chapman Management Education & 

Development Manager 

Primary Care 

East Norfolk Health Authority 

Lance Gardner Professional Officer The Queens Nursing Institute 

Terry Brugha * Senior Lecturer & Honnary 

Consultant Psychiatrist 

Rosamund Bryar Professor of Community 

Healthcare Nursing Practice 

Stephen Rogers Senior Lecturer in Primary 


Joan Lole Director of Nursing & Primary 


Paul Thomas Senior Lecturer Dept. Of 

General Practice 

University of Leicester 

University of Hull 

University College London 

Mancunian Community Health 

Imperial College School of 

Medicine @ St.Mary’s 

Ruth Hudson Education Officer Community Practitioners & 

Health Visitors Association

Jacky Hayden Dean of Postgraduate Medicine University of Manchester 

Christiana Johnson Health Promotion Officer Princess Royal Community Health 

Centre 

Beverley Haynes Senior Health Promotion Specialist Princess Royal Community Health 

Centre 

Peggy Newton Lecturer in Psychology Dept. Of General Practice 

Jeanette Naish Senior Lecturer in Primary Care Dept. General Practice & Primary 

Stuart Mee * Practice Manager The Crookes Practice 

Kay Robinson Primary Healthcare Facilitator South Humber Health Authority 

Brian McAvoy Professor of Primary Health Care Dept. Of Primary Care 


Susan Lonsdale Senior Principal Research Officer Dept. Of Health 

Sandra Dodgson Senior Development Manager N H S Development Unit 

Frances Fogg Primary Healthcare Facilitator North Notts Health Authority 

Wendy Whyte Regional Community Nursing 

Team Leader 

Mike Sharpe Regional General Manager of 

Medical Services 

Ron Pollock Assistant Director Support & 

Development/Finance 

British Forces Overseas 

British Forces Overseas 

Wakefield Health Authority 

Mike Vaughan Total Purchasing Project Manager Wakefield Health Authority 

Sasha Wishard Research Facilitator Tayside Centre for General Practice 

Marion Duffy Education Facilitator Tayside Centre for General Practice 

Chris Simmonds * Practice Manager Medical Centre Doncaster 

Jane Solomon * Locality Management Nottingham Health Authority 

Catherine Booth * General Practitioner G.P. Unit 

Ann Netton Assistant Director of PSSRU University of Kent 

Gwen Wilson * Development Manager Community 

Nursing 

Sheffield Community Health

Appendix III 

Effectiveness Measures 

Developed for Primary Health Care Teams 

Core Objectives for Primary Health Care teams 

Promote, maintain 

and improve health 

Enable personal 

and community 

responsibility for 

individual health 


resources 

Continuous 

personal and 


development 


commitment, stress 

and satisfaction 

Responsiveness to 

clients and 

community 

Collaboration and 

partnership with 

other relevant 

organisations 

� Provide high quality health care 

� Accurate identification of individual and population health 

care needs 

� Review and improve the effectiveness of health care 

provision 

� Manage illness, injury and disease taking account of 

agreed standards and evidence based practice 

� Enable patients/clients to make informed decisions about 

their own health. 

� Proactively encourage positive health behaviour 

� Implementation of health education and preventative 

care programmes 

� Human resources – skills, knowledge, expertise, time 

� Physical resources – budgets, equipment, premises 

� Individual annual training plans which take account of the 

plans of the PHCT 

� Equal access to training/development resources 

� Team working 

� Mechanisms for reviewing and acting upon staff 

dissatisfactions, conflicts and complaints 

� Gather information and feedback from clients/community 

stakeholders/opinion leaders 

Objective: Promote, maintain and improve health 

Techniques for reviewing whether services meet client needs 

A. What are the main aims of this service? 

B. What does the team (in collaboration or in addition to other agencies) 

currently do to meet a particular health/health promotion need? 

List all the provisions currently available in the team (and from other

agencies, if relevant). 

C. How do you know whether these provisions meet these health/health 

promotion needs? 

List evidence that can be used to determine this. 

D. Which aspects of this evidence suggest that you are meeting this 

health/health promotion need? 

E. Which aspects of this evidence suggest that you are not meeting this 

health/health promotion need? 

F. What provision would the team ideally like to have in place to meet 

this health/health promotion need? 

Next steps: 

Use the evidence discussed in C, D and E to develop measures to enable the team 

to evaluate more systematically whether they are meeting clients needs.

Objective: Promote, maintain and improve health 

Measure 1 - Review of quality in case management 

Measure =Percentage of cases judged to be managed appropriately on the most 

relevant quality dimensions. 

Steps to clarifying the measure: 

∗ Determine the types of cases to be reviewed (specific condition, e.g. 

diabetes/asthma, or a specific age group or type of patient population). 

∗ Decide which of the quality dimensions are most relevant to the cases being 

reviewed. 

∗ Decide what is an acceptable quality level on each dimension. 

∗ decide what is an acceptable % of cases to be judged as having been managed 

appropriately. 

Using the measure: 

∗ Rate each of the selected cases on the quality dimensions and give a total score. 

Note the dimensions where quality is above and below the acceptable level. 

∗ Calculate % of cases which fall above and below the acceptable level of cases 

being managed appropriately. 

∗ The review will result in two types of information 

⇒ dimension of quality for individual cases which fall below the acceptable 

standard. 

⇒ % of cases overall which are managed appropriately. 

N.B. For this measure need to develop an instrument for rating cases on each 

dimension which suggests evidence that can be used to make judgements, 

emphasise the importance of standardising ratings across cases and gives guidance 

in how to complete the instrument.

Dimensions of Quality 

Effectiveness: Is the treatment given the best available in a technical sense, 

according to those best equipped to judge? 

What is their evidence? What is the overall 

result of the treatment? 

Acceptability: How humanely and considerately is this treatment/service 

delivered? What does the patient think of it? What 

would/does an observant third party think of it (“How would I 

feel if it were my nearest and dearest?”) What is the setting 

like? Are privacy and confidentiality safeguarded? 

Efficiency: Is the output maximised for a given input or (conversely) is the 

input minimised for a given level of output? How does 

the unit cost compare with the unit cost elsewhere for 

the same treatment/service? 

Access: Can people get this treatment/service when they need it? Are 

there any identifiable barriers to service - for example, 

distance, inability to pay, waiting lists, and waiting times - 

or straightforward breakdowns in supply? 

Equity: Is this patient or group of patients being fairly treated relative to 

others? Are there any identifiable failings in equity - for 

example, are some people being dealt with less 

favourably or less appropriately in their own eyes than 

others? 

Relevance: Is the overall pattern and balance of services the best that 

could be achieved, taking account of the needs and wants of 

the population as a whole?


To what extent...... 

Is the treatment/service being 

given technically the best 

possible? 

Does the treatment/service 

being given conform to agreed 

protocols/standards? 

Is the current outcome from 

the treatment/service as would 

have been expected, given the 

patient’s condition at the start? 

Acceptability 


Is the patient’s privacy 

safeguarded? 

Is the patient’s confidentiality 

safeguarded? 

Is the patient treated with 

consideration and respect? 

Efficiency 


Are the inputs to the 

treatment/service (e.g. staff 

time, medication) minimised 

for a given level of output? 

Is the unit cost the same as for 

this treatment/service 

delivered elsewhere? 


To a very 

little 

extent 

To a very 

little 

extent 

To a very 

little 

extent 

To some 

extent 

To some 

extent 

To some 

extent 

To a very 

great 

extent 

To a very 

great 

extent 

To a very 

great 

extent

Access 


Can patients access the 

treatment/service when they 

need it? 

Do any of the following pose a 

barrier to accessing the 

treatment/service?: 

Location 

Distance 

Time of availability 

Inability to pay 

Waiting lists 

Waiting times 

Lack of appointment 

times 

Lack of resources to 

supply 

treatment/service 

Equity 


Is this group of patients being 

fairly treated relative to others? 

Are the resources available for 

this treatment/service 

comparable to those available 

for others? 

To a very 

little 

extent 

To a very 

little 

extent 

To some 

extent 

To some 

extent 

To a very 

great 

extent 

To a very 

great 

extent

Relevance 


Are the resources used for this 

treatment/service appropriate 

in the context of the needs and 

wants of the practice 

population as a whole? 

To a very 

little 

extent 

To some 

extent 

To a very 

great 

extent

Objective: Promote, maintain and improve health. 

Measure 2 - Young People’s health - Sexual Health 

Measure = Percentage unwanted teenage pregnancies in a 6 month period 

Percentage of teenagers prescribed the morning after pill in a 6 month 

period 

Percentage of teenagers requesting pregnancy tests in a 6 month period 


∗ Over a 3 month period monitor the number of unwanted teenage pregnancies 

and terminations, number of morning after pills prescribed, number of teenagers 

requesting pregnancy tests. This will establish a base line. 

∗ Compare the numbers (or % of total number of teenager girls on the practice list) 

with the teenage pregnancies, use of morning after pill, teenagers requesting 

pregnancy tests in other PHCTs, and/or with regional figures. This enables the 

team to assess the extent to which they are meeting the sexual health needs of 

young people. 

∗ Decide what is an acceptable level of unwanted teenage pregnancies, morning 

after pill, requests for pregnancy tests. 


∗ Over a 6 month period log each: unwanted teenage pregnancy; request for 

morning after pill; and request for a pregnancy test. 

∗ Note whether it is a small number of teenage girls who make the requests, or 

spread across a wide range of girls. 

∗ Note whether there are any patterns (i.e. times of the week/month). 

∗ After 6 months (or sooner if there are sufficient incidents of pregnancies/request 

for morning after pill/requests for pregnancy tests to form a judgement), collate 

the information collected. 

Next steps: 

∗ Compare the % for teenage pregnancies, requests for morning after pills and 

requests for pregnancy tests with (a) what were considered to be acceptable 

levels, and (b) with figures for other practices. 

∗ On the basis of this determine whether the current provision to meet the sexual 

health needs of young women is (a) being met (how do the figures for the PHCT 

compare with the acceptable level? Are they better, worse, the same?), and (b) 

how the extent to which these needs are being met compares with other 

PHCTs/regional averages.

∗ If the measures suggest that the sexual health needs of teenagers are not being 

met, introduce interventions to address this. The information about whether it is 

the same small number of young women requesting morning after pills/pregnancy 

tests will help to determine the type of interventions required. 

∗ Once interventions have been introduced, re-use the measure to determine 

whether the provision of services has improved. 

Interventions: 

∗ What type of follow-up is there when a teenager requests the morning after pill/a 

pregnancy test? 

∗ Gather more information about why young people take risks. 

∗ Implications for HIV/AIDS.

Objective: Promote, maintain and improve health. 

Measure 3 - Young People’s Health - Alcohol and Drug Misuse 

Measure = Number of teenagers attending A & E after drug overdose in a 3 

month period. 

Number of teenagers attending A & E after excessive alcohol 

consumption 

in a 3 month period. 


∗ Over a month monitor the number of A & E slips which record that a teenager has 

attended A & E for drug or alcohol abuse. 

∗ Compare these numbers with national/regional figures, and the number of other 

PHCTs. This will help establish the extent the team is meeting these health 

promotion needs of young people compared to other PHCTs. 

∗ Decide what is an acceptable number of A & E attendances for drug and alcohol 

abuse among teenagers. 


∗ Over a 3 month period log each A & E attendance by a teenager for (a) drug 

abuse, (b) alcohol abuse. 

∗ Note whether it is a small number of teenagers who attend A & E for drug and 

alcohol abuse, or if it is spread across a wide range of teenagers. 

∗ Note whether there are any patterns (times of the week/month). 

∗ After 3 months collate the information requested. Determine (a) number of 

incidents of drug and alcohol abuse at A & E, (b) number of teenagers who 

attend A & E once, number who attend regularly. 

Next steps: 

∗ Compare the number of A & E attendances for drug and alcohol abuse with (a) 

what the team judged to be an acceptable number and (b) with figures from other 

practices and regional/national figures. 

∗ On the basis of this determine whether the current health promotion to raise 

awareness about the changes of drug and alcohol abuse are (a) being met (how 

do the recorded numbers compare with the agreed acceptable level? Are they 

better, worse, the same?) and (b) how the extent to which the health promotion 

need is being met compares with other PHCTs/regional figures. 

∗ If the measures suggest that health promotion is not being effective, introduce 

interventions to assess this. The information about whether is it the same or 

different young people who misuse alcohol and drugs to determine the type of 

information required.

Measure 4 - Patient access to consulations with a GP 

Measure = The number of days that patients wait to see a GP of their choice 

The PHC design team believed that an important part of providing 

quality care was to ensure continuity of patient care. The aim was 

to ensure that patients had access to the GP of their choice (the GP 

who ha most often provided health care in the past) by reducing the 

length of time they had to wait to see this GP. 

Steps to clarifying the measure 

• Monitor the length of time patients have to wait to see each GP over a 1 month 

period. 

• If there are variations in the waiting time from week to week note the factors 

which might account for this (eg GP absences, increase in patient demand, 

services provided by other team members). 

• Decide what is the target waiting time for each GP. Set this target taking account 

of the factors which increase and reduce the waiting time. This target might be 

the number of days a patient has to wait to see a GP of their choice, or it might 

be more realistic to set a target which specifies the maximum and minimum 

range, to allow for fluctuation which are outside the team’s control. 

Using the measure 

• Over a 3 month period monitor the length of time patients have to wait to see 

each GP in the team. 

• If there are variations across weeks, months, or between GPs, note the factors 

which might account for these. 

Next steps 

• Depending on the target set, calculate the average length of time that patients 

have to wait to see a GP or calculate the maximum and minimum lengths of time 

they have to wait. Compare this with the target set. 

• If the target has been met, use the information gathered which explained 

fluctuations in the length of time patients had to wait to assess whether it might 

be possible to reduce waiting times further (ie, if increases in patient demands 

increased waiting times, is it possible to anticipate and plan for these increases?). 

• If the target was not met, use the information gathered which explains 

fluctuations to assess what changes need to be made so that the target can be 

met. Also consider whether the target is realistic.

Measure 5 – Patient access to a quality consulation with GPs 

Measure 1= Percentage of patients whose appointment with a GP is minutes 

duration in a 3 month period. 

Much of the discussion in the PHT design team concerned how to most effectively 

use the staff resources within the team to meet patient needs. The aim was to 

achieve this by having mechanisms in place which ensured that patients saw the 

health professional in the team most appropriate for their needs and as a 

consequence, reduce the number of patients who needed/wanted to see a GP. This 

would enable GPs to have longer (10 minute) appointments with those patients 

whose health needs require a GP consultation. 

GPs being able to have a longer appointments with patients was judged by the team 

to be a measure of quality of care because it is seen as an indication that patients 

needs are being met by the appropriate health professional in the team. 

It can also a measure effective use of resources. 

In addition, ithe measure is an indication that the mechanisms put in place to ensure 

that patients see the most appropriate health professional are effective (on the 

condition that the longer GP appointments do not increase the workloads of the other 

health professionals in the team). 


• Over a month monitor the number of patients who have 10 minute appointment 

with a GP (this is a booked appointment, not a shorter appointment which over 

runs). 

• Calculate the average number or % of patients in a week who can be offered a 

10 minute appointment. 

• Decide what is the target number or % of patients who can be offered a 10 

minute appointments. When setting the target it may also be useful to consider 

the types of patients on the practice list who might benefit from longer 

appointment so as to establish the level of possible demand. It will also be useful 

to consider other factors which might affect the demand. For example, will there 

be seasonal variations? 


• Over a 3 month period monitor the number or % of patients each week who are 

able to have a 10 minute appointment. 

• Note the types of patients seen and, if there are weekly variations, the factors 

which might account for these variations 

• Also note whether there are any unforeseen consequences (eg, increased work 

load for other team members, administrative difficulties).

Next steps 

• Compare the average number or % of patients who could be offered a 10 minute 

appointment with the target which was set. 

• If the target is achieved consider whether (a) any of the unforeseen 

consequences need to be taken into account, (b) whether there are ways that this 

target can be improved. 

• If the target is not achieved consider whether any changes to the factors which 

accounted for variations might help the team top achieve the target. Also 

consider any impact of the unforeseen consequences.

Measure 6 – Use of out of hours services by patient 

Measure = Percentage reduction in the use of private out of hours services by patients in a 6 

month 

period. 

The PHC design team believed that using out of hours services did not provide 

patients which the best quality service (eg, they are seen by a health professional 

who does not know their medical history). Thus reducing the number of patients 

using out of hours services would reduce number receiving poor quality treatment. A 

reduction would also lead to more effective use of resources in the team – the 

savings made from the reduction in the use of out of hours services could be used to 

employ an additional health profession in the team, eg a nurse practitioner. 


• Over a 3 month period monitor the use of the out of hours services by patients. 

• Note the types of patients who use the service (is it a few frequent users or 

widely spread). Are the reasons for the reasons for using the out of hours 

services different for frequent users and occasional users? If the reasons are 

different, would it be possible to reduce the out of hour usage of these two 

groups? If there are fluctuations in usage? Note factors which account for these 

variations. 

• Decide the acceptable level of out of hours service usage and the target amount 

of reduction. Set this target taking account of the factors which are associated 

with increases and decreases in usage (eg, seasonal variations, public holidays 

etc). It may be necessary to have separate targets for frequent users and 

occasional users. 


• Over a six month period monitor the use of the out of hours service. 

• If there are weekly of monthly variations in usage, note the factors which might 

account for these. 

Next steps 

• Calculate the average number of times the out of hours service has been used 

each month over the six month period and compare this with the target set. 

• If the target has been met, using the other information collected, consider 

whether the most appropriate patients have been using out of hours service, and 

whether there are ways that (a) the usage could be reduced further, and (b)

whether steps could be taken to ensure that the out of hours service is used by 

the most appropriate patients. 

• If the target was not met, use the information collected to consider changes which 

need to made to help ensure that the target is met in the future. Also use the 

information collected to consider whether the target is realistic.

Measure 7 – Patients have access to an appropriate health professional 

Measure = Percentage of patients who have contact with a health 

professional from the 

team at a time and location most appropriate to them and to the 

professional in a 6 month period. 

This measure emerged from discussions the PHC design team had about how to 

achieve quality of care by ensuring that patients’ needs were met by the health 

professional most qualified to meet those needs. 

This is a complex measure and more work is required to develop a measure which 

can be used to assess effectiveness. 

Agreement needs to be reached on the following: 

- which health needs can be most effectively met by which health professional. 

- how health needs are assessed 

- which health needs can be most effectively met in which location (eg, home, oneto-one 

consultation, booked appointment, drop-in, clinic etc.) This needs to take 

account of both patients’ and the health care professionals’ views. 

- what % of patients it might be possible for each health care professional in the 

team to see at a time and location most appropriate to them and the patient.

Measure 8 – Patients have access to a home visit from an appropriate health 

professional. 

Measure = Percentage of patients who have a home visit from the most 

appropriate 

health professional in a six month period. 

This measure emerged from a discussion of the use of staff resources within the 

team. The PHC design team were considering which team members carried out 

home visits, the time of day when it was most convenient to carry out home visits and 

how to determine whether home visits were appropriate (ie, some home visits meet 

social rather than health needs). The aim is to ensure that only patients who need a 

home visit receive one, and that they are visited by the health professional (DN, GP, 

pharmacist, HV etc) who has the expertise to meet their needs. 

This is a complex measure. The following needs to be determined before it can be 

developed in a measure of effectiveness. 

- which health (social) needs can only be met by a home visit 

- how to assess these needs 

- which of these health needs can be most effectively met by which health 

professional in the team 

- what % of patients can realistically be seen at home by the most appropriate 

health care professional.

Objective: Enable personal and community responsibility for individual health 

Measure 9 - Patients understand the role and function of the PHCT. 

Measure = Number of patient requests, use health professionals’ time and PHCT 

services which are inappropriate in a 3 month period. 

Steps to clarify the measure: 

∗ Patient understanding is demonstrated by appropriate use of the health 

professionals’ and other staff in the team, PHCT services, and appropriate 

requests for information. 

∗ Define what are judged to be inappropriate uses of: health professionals’ time, 

and other staff in the team; PHCT services; inappropriate requests for 

information. 

∗ Develop a checklist of the above and circulate to team members. 

∗ Decide what is an acceptable level of inappropriate uses of: health professionals’ 

time, and other staff in the team; PHCT services; inappropriate requests for 



∗ Over a two week period all members of the PHCT record the number of 

inappropriate uses of health professionals’ and other team members’ time, and 

inappropriate use of PHCT services and requests for information. 

∗ Note type of inappropriate use/request, and type of patient. 

∗ After two weeks collate the data from all team members and calculate the 

number of (a) inappropriate uses of health professionals’ time, (b) number of 

inappropriate uses of other staff members’ time, (c) number of inappropriate uses 

of PHCT services by patients, and (d) number of inappropriate requests for 


Next steps: 

∗ If the number of inappropriate uses of staff time, PHCT resources and/or 

requests for information are unacceptable, develop interventions to reduce the 

number. 

∗ Use information on the type of inappropriate use of time/services, and type of 

patients to target the information. 

∗ After the interventions have been put in place repeat the measuring process to 

assess progress.

Objective: Efficient Use of Resources 

Measure 10 - Patients able to manage minor illness 

Measure = Percentage of patients seen by health professionals in the team who had 

a minor illness which could have been managed themselves. 


∗ Define what is meant by ‘minor’ illness. 

∗ Develop a checklist of minor illnesses and circulate to all health professionals in 

the team. 

∗ Decide what is an acceptable level of patients to see with a minor illness 10% or 

40%? 

∗ Decide whether some groups of patients should be excluded. 


∗ Over a two week period the health professionals in the team log each patient 

seen, and record which patients attend for minor illness. 

∗ Note the type of minor illness, type of client. 

∗ After two weeks collate the data from team members and calculate (a) total 

number of patients seen, (b) total number attending with minor illness. It may be 

useful to look at % of patients with a minor illness seen by each type of health 

professional, and to note which types of minor illness patients attended with, and 

the types of patients presenting with a minor illness. 

Next steps: 

∗ If the measure indicates that an unacceptable % of patients are seen who have 

minor illnesses decide on interventions to reduce the %. 

∗ The data collected on types of minor illness, which health professionals are 

seeing these patients, the types of illnesses and types of patients can all be used 

to target the intervention/s. 

∗ After interventions have been put in place repeat the measuring processes to 

assess progress.

Instructions for Record Sheet 

The data are being collected over 5 working days, starting on XXX. You can continue 

to collect data in w/c XXX, if you miss any days in the previous week. 

Please record on the form information about every patient you have contact with on 

each of the 5 days. 

Codes for each column are also printed on the bottom of the form. 

Type of illness 

Column one 

MA = minor illness, acute C = chronic illness 

MC = minor illness, chronic A = acute illness 

Column two 

Please describe all types of minor illnesses you have recorded in addition to those in 

your leaflet, using medical terms. If the illness conforms to the definitions of minor 

illness in your leaflet, no further information is required. 

Type of contact 

Column three - 1 = phone 2 = home visit 3 = consultation 

Type of consultation 

Column four - 1 = routine 2 = emergency 

Type of Patient 

Column five - 1 = female 2 = male 

Column six - Patient’s age in years 

Seen before in last 7 days 

has the patient seen another health care professional in the last 7 days for the same 

illness as recorded in column 1? 

Column seven - record which health professional has seen the patient. 

1 = GP 2 = PN 3 = DN 4 = HV 5 = CPN 6 = other 

Other comments 

Column eight - Please write down any other important information, and, if relevant, 

note if the patient has been referred inappropriately by other agencies such as 

secondary care/A&E/social services/dentist, as well as inappropriate internal 

referrals. 

Please give ALL completed recording forms to the Practice Manager.

Date: Day of week: Name: Job title: 

1 

2 

3 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

Type of illness 

1) Code 2) Description of 

illness 

3) Type of 

contact 

4) Type of 

consultatio 

n 

Type of patient 

5) Gender 6) 

Age 

7) Seen 

before in 

last week 

8) Comments 

1) Minor/Acute = MA 3) 1 = phone 5) 1 = female 7) 1 = GP 8) Please include other 

information, and 

Minor/Chronic = MC 2 = home visit 2 = male 2 = PN 

referrals from social services and

Chronic = C 3 = consultation 3 = DN secondary care, other 

team members. 

Acute = A 6) Age in years 4 = HV 

5 = Other 

2) Please describe illness if not 4) 1 = routine 

minor according to the 2 = emergency 

agreed definitions.

Measure 11 - Patients/clients who do not attend for an appointment 

Measure = Average percentage of total patients appointments not kept in a week (calculated 

over a 3 

month period). 


∗ Monitor the DNAs for a one month period for each professional group (GP, DN, SN) to 

establish the current level in a one week period. 

∗ Collect information on DNA levels for other comparable practices (i.e. have a similar type 

of practice population). 

∗ Decide what is an acceptable DNA level for each professional group. 


∗ Monitor the DNAs for a two month period for each professional group. 

∗ Monitor, where possible, the following: 

⇒ which patients DNA (persistent or across a wide range?) 

⇒ characteristics of DNAs (age/gender/ethnicity) 

⇒ when patients DNA (i.e. time of day/a particular GP, PN etc,/regular appointments 

booked in advance) 

⇒ whether DNAs make another appointment 

⇒ whether DNAs use other services (e.g. out of hours, home visit) 

∗ Calculate the average % of patients/clients who DNA for each professional group in a 

one week period (this is the number of DNAs as a % of the total number of appointments 

made in each week). 

∗ Compare the DNA average with the acceptable level for each occupational group and 

with other practices. 

∗ Compare the % DNAs for each week in the two month period - does it vary from week to 

week? If so, can these differences be explained? 

∗ Use the additional information collected to assess whether discernible patterns in the 

DNAs. Does it happen at certain times of the day, and/or do certain types of patients 

DNA more than others? This information can be used to make decisions about how to 

reduce DNAs. The information about whether DNA patients make another appointment 

and/or use other services will provide additional evidence about the cost of DNA to the 

team.

Next steps: 

∗ If the DNA levels for the team as a whole and/or for specific occupational groups are 

unacceptably high introduce initiatives to reduce the level, and monitor progress using 

the measure. 

∗ The additional information collected will help to establish what types of initiatives 

might help to reduce DNAs. 

∗ It may also be necessary to gather information from patients and clients about the 

reasons for DNA (is it because they forgot to attend? Because it is difficult to cancel an 

appointment? Because they are unaware of the implications to the team of DNA?).

Measure 12 – Efficient use of administrative systems 

Measure = Percentage of patients not attending appointments with health professionals in the 

team 

which result from errors in the administrative system. 

The additional work carried out at in the PHCT to explore the reasons why patients 

DNA revealed some problems with the administration systems. The result was that 

patients cancelled their booked appointment, but this was not entered on the system. 

In addition some patients reported that as they had attended the surgery close to a 

booked appointment they assumed that this had been cancelled. 

These findings suggest that some reduce in DNA rates would result from developing 

and improving current systems. 

Developing a measure requires the following: 

- further work to identify the range of system problems which could be improved by 

the team 

- calculate the current number of DNAs which result from system problems 

- improve and develop the system 

- continue to monitor the reasons for DNA and assess whether the number resulting 

from system problems decreases / or monitor the DNA rate and if this decreases 

attribute this to the improvements and developments in the system.

Measure 13 - Efficient use of GP resources in the team 

Measure = Average number of patients seen by a GPs in a week 

The PHCT had introduced a ‘sit and wait’ session; all patients who went to the surgey 

between 10.00 qnd 11.00 were seen by a GP. Introducing the sit and wait session 

enabled the resources of the GPs to be used differently. Two GPs held patient 

consultations while a third carried out administrative tasks, dealt with telephone 

queries and carried out home visits. The aim was to offer the same number of faceto-face 

consultations with patients, but with a reduced GP resource. 

It was decided, therefore, that maintaining the number face-to-face consultations with 

patients was an indication of the success of the sit and wait. 

Data from the practice computer showed that there had been a substantial 

reduction in the number of patients seen by GPs (comparisons were made 

between a 1 week period in 1999 and the same week in 1998). 

Discussion of the reasons why GPs might be seeing fewer patients revealed that this 

reduction might indicate that the practice was infact using resources more efficiently. 

Reasons proposed were: 

- Less use of locum doctors for home visits (therefore fewer patients being 

advised to see their own GP after the home visit). 

- Nurses seeing more patients (diabetics, blood clinic, hypertensive), nurse 

practitioner (available on Fridays). 

- Patients can call the surgery and talk to a GP and get advice. 

- The pharmacist visits some patients at home to discuss medication. 

This work emphasises the importance of looking at the activities of the team as a 

whole when assesses the effectiveness of specific aspects.

Objective: Continuous personal and professional development 

Measure 14 – Team member access to training 

Measure = Percentage of who are satisfied with the extent to which their training needs are 

assessed 

and met in the previous year. 


� Agree what is an acceptable level of satisfaction within the team. 


� Each member of the PHCT completes the measure of satisfaction with training. 

� Calculate the mean satisfaction with training score for each person (total the 

responses from each question ….. and divide by the number of questions). Then 

calculate what % of staff report a satisfaction level at, above and below the 

ageed acceptable level. 

Next steps 

Analysis of the responses to the individual questions in the training satisfaction 

measure can be used to determine the steps which need to be taken to improve 

access to training within the team. For example, these responses can indictate 

whether there are concerns about funding available to support training, or if there are 

issues relating to the identification of training needs. The former could be resolved 

by identifying additional sources of funding, while the latter could be tackled via the 

appraisal system.

Objective: High team member commitment, stress and 

satisfaction. 

Measure 15- Team member commitment and satisfaction 

Measure = Percentage of staff in the team who feel committed and satisfied 


• Agree what is an acceptable level of commitment within the team 

• Agree what is an acceptable level of job satisfaction 


• Each member of the PHCT completes the measures of commitment and 

satisfaction. It is important that confidentiality is maintained and that it is not 

possible for individual responses to be identified 

• Calculate the mean job satisfaction for each person (total the responses from 

each question, extremely dissatisfied = 1 to extremely satisfied = 7 and divide by 

the number of questions, 16). Then calculate what % of staff report a satisfaction 

level at and above the agreed acceptable level for the team 

• Calculate the mean commitment for each person (total the responses from each 

question, strongly agree = 5, strongly agree = 1, and divide by the number of 

questions, 6). Then calculate what % of staff report a level of commitment at and 

above the agreed acceptable level for the team 

Next steps 

Analysis of the responses to the individual questions in the commitment and job 

satisfaction measure can be used to determine the steps which need to be taken to 

improve the overall levels of commitment and satisfaction within the team.

Measure 16 - Team members use each others skills, knowledge and expertise 

appropriately 

Measure = Percentage of team members who report that 

skills, knowledge and expertise 

within the team are used appropriately in 3 month 

period. 


� Agree what is an acceptable level of appropriate use of skills, knowledge and 

expertise. 


• Each member of the team completes the questions on the use of each others 

skills, knowledge and expertise. 

• For each question, calculate the extent to which skills, knowledge and expertise 

are used appropriately (total the responses on each dimension = 1, 

= 5 and then calculate the mean (divide the total by the number of dimensions). 

Next steps 

If the levels of awareness and appropriate use of skill, knowledge and expertise are 

below the acceptable level the team could improve this by holding more effective 

meetings (when all members are encouraged to contribute to decision-making), by 

getting involved in joint projects together, and carrying out work shadowing.

Measure 17 - Effective team working 

Measure = Percentage of requests for help and information and referrals from other 

team members which are inappropriate in a 3 month period. 


• Agree what is an acceptable % inappropriate requests for help and information, 

and level of inappropriate referrals from other team members 


• Over a specified period (one or two weeks) each member of the team logs each 

time another team member requests help and information, and refers a patient. 

Against each, each team member notes whether this was an appropriate or 

inappropriate request for help/information or patient referral. It may also be 

useful to note which team member made the request for help/information or 

made the referral 

• At the end of the specified period calculate what percentage of the total number 

of requests for information and patient referrals were inappropriate. Compare 

this with the acceptable levels agreed.

Objective: Responsiveness to client and community 

Measure 18 - Patients’ Experiences of the PHCT service (1) 

Measure = Percentage of patients who report that their experiences of the PHCT 

services match the standard agreed by the PHCT. 

This can be assessed by measuring patients’ experiences of the PHCT. 

Steps to developing a measure: 

∗ Identify all the aspects of the PHCT’s work and how it is delivered which are 

known to be associated with patients satisfaction, e.g. not having to wait, getting 

repeat prescriptions, phone answered quickly, being able to get advice etc. 

∗ Develop a checklist for patient asking if they have experienced each of the 

aspects associated with satisfaction. 

∗ Either ask about experiences of the PHCT in general, e.g. 

⇒ Do you get your repeat prescription within 48 hours? sometimes 

always never 

∗ Or ask about the contact with PHCT the patient has just had, e.g. 

⇒ Did you have to wait more than 2 days to get an appointment with the 

GP? yes no 

∗ Identify other information you would like to collect from patients which might help 

you to use or understand the information you collect on patients’ experiences 

(e.g. age, gender, number of visits to the surgery in the previous month). It might 

be useful to ask patients to write their own comments. 

∗ Consider what would be acceptable and unacceptable responses to the patient’s 

experiences questions, e.g. would you expect 90% of patients to report they got a 

repeat prescription within 48 hours or 10%? Also consider whether some areas 

are more important than others. 


∗ Over a one week period ask all patients attending the surgery to complete a 

checklist. Send a % of questionnaires to home addresses, and distribute via DN, 

HV etc. 

∗ Collate the information from patients. Calculate a total score for each patient and 

the mean. 

It may be useful to look at responses on each item separately (particularly if you 

considered some patient experiences to be more important), and to identify whether 

the views of different types of patients vary.

Next steps: 

∗ If patients’ experiences of some aspects of the PHCT work are not as positive as 

the team had anticipated develop interventions to improve these. Or you may find 

experiences vary across different types of patients and the team want to take 

steps to remedy this. 

∗ After interventions have been put in place repeat the patient survey to assess 

progress.

Measure 19 - Patients’ experiences of the PHCT services (2) (Using the existing 

measure) 

Measure = Percentage of patients whose experiences of the PHCT services meet 

the standard set by the team. 


∗ On each of the questions in the patient Opinion survey agree the ideal standard 

the PHCT wants to achieve for example question 1, the length of time patients 

wait to get an appointment with a GP, what % of patients does the team aim to 

see on the same day/next day/after 2 days/3 days? 

∗ On each of the questions in the Patient Opinion survey agree the expected 

standard that the PHCT currently achieves. 


∗ Over a one or two week period distribute questionnaires to patients attending the 

health centre/surgery, attending clinics, and those seen by the HV, DN, CPN and 

by other professionals carrying out domicillary care. Also survey a sample of 

patients, selected at random from the practice list, who have not been seen 

during the week. 

∗ On each question calculate 

⇒ % of patients whose experiences of the PHCT services meet the ideal 

standards set by the teams. 

⇒ % of patients whose experience of the PHCT services meet the expected 

standard. 

∗ Calculate a total score for % of patients whose experiences meet the ideal 

standard (total number of questions where patients’ experiences met the ideal 

standard and calculate this number as a % of the total number of questions). 

∗ Calculate a total score for % of patients whose experiences meet the expected 

standard (total the number of questions where patients’ experiences met the 

expected standards and calculate this number as a % of the total number of 

questions).

___________________ 

Patient Opinion Survey 

Date - 

Please could you answer the questions listed below. Your answers will help us to 

improve the service we provide for patients. 

Age __________ years Male Female 

1. The last time you wanted an appointment with any of the GPs, how soon did 

you get one? 

same day 

next day 

after 2 days 

longer ___________ 

2. The last time you wanted an appointment with the GP of your choice, how 

soon did you get one? 

same day 

next day 

after 2 days 

after 3 days 

longer ___________ 

3. How could the appointment service be improved? 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

4. The last two times that you phoned the surgery, how long did you wait for 

the phone to be answered? 

1st time _________ mins Time of day: morning afternoon 

2nd time _________ mins Time of day: morning afternoon

5. The last two times that you asked for a repeat prescription, how long did you 

have to wait to get it? 

1st time ______________ days 

2nd time ______________ days Not applicable 

6. Have you ever experienced problems/delays with getting a repeat 

prescriptions? 

Yes No 

7. If yes, please give details of where the delay occurred e.g. at the Health 

Centre or at the chemist 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

8. How could the repeat prescription service be improved? 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

9. Have you ever used the services of the Practice Nurse? 

Yes No 

If No, please go to Question 13. 

10. Did you have an appointment? 

Yes No 

11. The last two times you had an appointment with the Practice Nurse, how 

long after the appointment time did you have to wait to see her? 

1st time ____________ mins 

2nd time ____________ mins

12. If your GP referred you to the Practice Nurse, how long did you sit in the 

waiting room until the practice nurse was available? 

_____________ mins 

Did you know that you could make an appointment to see the Practice Nurse? 

Yes No 

13. Have you required a doctors appointment and had to wait for the Practice 

Nurse to phone? 

Yes No 


14. The last two times you used this service how long after 2pm did you have 

to wait for the Practice Nurse to phone you? 

1st time _____________ mins 

2nd time _____________ mins 

15. How could the Practice Nurse services be improved? 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

16. Which of the following services do you think are offered by Health 

Visitors? Which have you used? 

Ante natal care 

Post natal advice/support 

Child development assessment 

Behaviour management 

Childcare advice 

Continence advice 

Adult support/advice 

Elderly support/advice 

offered used 

If you do not use the services of the Health Visitor, please go to question 20. 

17. Who is your named Health Visitor? _________________________________

18. In the last month: 

How many morning clinics did you attend? 

How many afternoon clinics did you attend? 

How long did you (your child) wait to be seen at each clinic? 

morning afternoon 

__________ mins __________ mins 




19. How could the services offered by Health Visitors be improved? 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

20. Have you ever used of the services of District Nurses? 

Yes No 


21. Have you got a named District Nurse? 

Yes No 

22. If yes, who is your named District Nurse? __________________________ 

23. How long did you have to wait for a visit from a District Nurse for the 

following: 

(i) Urgent condition ________ hours Not applicable ________ 

days 

(ii) Discharge from hospital ________ hours Not applicable 

________ days 

(iii) Routine referral from GP________ hours Not applicable ________ 

days 

(iv) Nursing home assessment________ hours Not applicable ________ 

days

24. Did your GP tell you that they would arrange for the District Nurse to call? 

Yes No 

If yes, did this happen within the time period given by the GP? 

Yes No Not applicable 

25. Hospital discharge (if you have not been discharged from hospital in the 

past month, please ignore this section) 

Did the hospital tell you that the District Nurse would call to see you? 

Yes No 

Did you have to contact the Health Centre before the District Nurse made a visit? 

Yes No 

How long did you wait following discharge to see the District Nurse? ________days 

26. How could the District Nursing services be improved? 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

27. Please write below any other comments you would like to make about the 

Practice. 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________

__________________________________________________________________ 

__________________________________________________________________ 

__________________________________________________________________ 

____________________________________________________________ 

Many thanks for your help. 

Other measures – developed in training workshop 

Quality 

� % of patient records which are: relevant; concise; contemporaneous; legible; 

dated; signed and actioned. 

� % of previouly agreed conditions for which there is an evidence based protocol 

which is reviewed annually. 

� % of evidence based protocols which are audited. 

� % of time spent on patient and non-patient contact. 

� Number of complaints about access to services. 

� Number of inappropriate experiences of access. 


� Number of suggestions which are agreed and acted upon. 

� % of time in a month when GPs are available for consultation with other members 

of the PHCT. 

Administrative efficiency 

� % of time spent looking for case notes 

� % of time spent preparing repeat prescriptions

Appendix IV 

Training Programme - 

Tools and Techniques for Assessing 

Performance 

The Productivity Measurement and Enhancement System (ProMES) was used in the 

research to develop effectiveness measures from primary care. Objectives were 

developed in workshops with domain relevant experts from primary care (see 

Appendix III) and effectiveness measures were developed with representatives two 

primary health care teams (see Chapter 3 and Appendix II). ProMES is a 

theoretically grounded approach, based on the NPI theory of motivation (Naylor, 

Pritchard & Ilgen (1980), that has very practical applications. A critical feature of the 

ProMES process is that those people who performance is being assessed are 

involved in developing their own measurement and feedback systems. Participants 

learn to set clear objectives, to identify ways of measuring whether they are 

acheiveing these objectives, and to collect and use information to provide feedback 

on performance. 

Two key lessons were learnt from the Workshops and the work carried out with 

primary health care team members developing measures. Firstly, the ProMES 

process provides a valuable learning experience, and secondly, it is possible to 

identify common objectives for primary care and to develop measures to assess 

performance against these objectives. 

Having demonstrated the utility and value of ProMES, and encouraged by the 

exepriences of the representatives from primary care who had experienced the 

ProMES process, the research team developed a ProMES training programme. The 

programme was designed to train primary health care team members, and trust and 

health authority staff working with primary care teams, in the ProMES technique.

Letters were sent to all the primary health care teams involved in the research 

inviting representatives to attend the training programme. Responses were received 

from only two teams and four team members attended the training. Letters of 

invitation were also sent to representatives working with primary health care teams in 

the local community trust and health authority and four people attended from these 

organisations. 

Details of the training programme are provided below.

Training Plan 

Day 1 

Tools and Techniques for Assessing Performance 

11.00 - 11.15 - Overall objectives of the training programme: 

Introductions 

OHP - Aims and objectives 

• To develop skills which enable the participants to develop performance measures 

with primary health care teams. 

• To develop skills which the participants can use to identify and use evidence to 

assess performance in primary health care teams. 

• To teach participants how to use the measures produced by the research team. 

What else would the participants want to include? What specifically do they want to 

get out of the training? 

11.15 - 12.00 - Introduction 

The purpose of this session is to: 

(a) clarify what is meant by ‘performance’ 

(b) provide participants with an understanding of the contribution that measuring 

performance can make to team effectiveness in primary care, 

(c) raise awareness of the complexities of measuring performance in primary care. 

What is ‘performance’? 

It is important to be clear about what it is we are trying to measure. 

Discussion session - What do they understand by ‘the performance of a PHCT’? 

The definition to use: The outcomes from a team, what they produce, what they are 

trying to achieve. 

Introduce the basic principles of ProMES 

(Handout 1) 

- productivity 

- motivation 

- feedback 

- prioritising effort. 

Basic approach: 

- Design team 

- Clarify objectives 

- Develop measures of the objectives 

- Gather information with the measures and use this to assess extent to which 

meeting objectives, and to identify changes which can be made to improve 

performance. 

(Handout 2, Handout 3) 

Measuring performance and team effectiveness. 

(i) The importance of effective team working in multidisciplinary groups.

(ii) The principles of effective team working (clarity of objectives and feedback on 

whether achieving these objectives, participation, task style, support for innovation, 

reflexivity). 

Feedback is only useful in the context of clear goals. 

To measure performance PHCTs need to have clear objectives. Using measures 

can provide feedback on performance. In addition the process of developing and 

using measures requires participation and reflexivity. Thus measuring performance 

can make a considerable contribution to effective team working. 

Developing and using measures also enables PHCTs to use evidence based 

practice. 


The difficulties of measuring performance in primary care 

Given what we are trying to achieve (measure the outcomes from PHCTs) Why might 

this be difficult? 

Discussion with the group. 

- multiple stakeholders, therefore, lack of agreement re. objectives, outcomes, 

desirable outcomes 

- outcomes difficult to measure (eg quality of care, patient satisfaction) 

- lack of sound evidence. 

- aspects not within the team’s control. 

12.00 - 1.00 - Basic Principles for Assessing Performance 


(a) Agree the objectives for primary care. 

(b) Identify potential sources of information which could be used to evaluate 

performance against these objectives. 

(c) Consider what are good and bad measures of performance. 

(Handout 6) 

Step 1 - Setting objectives 

Outline the process used to develop the Objective for Primary Care (workshop, work 

with teams). 

Present the group with the Objectives. Rate the objectives in terms of importance 

(purpose of this is to get them thinking critically). Do they disagree with any of the 

objectives? 

(Handout7, Handout 8) 

Critically evaluate the objectives using the ‘criteria for good objectives’. 

(Handout 9) 

Step 2 - Identifying sources of feedback information 

Work in pairs, each discuss 2 objectives, and identify sources of information available 

which could provide feedback on performance on these objectives. (the aim at this 

stage is to raise awareness about all the sources of information available, not 

necessarily to identify the best sources). 

Step 3 - What is a good measure? 

Discussion of good and bad measures. Introduce the idea that what it is easy to 

measure, is not necessarily the best measure. 

Discuss the ‘criteria for a good measure’. 

(Handout 10) 

2.00 - 3.30 - Measuring Use of Resources

The purpose of this session is to give participants the opportunity to work through the 

process of developing a measure. 

The task is for the group to develop a measure / measures which will indicate 

whether resources are being used effectively in a team. 

An example of a measure. In manufacturing organisations wastage of raw materials 

can add considerable amount to costs. A measure of performance in relation to the 

objective ‘Efficient use of Resources’ could be, therefore, % reduction in the waste of 

raw materials. 

Exercise 

The group/s consider the following questions and develop a measure of use of 

resources. 

• What are the resources used / available to a PHCT? (eg financial, skills, 

knowledge, equipment, time, rooms)? 

• What evidence is available to indicate that resources are being used efficiently? 

• What evidence is available to indicate that resources are being use inefficiently? 

• Which resources is it most critical to use efficiently? (Ie which potentially have 

the greatest impact on the performance of the team?) 

• Decide on one aspect of resources and develop a measure. 

• Critically appraise the measure using the ‘criteria for measures’. 

The groups work on their own with support from the trainers. 

They need to select a scribe and someone willing to feedback in the plenary session. 

The group give feedback on the process they went through to develop a measure, 

and the measure developed 

(Handout 12) 

4.00 - 5.30 Plenary Session 

Feedback. What aspects of the process did they find easy/difficult? What problems 

did they encounter? Did they develop a good measure? 

Review learning (from the whole day) 

Day 2 

9.00 - 10.45 - Measuring Quality of Care 

The purpose of this session is to give participants more experience of working 

through the process of developing a measure. 

iReview the learning points from the session on developing measures on use of 

resources (ie what have they learnt and will do differently ?) 

The task is to develop a measure / measures of in relation to the objective Quality of 

Care. This is a difficult exercise so we are providing some materials which might 

help. Introduce the 5 dimensions of quality. 


Exercise. 

The group/s consider the following questions. 

• What is meant by quality of care in primary care? Whose perspective should be 

taken into account? 

• What evidence is available to indicate that good quality of care is being provided 

by the PHCT? 

• What evidence is available to indicate that quality of care is not good?

• Which aspects of the PHCT services / types of conditions is it most critical to 

focus on? (ie which would improvements in service / care have the greatest 

impact on team performance?) 

• Decide on one aspect of quality of care and develop a measure. 


The groups work on their own with support from the trainers. 

They need to select a scribe and someone willing to feedback in the plenary session. 

It is a difficult task, but we will be there to help. 

We want them to feedback on the process they went through to develop a measure, 

and the measure developed 

11.00 - 11.30 - Plenary session 

Feedback. What aspects of the process did they find easy/difficult? What problems 

did they encounter? Did they develop a good measure? 

Review learning. 

Important to emphasise that they are not now experts in developing measures, but 

are more aware of the process and the difficulties. With support from me they can do 

this with teams. 

11.30 - 12.30 - Developing measures with teams / PCGs 

The purpose of this session is to provide participants with practical skills in running 

measurement development sessions with PHCTs 

Run this as a how to do it information giving session. 

Hightlight pitfalls and problems. Emphasis thet MUST follow the correct process. 

MUST allow everyone to have a voice. Must NOT impose their own objectives / 

agenda. In addition , given the nature of primary care, the process can generate 

conflict - because it starts to make the implicit explicit and hightlight differences in 

persepctives and values. 

Plus give the group the opportunity to discuss concerns, problems, obstacles that 

they foresee. etc. 

(Handouts 15 - 22) 

For example - setting-up the design team, explaining the purpose, agreeing 

objectives, starting to develop measures, logging progress, action planning, 

gathering information, assessing the value of information, using information 

1.30 - 3.00 - Using Performance Measures 


(a) Familarise the participants with the measures developed by the research team so 

that they understand how and when ( to use them. (how to gather evidence) 

(b) Develop an understanding of how to use the feedback from measures to prioritise 

activities within the PHCT, and to change existing working practices/services. (how to 

use evidence) 

Explain how (the process) and why (to help teams to get feedback on aspects of their 

performance which were considered important to improving overall effectiveness) the 

measures were developed and used by the researchers. 

Provide each participant with a pack of measures (need to think on an interesting 

way of doing this). Discuss when and how the measures might be useful. 

(Handouts 23, Handout 24) 

Present some feedback data from the measures to the participants and discuss:

(a) how they would interpret this, what else they might need to know? 

(b) what actions might be taken as a result of the feedback? 

3.15 - 4.00 - Plenary Session 

Review of learning 

Next steps and action plans 

Contacting the research team for support 

Support network/further meetings/next training. 

Handout 1 

Measuring and Enhancing Effectiveness in 

Primary Health Care Teams 

Measuring and enhancing system effectiveness is an important element in any 

organisational system, and Pritchard (Pritchard, Jones, Roth, Stuebing & Ekeberg, 

1988, 1989; Pritchard, 1990) has developed a sophisticated and widely applicable 

approach to this - the productivity measurement and enhancement system 

(ProMES). 

The ProMES approach is based on the theory of motivation presented by Naylor, 

Pritchard, and Ilgen (1980). In this theory, motivation is maximised when people see 

clear connections between their efforts and the behavioural “products” or results of 

these efforts, there are clear perceived connections between a person’s products and 

their evaluations, and there are clear connections between these evaluations and 

valued outcomes. When these conditions are met, motivation is high. In addition, 

motivation is maximised when the different evaluators and controllers of rewards in

the person’s environment such as the person himself/herself, peers, different 

supervisors, top management, and union personnel agree as much as possible on 

what should be done in the work and how it should be evaluated. When such 

agreement exists, the efforts of the person are more clearly directed and the same 

amount of effort results in greater productivity. In addition, stress and wasted effort 

are reduced. 

The ProMES system develops a formal method to measure productivity and uses 

these measurements as feedback to people doing the work to help them increase 

their productivity through maximising motivation. The idea is to maximise the 

variables indicated in the theory so that motivation will also be maximised. People 

are given the tools to do the work better and at the same time help them feel a sense 

of ownership in the resulting system and empowerment in determining important 

aspects of their work. 

One of the key elements in ProMES is feedback. People doing the work get regularly 

occurring, high quality feedback about how the work unit is doing. The personnel in 

the work unit then use this feedback to develop plans for improving productivity. 

Feedback after this time tells them how well the plans they developed have actually 

improved productivity. Furthermore, since they are heavily involved in the design of 

the measurement system and resulting feedback system, they have more confidence 

in its validity and accept it more than systems imposed from above. The ProMES 

approach has been applied and evaluated in a wide range of settings (Pritchard, 

1995) and substantial improvements in performance have been shown as a result of 

using ProMES.

Handout 2 

Practical tips and guidelines 

Why use this system? 

• it makes you think! 

• it gives you useful information 

• it indicates where you should focus your resources 

• it allows you to define your own measurement system - it puts you in control 

• it increases your participation 

• you are the first to know about any problems 

• people report less stress 

• people know how they are being evaluated 

• everyone has to agree the priorities - they are not imposed 

• you get valuable feedback

Handout 3 


Key implementation principles 

• Measurement is the foundation 

• It takes a lot of work to measure well 

• What you measure is what you get 

• Measures for decision making are different from those for motivation 

• Good measurement makes feedback easy 

• Good feedback leads to productivity improvements 

• People want to do a good job 

• The key is to give them the tools 

• People want control over their lives 

• Acceptance of the system is essential for success 

• Participation leads to acceptance

Handout 4 

Teamworking in Primary Care 

The idea that teams are important to modern organisations was established about 70 

years ago. However, in only the past 15 years has the idea been seized and widely 

acted on by large numbers of organisations in the public and private sectors (Guzzo, 

1996). But how effective are teams within organisations generally? 

Macy and Izumi (1993) conducted an analysis of 131 organisational change studies 

in order to determine their effectiveness. Those interventions with the greatest 

effects on financially-related measures of organisational performance were team- 

related interventions. These also reduced turnover and absenteeism more than did 

other interventions, showing that team-oriented practices can have broad positive 

effects in organisations. Abblebaum and Batt (1994) offer convergent evidence. 

They reviewed the results of a dozen surveys of organisational practices as well as 

185 case studies of innovation in management practices. They too found compelling 

evidence that teams contribute to improving organisational effectiveness, particularly 

increasing efficiency and quality. Other researchers provide evidence of the impact 

of team-based work practices on organisational performance. Kalleburg and Moody 

(1994) studied over 700 work establishments and found that those in which 

teamwork was developed were more effective in their performance than those in 

which were not used. 

The importance of teamworking has been emphasised in numerous reports and 

policy documents on the National Health Service. One recent document (NHSME 

1993) particularly emphasised the importance of teamworking if health and social 

care for people in local communities were going to be of the highest quality and 

efficiency.

‘The best and most cost-effective outcomes for patient and clients 

are achieved when professionals work together, learn together, 

engage in clinical audit of outcomes together, and generate 

innovation to ensure progress in practice and service.’(para 4.3) 

Overall, research based evidence of teamworking in primary health care in the UK is 

consistent with research in other sectors in suggesting the value of this way of 

working for effectiveness and efficiency. Primary care team working has been 

reported to improve health delivery and staff motivation (Wood, Farrow and Elliot, 

1994) and to have led to better detection, treatment, follow-up and outcome in 

hypertension (Adorian, Silverberg, Tomer and Wamosher, 1990). In a longitudinal 

study of 68 primary health care teams, Poulton (1995) found a clear relationship 

between teamwork and effectiveness. Those teams with high levels of clarity of team 

objectives and team members commitment to those objectives were more effective 

than those with unclear objectives. 

However, despite these encouraging research studies, there is considerable 

evidence that the context of primary health care is such that there are substantial 

barriers to co-operation and collaboration in the delivery of primary health care. 

Bond et al (1985) found little interprofessional collaboration in primary health care 

teams in their study of 309 paired professionals. West and Poulton (1995) examined 

primary health care team functioning in 68 practice teams and found that on all 4 

dimensions of team functioning primary health care teams scored significantly lower 

than the other team types. West, Poulton and Hardy (1994) in a study of 9 primary 

health care teams identified structural, managerial and employment patterns in 

primary care as crucial in undermining the effectiveness of teamworking. These 

barriers to co-operation and collaboration need to be removed or reduced for 

teamworking to be effective in primary heath care.

There are a number of key elements to effective teamwork (Guzzo and Shea, 1992): 

• First, Individuals should feel that they are important to the success of the team. 

When individuals feel that their work is not essential in a team, they are less likely 

to work effectively with others or to make strong efforts towards achieving team 

effectiveness. Roles should be developed in ways which make them 

indispensable and essential. 

• Individuals roles in the team should be meaningful and intrinsically rewarding. 

Individuals tend to be more committed and creative if the tasks they are 

performing are engaging and challenging. 

• Teams should also have intrinsically interesting tasks to perform. Just as people 

work hard if the tasks they are asked to perform are intrinsically engaging and 

challenging, when teams have important and interesting tasks to perform, they 

are committed, motivated and co-operative (Hackman, 1990). 

• Individual contributions should be identifiable and subject to evaluation. People 

have to feel not only that their work is indispensable, but also that their 

performance is visible to other team members. 

• Above all there should be clear, shared team goals with built-in performance 

feedback. Research evidence shows consistently that where people are set clear 

targets at which to aim, their performance is generally improved. For the same 

reasons it is important for the team as a whole to have clear team goals with 

performance feedback. 

In primary health care, by and large, the first three conditions for effective 

teamworking hold true. However, in primary health care teams it is rare for individual 

contributions to be measured and feedback on performance given. Moreover, 

primary health care teams tend not to have clear, specific objectives and goals and

feedback on performance against those objectives is rarely available. The 

development of teamworking in primary healthcare, therefore, needs to focus on 

developing clear, shared objectives and on providing feedback on performance.

Handout 5 

The difficulties of measuring performance in primary care 

• There are multiple stakeholders in primary care (different professional groups, 

and organisations), therefore, lack of agreement about objectives, what are the 

outcomes from primary care teams, and what are desirable outcomes. 

• Many of the outcomes are difficult to measure (e.g. quality of care, patient 

satisfaction). 

• There is a lack of sound evidence. 

• Many of the factors which influence outcomes are not within the team’s control 

(e.g. other agencies, characteristics of practice population).

Handout 6 


Setting Objectives 

• ask the team what it is they are trying to accomplish for their organisation 

• focus on larger objectives - give the group examples which are as similar to their 

work as possible 

• this stage is typically not difficult 

• consensus should be easy to reach at this stage 

• the discussion at this point sets the tone for the future - there needs to be 

balance between the facilitator saving the group time and taking control

Handout 7 

Core Objectives for Primary Health Care 

♦ To promote, maintain and improve health 

Provide high quality health care 

Accurate identification of individual and population health and care needs 

Review and improve the effectiveness of health care provision 

Manage illness, injury and disease taking account of agreed standards and 

evidence based practice 

♦ Enable personal and community responsibility for individual health 

Enable patients/clients to make informed decisions about their own health 

Proactively encourage positive health behaviour 

Implementation of health education and preventative care programmes 

♦ Efficient use of resources 

Human resources - skills, knowledge, expertise, time 

Physical resources - budgets, equipment, premises 

♦ Continuous personal and professional development 

Individual annual training plans which take account of the plans for the PHCT 

Equal access to training/development resources 

♦ High team member commitment, stress and satisfaction

Teamworking 

Mechanisms for reviewing and acting upon staff dissatifactions, conflicts and 

complaints 

♦ Responsiveness to clients and community 

Mechanisms for gathering information and feedback from clients/community 

stakeholders/opinion leaders. 

♦ Collaboration and partnership with other relevant organisations

Handout 8 

Core Objectives for Primary Health Care Teams 

To what extent do you think your team effectively meets the following 

objectives and sub-objectives? 

To promote, maintain and improve health Of no Very 

importance important 

1 2 3 4 5 6 7 

- Provide high quality health care 

5 6 7 

1 2 3 4 

- Accurate identification of individual and 

population health and care needs 1 2 3 4 5 6 

7 

- Review and improve the effectiveness of 

health care provision 1 2 3 4 

5 6 7 

- Managing illness, injury and disease taking 

account of agreed standards and evidence 1 2 3 4 

5 6 7 

based practice 

Enable personal and community responsibility 

for individual health 1 2 3 4 5 6 7 

- Enable patients/clients to make informed decisions 

about their own health 1 2 3 4 5 6 

7 

- Proactively encourage positive health behaviour 

1 2 3 4 5 6 7 

- Implemention of health education and 

preventative care programmes 1 2 3 4 5 6 

7

Efficient use of resources Of no Very 

importance important 

1 2 3 4 5 6 7 

-Human resources (skills, knowledge, expertise 

time) 1 2 3 4 5 6 

7 

- Physical resources (budgets, equipment, premises) 

1 2 3 4 5 6 7 

Continuous personal and professional 

development 1 2 3 4 5 6 7 

- Individual annual training plans which take 

account of the plans for the PHCT 1 2 3 4 5 6 

7 

- Equal access to training/development 

resources 1 2 3 4 5 6 

7 

High team member commitment, stress 

and satisfaction 1 2 3 4 5 6 

7 

- Teamworking 

1 2 3 4 5 6 7 

- Mechanisms for reviewing and acting upon 

staff dissatisfactions, conflicts and complaints 1 2 3 4 5 6 

7 

Responsiveness to clients and community 

1 2 3 4 5 6 7 

- Gather information and feedback from clients/ 

community stakeholders/opinion leaders 1 2 3 4 5 6 

7 

Collaboration and partnership with other 

relevant organisations 1 2 3 4 5 6 

7

Handout 9 

Criteria for Objectives 

• stated in clear terms 

• if exactly that objective was done, the organisation would benefit 

• the set of objectives must cover all important aspects of the work 

• objectives must be consistent with the broader organisation 

• higher management must be committed to each objective 

• keep the number of objectives manageable, normally 3 to 8

Handout 10 


Criteria for measures 

• the measure must be consistent with the objectives of the broader organisation 

• if the measure was maximised would the organisation benefit 

• all important aspects of each objective must be covered by the set of measures 

• higher management must be committed to the measures 

• measures must be under control of the staff 

• measures must be understandable and meaningful to staff 

• it must be possible to provide information on the measure in a timely manner 

• the data must be cost effective to collect 

• the information provided by the measure must neither be too general or too 

specific

Handout 11 

Measuring Use of Resources 

• What are the resources used / available to a PHCT? (eg financial, skills, 

knowledge, equipment, time, rooms)? 

• What evidence is available to indicate that resources are being used efficiently? 

• What evidence is available to indicate that resources are being used inefficiently? 

• Which resources is it most critical to use efficiently? (i.e. which potentially have 

the greatest impact on the performance of the team?) 

• Decide on one aspect of resources and develop a measure. 


Select a scribe and someone willing to feedback in the plenary session. 

. 

We want them to feedback on the process they went through to develop a measure, 

and on the measure/s developed

Handout 12 


Developing Measures 

• ask how they would show that the stated objectives were being met 

• this is a difficult step for the design team to do 

• it is frustrating - tell the group they will feel this 

• you must train the design team to develop and evaluate measures 

• the design team may not know the answer but they can find out 

• if someone tells you that you cannot measure what they do then ask them how 

they think they are doing?, is it different to last year?. If they have an idea of their 

performance then it can be measured.

Handout 13 


Effectiveness: Is the treatment given the best available in a technical sense, 

treatment? 

according to those best equipped to judge? 

What is their evidence? What is the overall result of the 

Acceptability: How humanely and considerately is this treatment/service 

delivered? What does the patient think of it? What would/does 

an observant third party think of it (“How would I feel if it were 

my nearest and dearest?”) What is the setting like? Are 

privacy and confidentiality safeguarded? 

Efficiency: Is the output maximised for a given input or (conversely) is the 

input minimised for a given level of output? How does the unit 

cost compare with the unit cost elsewhere for the same 

treatment/service? 

Access: Can people get this treatment/service when they need it? Are 

there any identifiable barriers to service - for example, distance, 

straightforward 

inability to pay, waiting lists, and waiting times - or 

breakdowns in supply? 

Equity: Is this patient or group of patients being fairly treated relative to 

others? Are there any identifiable failings in equity - for 

example, are some people being dealt with less favourably or 

less appropriately in their own eyes than others? 

Relevance: Is the overall pattern and balance of services the best that could 

be achieved, taking account of the needs and wants of the 

population as a whole?

Handout 14 

Measuring Quality of Care 

• What is meant by quality of care in primary care? Whose perspective should be 

taken into account? 

• What evidence is available to indicate that good quality of care is being provided 

by the PHCT? 

• What evidence is available to indicate that quality of care is not good? 

• Which aspects of the PHCT services / types of conditions is it most critical to 

focus on? (ie which would improvements in service / care have the greatest 

impact on team performance?) 

• Decide on one aspect of quality of care and develop a measure. 


Select a scribe and someone willing to feedback in the plenary session. 

Feedback on the process they went through to develop a measure, and the on the 

measure/s developed

Handout 15 

Basic ProMES Approach 

• Gaining management and staff support 

• Set-up a design team 

• Identifying objectives 

• Develop measures for the objectives 

• Gather information with the measures 

• Feedback from the measures 

• Identify changes which can be made to improve performance.

Handout 16 


Conditions for success 

• Management support - this means public support of the project on a regular 

basis, providing the resources of the project regularly, solving project problems 

and continuing the project until a clear evaluation can be made 

• Trust between management and staff - process needs to be fully explained 

including advantages and costs, explain why us?, make participation voluntary, 

explain how the whole team will be involved even though only part will be on the 

design team, explain how the design team will be chosen 

• All interested parties approve the project - consider stakeholders, partners, 

unions 

• Values match between management and staff - all see potential improvement as 

valuable and have a long range perspective, all see participation/acceptance as 

essential 

• Stable personnel and group structure - are there any major upheavals in staff 

premises or technology

Handout 17 


Resources Needed for Development 

• Time for design team meetings 

• Uninterrupted meeting setting 

• Full attendance by design team 

• Access to existing data 

• Meeting with management for approval of the system 

Resources needed for implementation 

• Collecting of existing and new data for feedback 

• Preparation and distribution of feedback results 

• Regular meetings of the group 

• Regular meetings of the group members to discuss feedback reports

Handout 18 


Checklist for starting a project 

• All interested constituencies have been involved 

• Benefits and costs clearly explained to all 

• Have assessed trust and common values 

• Have management support (see number 2) 

• Have staff support (see number 2)

Handout 19 


Selecting the design team 

• people who are respected 

• must be a cross section of the larger group e.g. practice nurse, senior 

receptionist, general practitioner, district nurse, practice manager, health visitor 

• no-one occupational group should dominate 

• if someone is unable to attend they must nominate a deputy to represent them 

• individuals should feel confident about themselves and who/what they represent 

and feel able to represent the views of their group

Handout 20 


Logging progress 

• keep an accurate record of the progress made at each meeting 

• provide the design team with an update of their progress at regular intervals 

• you may find that between meetings the design team do not any homework and 

you will need to review previous sessions at the beginning of new sessions 

• provide the team with the list of objectives when completed along with their list of 

measures 

• the design team must also report progress to the other members of the larger 

group and your updates is a useful way of achieving this 

• the team will need reassurance that progress is being made even if it is minor to 

spur them on to the next stage

Handout 21 


Action planning 

• at the end of each session you will need to plan for the actions to be carried out 

by the next session 

• this may include collecting information and specific data 

• it must be clear from the outset that this is not the responsibility of the facilitator 

• members of the team will need to ‘volunteer’ to carry out actions 

• it is easy to walk away from a session believing that everyone knows what they 

are soposed to do - it is more than likely someone does not 

• check and check until you are satisfied that everyone understands their 

responsibilities 

• if you do this regularly the team will start to check you! 

• it is a good idea to have a session plan, you must be clear about what you want 

to achieve at each session 

• also record the feedback the team give you at the beginning of the session, it 

often proves useful later

Handout 22 


Possible problems 

• lack of commitment from the design team - not present at meetings or lack of 

response 

• getting stuck - cant see how to move forward 

• design team going off on a tangent - avoiding what can be hard thinking work 

• disagreement between members - possible personal issues 

• domineering members - other members passively agreeing 

• feeling lost with it all - do not know what to do next 

• not been given the required time and space for the sessions or interrupted 

• larger team losing interest 

• management support withheld 

• no-one willing to collect data 

• got the data don’t know what to do next

Handout 23 


Gathering information 

• the information gathered must be of good quality 

• the team must think about the most effective ways to gather information 

• you will need to discuss their expectations, what do they expect to be the 

outcome 

• they may need to design record sheets or charts or questionnaires which must be 

piloted to evaluate their effectiveness 

• who will distribute, collect, collate, evaluate and present the data to the design 

team 

• these may all be new skills but is an excellent development opportunity 

• the team will need support in this, from you and from each other 

Assessing the value of the information 

• does the data answer the question 

• are you satisfied that the data is good quality 

• did you discuss how to asses the data before you began 

• do you have the resources to assess the data, people, time, technology

Handout 24 


Using information 

• does this data provide you with useful information 

• you will need to discuss dissemination with the team 

• you must feedback the results of data gathering if you want people to co-operate 

in the future 

• what next - if you have some useful information you can then use this to plan 

ahead and use the information to make your case for change

_______________________________________________________________ 

_____ 

BIBLIOGRAPHY 

______________________________________________________ 

_____ 

Adorian, D., Silverberg, D.S., Tomer, D. & Wamasher, Z. (1990). Group discussion 

with the health care team: A method of improving care of hypertension in general 

practice. 

Journal of Human Hypertension, 4 (3), 265 - 268. 

Alderfer, C.P. (1977). Group and intergroup relations in J.R. Hackman and J.L. Suttle 

(eds) Improving the quality of work life. Pallisades, C.A.: Good year. pp 277 - 296. 

Alexander, J. A., Lichtenstein, R. & D’Aunno, T. A. (1996). The effects of treatment 

team diversity and size on assessments of team functioning. Hospital & Health 

Services Administration, 41, 37-53. 

Allen, N. J. (1996). Affective reactions to the group and organisation. In M. A. West 

(Ed.), Handbook of Work Group Psychology (pp. 371-396). Chichester: Wiley. 

Amabile, T.M. (1983). The social psychology of creativity: A componential 

conceptualization. Journal of Personality and Social Psychology, 45, 357-376. 

Ancona, D.F. & Caldwell, D.F. (1988). Bridging the boundary: External activity and 

performance in organisational teams. Administrative Science Quarterly, 37, 634-665. 

Anderson, N.R. & King, N. (1993). Innovation in organisations. In C.L.Cooper & 

I.T. Robertson (eds). International Review of Industrial and Organizational 

Psychology, 

Vol 8, Chichester: Wiley. 

Anderson, N, & West, M.A. (1994). The Team Climate Inventory: Manual and User’s 

Guide. Windsor, England: NFER-Nelson. 

Anderson, N. & West, M.A. (1998). Measuring climate for work group innovation: 

development and validation of the team climate inventory: Journal of Organizational 

Behaviour, Vol 19, 235 - 258. 

Applebaum, E. & Batt, R. (1994). The New American Workplace. Ithaca, NY: ILR 

Press. 

Audit Commission (1992). Homeward Bound: A New Course for Community Health. 

London: HMSO. 

Bales, R.F., Strodtbeck, F.L., Mills, T.M. & Roseborough, M.E. (1951). Channels of 

communication in small groups. American Sociological Review, 16, 461-468. 

Baumeister, R.F. & Leary M.R., (1995). The need to belong desire for interpersonal 

attachments as a fundemental motivator. Psychological Bulletin, 117, 497-529.

Berger, J., Fisek, M.H., Norman, R.Z., & Zelditch Jr, M. (1977). Status characteristics 

and social interaction. NY: Elsevier. 

Berger, J., Rosenholtz, S.J., & Zelditch Jr., M. (1980). Status organizing processes. 

Annual Review of Sociology, 6, 479-508. 

Bhugra, D., Bridges, K., & Thompson, C. (1995). Caring for a community: the 

community care policy of the Royal College of Psychiatrists. London: Royal College 

of Psychiatrists. 

Billings, R.S., Milburn, T.W. & Schaalman, M.L. (1980). A model of crisis perception: 

A theoretical and empirical analysis. Administrative Science Quarterly, 25, 300-316. 

Blakar, R.M. (1985). Towards a theory of communication in terms of precondition: 

A conceptual framework and some empirical explorations. In H. Giles and R.N. St 

Clair 

eds), Recent Advances in Language, Communication and Social Psychology. 

London: Lawrence Erlbaum. 

Blau, Peter M. (1977). Inequality and Heterogeneity. New York: Free Press. 

Bobko, P., & Colella, A. (1994). Employee reactions to performance standards: 

A review and research proposition. Personnel Psychology, 47, 1-29. 

Bond, J., Cartilidge, A.M., Gregson, B.A., Philips, P.R., Bolam, F., & Gill, K.M. (1985). 

A study of interprofessional collaboration in primary health care organisations. 

Report No 27 (2), Newcastle-upon-Tyne, Health Care Research Unit, University of 

Newcastle-upon-Tyne. 

Borrill, C.S. & West, M.A. (1997). Effectiveness in primary health care. CAIPE 

bulletin. 

No 14. 

Borrill, C.S. & West, M.A. (1998). Strain in primary health care. Unpublished report. 

Institute of Work Psychology, University of Sheffield, England. 

Borrill, C.S., Wall. T.D., West, M.A., Hardy, G.E., Shapiro, D.A., Haynes, C.E., Stride, 

C.B., Woods, D. and Carter, A.J. (1998) Stress among staff in NHS Trusts. Institute 

of Work Psychology, University of Sheffield, Psychological Therapies Research 

Centre, University of Leeds. 

Bottger, P.C. & Yetton, P.W. (1987). Improving group performance by training in 

individual problem solving. Journal of Applied Psychology, 72, 651-657. 

Bowers, D.G. & Seashore, S.E. (1966). Predicting organisational effectiveness with a 

four-factor theory of leadership. Administrative Science Quarterly, 11, 238-263. 

Brewer, N., Wilson, C. & Beck, K. (1994). Supervisory behavior and team 

performance amongst police patrol sergeants. Journal of Occupational and 

Organizational Psychology, 67, 69-78. 

Brown, R.J. (1988). Group Processes: Dynamics Within and Between Groups. 

London: Blackwell.

Bryk, A. & Raudenbush, S. (1992) Hierarchical Linear Models: Applications and data 

analysis methods. In J. Deleeuw (Ed.) Advanced quantitative techniques in the 

social sciences series. Newbury, CA: Sage Publications. 

Burns, T., & Stalker, G.M. (1966). The Management of Innovation. London: Tavistock 

Publications. 

Carletta, J., Garrod, S., & Fraser-Krauss, H. (1998). Communication and Placement 

of Authority in Workplace Groups — The Consequences for Innovation. Small Group 

Research, 29(5), 531-559. 

Carter, M.F., Evans, K.E., Crosby, C., Prendeergast, L.A., & De Sousa Butterworth, 

K.A. (1997). The all-Wales community mental health team survey. Bangor: Health 

Services Research Unit. 

Campion, M.A., Medsker, G.J. & Higgs, A.C. (1993). Relations between work group 

characteristics and effectiveness: Implications for designing effective work groups. 

Personnel Psychology, 46, 823-850. 

Campion, M.A., Papper, E.M. & Medsker, G.J. (1996). Relations between work 

team characteristics and effectiveness: A replication and extension. Personnel 

Psychology, 49, 429-689. 

Cant, S. & Killoran, A. (1995) Team tactics: a study of nurse collaboration in general 

practice, Health Education Journal, 52, 203 - 8. 

Coch, L. & French, J. R. (1948). Overcoming resistance to change. Human 

Relations, 

1, 512-532. 

Cohen, S.G. & Bailey, D.E. (1997) What makes teams work: Group effectiveness 

research from the shop floor to the executive suite. Journal of Management, No 3. 

239 - 290. 

Connolly, T., Conlon, E.J. & Deutsch, S.J. (1980). Organizational effectiveness: a 

multi-disciple-constituency approach, 98, 310 - 357. 

Cott, C. (1997). “We decide, you carry it out”: A social network analysis of 

multidisciplinary long-term care teams. Social Science & Medicine, 45 (9), 1411- 

1421. 

Cowan, D.A. (1986). Developing a process model of problem recognition. Academy 

of Management Review, 11, 763-776. 

D'Zumla, T.J. & Goldfried, M.R. (1971) Problem solving and behaviour modifications. 

Journal of Abnormal Psychology. 78, 107 - 126. 

Davenport, T.H. (1993). Process Innovation: Re-engineering Work Through 

Information Technology. Cambridge, MA: Harvard Business School Press. 

Deming, W.E. (1986). Out of the Crisis. Cambridge, MA: Center for Advanced 

Engineering Study, Massachusetts Institute of Technology.

Department of Health (1990). The Care Programme Approach for people with a 

mental illness referred to the specialist psychiatric services. London, Department of 

Health, HC (90) 23/LASSL (90) 11. 

Department of Health (1995). Building bridges: a guide to arrangements for interagency 

working for the care and protection of severely mentally ill people. London: 

HMSO. 

Department of Health (1997). The Patient's Charter: mental health services. London, 

Department of Health. 

Department of Health (1999). National Service Framework for Mental Health: Modern 

standards and service models. London: Department of Health. 

Dreachslin, J.L., Hunt, P.L. & Sprainer, E. (2000). Workforce diversity: Implications 

for the effectiveness of health care delivery teams. Social Science & Medicine, 50, 

1403-1414. 

Dreachslin, J.L., Hunt, P.L. & Sprainer, E. (1999a). Communication patterns and 

group composition: Implications for patient-centred care team effectiveness. Journal 

of Healthcare Management, 44, 252-268. 

Dreachslin, J.L., Hunt, P.L. & Sprainer, E. (1999b). Key indicators of nursing team 

performance: Insights from the front line. The Health Care Supervisor, 17, 70-76. 

Drolen, C.S. (1990). Current community mental health center operations: 

Entrepreneurship or business as usual? Community Mental Health Journal, 26, 547- 

558. 

Drory, A. & Shamir, B. (1988). Effects of organizational and life variables on job 

satisfaction and burnout. Group and Organization Studies, 13 (4), 441-455. 

Eden, D. (1990). Pygmalion without interpersonal contrast effects: Whole groups gain 

from raising manager expectations. Journal of Applied Psychology, 75, 394-398. 

Eggert, G.M., Zimmer, J.G., Hall, W.J. & Friedman, B. (1991). Case management: 

A randomised controlled study comparing a neighbourhood team and a centralized 

individual model. Health Services Research, 26 (4), 471-507. 

Faulkner, A. (1997). Knowing our own minds: A survey of how people in emotional 

distress take control of their lives. London: Mental Health Foundation. 

Fay, N., Garrod, S., & Carletta, J. (2000). Group discussion as interactive dialogue or 

serial monologue: The influence of group size. Psychological Science, 11(6), 487- 

492. 

Field, R. & West, M.A. (1995). Teamwork in primary health care. Two Perspectives 

from practices. Journal of Interprofessional Care, 9, 2, 123-130. 

Freeman, M., Miller, C. & Ross, N. (2000). The impact of individual philosophies of 

teamwork on multi-professional practice and the implications for education. Journal of 

Interprofessional Care, 14 (3), 237-247.

Galbraith, J. R. (1993). The business unit of the future. In J. R. Galbraith, E.E. Lawler 

III & Associates (Eds), Organizing for the Future: The New Logic for Managing 

Complex Organizations. San Francisco: Jossey-Bass. 

Galbraith, J. R. (1994). Competing with Flexible Lateral Organisations (2nd edn). 

Reading, MA: Addison-Wesley. 

Galbraith, J.R., Lawler, E.E. III & Associates (1993). Organizing for the Future: The 

New Logic for Managing Complex Organizations. San Francisco: Jossey-Bass. 

George, J.M. (1989). Mood and absence. Journal of Applied Psychology, 74, 317- 

324. 

George, J.M. (1990). Personality, affect, and behavior in groups. Journal of Applied 


George, J.M. (1995). Leader positive mood and group performance: The case of 

customer service. Journal of Applied Social Psychology, 25, 778-794. 

George, J.M. (1996). Group affective tone. In M.A. West (Ed.), Handbook of Work 

Group Psychology (pp. 77-94). Chichester: Wiley. 

George, J.M. & Bettenhausen, K. (1990). Understanding pro-social behaviour, sales 

performance and turnover. A group-level analysis in a service context. Journal of 

Applied Psychology, 75, 698-709. 

Gladstein, D. (1984). Groups in context: A model of task group effectiveness. 

Administrative Science Quarterly, 29, 499-517. 

Goldberg, D.P. & Williams, P. (1991). A user's guide to the General Health 

Questionnaire. Windsor: NFER-Nelson. 

Goldberg. D.P. (1972). The detection of minor psychiatric illness by questionnaire. 

Oxford: Oxford University Press 

Goni. S. (1999). An analysis of the effectiveness of Spanish primary health care 

teams. Health Policy, 48, 107-117. 

Grusky, O. (1995). The organization and effectiveness of community mental health 

systems. Administration & Policy in Mental Health, 22, 361-388. 

Guzzo, R.A. (1996). Fundamental considerations and about work groups. In M.A. 

West (ed) Handbook of Work Group Psychology. Chichester: John Wiley. 

Guzzo, R. A. & Dickson, M. W. (1996). Teams in organisations: Recent research on 

performance and effectiveness. Annual Review of Psychology, 46, 307-338. 

Guzzo, R.A., Jette, R.D., & Katzell, R.A. (1985). The effects of psychologically based 

intervention programs on worker productivity: A meta-analysis. Personnel 


Guzzo, R. A. & Salas, E. (Eds) (1995). Team Effectiveness and Decision Making in 

Organisations. San Francisco: Jossey-Bass.

Guzzo, R.A. & Shea, G.P. (1992). Group performance and intergroup relations in 

organisations. In M. D. Dunnette and L. M. Hough (Eds), Handbook of Industrial and 

Organizational Psychology, (Vol 3, pp. 269-313). Palo Alto, CA: Consulting 

Psychologists Press. 

Hackman, J.R. (1987). The design of work teams. In J.W. Lorsch (ed) Handbook of 

Organisational Behaviour. Englewood Cliffs, NJ: Prentice-Hall. Pp 315 - 342. 

Hackman, J.R. (1990). (Ed), Groups That Work (and Those That Don't): Creating 

Conditions for Effective Teamwork. San Francisco: Jossey-Bass. 

Hackman, J.R., Brousseau, K.R. & Weiss, J.A. (1976). The interaction of task design 

and group performance strategies in determining group effectiveness. 

Organizational Behavior and Human Performance, 16, 350-365. 

Hackman, J.R. & Morris, C.G. (1975). Group task, group interaction process, and 

group performance effectiveness: A review and proposed integration. In L. Berkowitz 

(Ed.), Advances in Experimental Social Psychology, (Vol. 8). New York: Academic 

Press. 

Hannigan, B. (1999). Joint working in community mental health: prospects and 

challenges. Health and Social Care in the Community, 7, 25-31. 

Hardy, G. E., Shapiro, D.A., Hayes, C.E. & Rick, J.E. (1999). Validation of the 

General Health Questionnaire using a sample of employees from the health care 

services. Submitted. 

Haynes, C.E., Wall, T.D., Bolden, R.I. & Rick, J.E. (1998). Measures of perceived 

work characteristics for health service research: test of a measurement model and 

normative data. Submitted. 

Hedburgh, B.L.T., Nystrom, P.C. and Starbuck, W.H. (1976) Company on seesaws: 

prescriptions for a self designing organisation. Administrative Science Quarterley, 

21, 41 - 65. 

Hill, F. (1998). Trying to catch a cloud: organizational climate in the NHS. 

Unpublished PhD Thesis, Institute of Work Psychology, University of Sheffield. 

Hirokawa, R.Y. (1990). The role of communication in group decision-making efficacy: 

A task-contingency perspective. Small Group Research, 21, 190-204. 

Hoffman, L.R. & Maier, N.R.F. (1961). Sex differences, sex composition, and group 

problem-solving. Journal of Abnormal and Social Psychology, 63, 453-456. 

Hogg, M. & Abrams, D. (1988). Social Identifications: A Social Psychology of 

Intergroup Relations and Group Processes. London: Routledge. 

Hughes, S.L., Cummings, J., Weaver, F., Manheim, L., Brawn, B. & Conrad, K. 

(1992).

A randomised trial of the cost effectiveness of VA hospital-based home care for the 

terminally ill. Health Services Research, 26 (6), 801-817. 

Jackson, G., Gater, R., Goldberg, D., Tantam, D. Loftus, L. & Taylor, H. (1993). A 

new community mental health team based in primary care: A description of the 

service and its effect on service use in the first year. British Journal of Psychiatry, 

162, 375-384. 

Jackson, L.A., Sullivan, L.A. & Hodge, L.N. (1993). Stereotype effects on 

attributions, predictions and evaluations: No two social judgements are quite alike. 

Journal of Personality and Social Psychology, 65 (1), 69-84. 

Jackson, S.E. (1996). The consequences of diversity in multidisciplinary work teams. 

In 

M.A. West (Ed.), Handbook of Work Group Psychology, pp. 53-76, Chichester: Wiley. 

Jacobs, D. & Singell, L. (1993). Leadership and organizational performance: 

Isolating links between managers and collective success. Social Science Research, 

22, 165-189. 

Janis, I.L. (1982). Groupthink: A Study of Foreign Policy Decisions and Fiascos, 2nd 

ed. Boston: Houghton Mifflin. 

Jansson, A., Isacsson, A. & Lindhom, L.H. (1992). Organization of health care teams 

and the population’s contacts with primary care. Scandinavian Journal of Health 

Care, 10, 

257-265. 

Jervis, I.L. (1976). Perception and Misperception in International Politics. Princeton, 

NJ: Princeton University Press. 

Jones, R.V.H. (1992). Teamworking in primary care:how do we know about it? 

Journal of Interprofessional Care, Vol 6, p25-29. 

Juran, J.M. (1989). Juran on Leadership for Quality. New York: Free Press. 

Jussim, L. (1986). Self-fulfilling prophecies: A theoretical and integrative review. 

Psychological Review, 93 (1), 429-445. 

Jussim, L., Coleman, L.M. & Lerch (1987). The nature of stereotypes: A comparison 

and integration of three theories. Journal of Personality and Social Psychology, 52 

(3), 536-546. 

Kalleburg, A.L. & Moody, J.W. (1994). Human Resource Management and 

Organisational Performance. American Behaviourist Scientist, 37, 948 - 962. 

Kanter, R.M. (1983). The Change Masters: Corporate Entrepreneurs at work. 

New York: Simon & Schuster. 

Kiesler, S. & Sproull, L. (1982). Managerial responses to changing environments: 

perspectives in problem solving from social cognition. Administrative Science 

Quarterley, 27, 548 - 570. 

Kimble, C.E., Marsh, N.B. & Kiska, A.C. (1984). Sex, age and cultural differences in 

self-reported assertiveness. Psychological Reports, 55, 419-422.

King, N. (1990). Innovation at work: The research literature. In M. A. West & J. L. 

Farr (Eds), Innovation and Creativity at Work: Psychological and Organisational 

Strategies, pp. 15-59, Chichester: Wiley. 

King, N., Anderson, N.R. & West, M. (1991). Organizational innovation in the UK: A 

case study of perceptions and processes. Work and Stress, 5 (4), 331-339. 

King, R., Le Bas, J., & Spooner, D. (2000). The impact of caseload on the personal 

efficacy of mental health case managers. Psychiatric Services, 51, 364-368. 

Kinnunen, J. (1990). The importance of organizational culture on development 

activities in a primary health care organisation. International Journal of Health 

Planning and Management, 5, 65-71. 

Klimoski, R. & Mohammed, S. (1994). Team mental model: Construct or metaphor? 

Journal of Management, 20, 403-437. 

Komaki, J.L., Desselles, M.L. & Bowman, E.D. (1989). Definitely not a breeze: 

Extending an operant model of effective supervision to teams. Joumal of Applied 


Koshuta, M. & McCuddy, M.K. (1989). Improving productivity in the health care 

industry: 

An argument and supporting evidence from one hospital. The Health Care 

Supervisor. 

LaFrance, M. & Mayo, C. (1978). Moving Bodies: Nonverbal Communication in 

Social Relationships. Monterey, C.A.: Brooks/Cole. 

Landsberger, H.A. (1955). Interaction process analysis of the mediation of 

labormanagement disputes. Journal of Abnormal and Social Psychology, 51, 522- 

528. 

Latham, G.P., Erez, M. & Locke, E.A. (1988). Resolving scientific disputes by the 

joint design of crucial experiments by the antagonists: Application to the Erez Latham 

dispute regarding participation in goal setting. Journal of Applied Psychology, 73 (4), 

753-772. 

Lawler, E.E. & Hackman, J.R. (1969). Impact of employee participation in 

development of pay incentive plans: A field experiment. Journal of Applied 


Lawrence, P.R. & Lorsch, J. (1967). Organization and Environment. Cambridge, 

NIA:Harvard University Press. 

Macy, B.A. & lzumi, H. (1993). Organizational change, design and work innovation: 

A meta-analysis of 131 North American field studies-1961-1991. Research in 

Organizational Change and Design (Vol. 7). Greenwich, CT: JAI Press. 

Maier, N.R.F. (1963). Problem-solving Discussions and Conferences: Leadership 

Methods and Skills. New York: McGraw-Hill. 

Maier, N.R.F. (1970). Problem Solving and Creativity in Individuals and Groups. 

Monterey, CA: Brooks/Cole.

Maier, N.R.F. & Solem, A.R. (1962). Improving solutions by turning choice situations 

into problems. Personnel Psychology, 15, 151-157. 

Main, J. (1989). At last, software CE0s can use. Fortune, 13 March, 77 - 83. 

Markiewicz, L. & West, M.A. (1996). Team-based Organisation. Aberdeen: 

Grampian/ECITB. 

Markiewicz, L. & West, M.A. (1996). Team-based Organisation. Aberdeen: 

Grampian/ECITB. 

Mathison, D.L. & Tucker, R.K. (1982). Sex differences in assertive behaviour: 

A research extension. Psychological Reports, 51(3), 943-948. 

Maxwell, R.J. (1992). Dimensions of quality revisited: from thought to action. Quality 

Health Care 1, 171-177. 

Maznevski, M.L. (1994). Understanding our differences: Performance in decision 

making groups with diverse members. Human Relations, 47 (5), 531-552. 

McClure, L.M. (1984) Teamwork, myth or reality: community nurses effectiveness 

with general practice attachment. Journal of Epidemiology and Community Health, 21 

(1), 

68 - 74. 

McGrath, J.E. (1984). Groups: Interaction and Performance. Englewood Cliffs, NJ: 

Prentice-Hall. 

Miceli, M.P. & Near, J.P. (1985). Characteristics of organisational climate and 

perceived wrong-doing associated with whistle-blowing decisions. Personnel 

Psychology, 38, 

525-544. 

Milliken, F.J. & Martins, L.L. (1996). Searching for common threads: Understanding 

the multiple effects of diversity in organizational groups. Academy of Management 

Review, 21(2), 402-433. 

Mistral, W., & Velleman, R. (1997). Community mental health teams: The 

professionals' choice? Journal of Mental Health, 6, 125-140. 

Mitrot, I.I. & Featheringham, T.R. (1974) On systematic problem solving and the error 

of the third kind. Behavioural Science, 19, 383 - 393. 

Mohman, S.A., Cohen, S.G. & Mohrman, A.M., Sr (1995). Designing Team-Based 

Organizations. San Francisco: Jossey-Bass. 

Mullarkey, S., Wall, T.D., Warr, P.B., Clegg, C.S. & Stride, C. (1999). Measures of 

job satisfaction, mental health and job-related well-being: A bench-marking manual. 

Sheffield, England: Sheffield Academic Press Ltd. 

Mumford, M.D. & Gustafson, S.B. (1988). Creativity syndrome: Integration, 

application and innovation. Psychological Bulletin, 103, 27-43.

Myer, C. (1993). How to Align Purpose, Strategy and Structure for Speed. New 

York: Free Press. 

Naylor, J.C., Pritchard, R.D., & Ilgen, D.R. (1980). A theory of behaviour in 

organisations. New York:Academic Press. 

Netten, A. & Dennett, J. (1997). Unit lists of health and social care. London: PSSRU. 

Nievaard, A.C. (1987). Communication climate and patient care: Causes and effects 

of nurses’ attitudes to patients. Social Science and Medicine, 24 (9), 777-784. 

Onyett, S. (1995). Responsibility and accountability in community mental health 

teams. Psychiatric Bulletin, 19, 281-285. 

Onyett, S. (1997). The challenge of managing community mental health teams. 

Health and Social Care in the Community, 5, 40-47. 

Onyett, S., Pillinger, T. & Muijen, M. (1995). Making community mental health teams 

work. London: Sainsbury Centre for Mental Health. 

Pearce, J.A. & Ravlin, E.C. (1987). The design and activation of self-regulating work 

groups. Human Relations, 40, 751-782. 

Peck, E., & Norman, I.J. (1999). Working together in adult community mental health 

services: Exploring inter-professional role relations. Journal of Mental Health, 8, 

231-243. 

Peck, E., & Parker, E. (1998). Mental health in the NHS: Policy and practice 1979-98. 

Journal of Mental Health, 7, 241-259. 

Peiro, J.M., Gonzalez-Roma, V., & Romos, J. (1992) The infleince of work team 

climate on role stress, tension, satisfaction and leadership perceptions. European 

Review of Applied Psychology, 42 (1) 49-46. 

Pincus, H.A., Zarin, D.A. & West, J.C. (1996). Peering into the 'black box': measuring 

outcomes of managed care. Archives of General Psychiatry, 53, 870-877. 

Podsakolf, P.M. & Todor, W.D. (1985). Relationships between leader reward and 

punishment behavior and group processes and productivity. Journal of Management, 

11, 55-73. 

Porac, J. F. & Howard, H. (1990). Taxonomic mental models in competitor definition. 

Academy of Management Review, 2, 224-240. 

Poulton, B. C. & West, M. A. (1993). Effective multidisciplinary teamwork in primary 

health care. Journal of Advanced Nursing, 18, 918-925. 

Poulton, B. C. & West, M. A. (1994). Primary health care team effectiveness: 

Developing a constituency approach. Health and Social Care, 2, 77-84. 

Poulton, B.C. & West, M.A. (1997). A failure of function: teamwork in primary health 

care. Journal of Interprofessional Care, 11, No 2, 1997.

Pritchard, R. D., Jones, S. D., Roth, P. L., Stuebing, K. K. & Ekeberg, S. E. (1988). 

Effects of group feedback, goal setting, and incentives on organizational productivity. 

Journal of Applied Psychology, 73, 337-358. 

Pritchard, R.D. (ed) (1995) Productivity Measurement and Improvement: 

Organisational Case Studies. New York: Praeger. 

Pritchard, R.D., Jones, S.D., Roth, P., Stuebing, K.K., & Ekeberg, S.E. (1989). The 

evaluation of an integrated approach to measuring organisational productivity. 

Personnel Psychology, 42 (1) 69-115. 

Pritchard, R.D. (Ed) (1995). Productivity Measurement and Improvement: 

Organisational Care Studies: New York: Praeger. 

Pritchard, R.D., Jones, S.D., Roth, P.L., Stuebing, K.K. & Ekeberg, S.E. (1988). The 

effects of feedback, goal setting, and incentives on organisational productivity. 

Journal of Applied Psychology Monograph Series, 73 (2), 337-358. 

Prosser, D., Johnson, S., Kuipers, E., Szmukler, G., Bebbington, P., & Thornicroft, G. 

(1996). Mental Health, 'Burnout' and job satisfaction among hospital and communitybased 

mental health staff. British Journal of Psychiatry, 169, 334-337. 

Quinn, R.E. & Rohrbaugh, J. (1983). Predicting sales success through handwriting 

analysis: an evaluation of the effects of training and handwriting sample content. 

Journal of Applied Psychology 68 (2), 212 - 17. 

Redmond, M.V. (1989). The functions of empathy (decentering) in human relations. 

Human Relations, 42, 593-605. 

Redmond. M.V. (1992). A multi-dimensional theory and measure of decentering. 

Unpublished manuscript. 

Reed J. (1995). Leadership in the mental health service: What role for doctors? 

Psychiatric Bulletin, 19, 67-72. 

Rees, A., Stride, C.B., Shapiro, D.A., Richards, A. and Borrill, C.S. (in press). 

Psychometric properties of the Community Health Team Questionnaire. (CMHTEQ) 

Journal of Mental Health. 

Richards, A. & Rees, A. (1998) Developing Criteria to measure the effectiveness of 

community mental health teams. Mental Health Care, 2, 14 - 17. 

Roberts, J.M. (1995) The History of the World. Hammondsworth, Middlesex: 

Penguin. 

Ross, F., Rink, E. & Furne, A. (2000). Integration or pragmatic coalition? An 

evaluation of nursing teams in primary care. Journal of Interprofessional Care, 14 (3), 

259-267. 

Rousseau, D.M. (1985) Issues of level in organisational research: multi-level and 

cross-level perspectives. Research in Organisational Behaviour, 7, 1 - 37. 

Sainsbury Centre for Mental Health (1997). Pulling together: The future roles and 

training of mental health staff. London: Sainsbury Centre for Mental Health.

Schober, M.F., & Clark, H.H. (1989). Understanding by addressees and overhearers. 

Cognitive Psychology, 21, 211-232. 

Schwenk, C.R. (1988). The Essence of Strategic Decision-making. Cambridge, NIA: 

Heath. 

Senge, P. (1990). The Fifth Discipline: The Art and Practice of the Learning 

Organization. New York: Doubleday Currency. 

Shaw, M.E. (1976). Group Dynamics: The Psychology of Small Group Behavior. New 

York: McGraw-Hill. 

Shaw, M.E. (1981). Group Dynamics: The Psychology of Small Group Behavior. 

New York: McGraw-Hill. 

Sluyter, G.V. (1995). Mental health leadership training: A survey of state directors. 

Journal of Mental Health Administration, 22, 201-204. 

Smircich, L. (1983). Organization as shared meaning. In L.R. Pondy, P. Frost, G. 

Morgan & T. Dandridge (Eds), Organizational Symbolism (pp. 55-65). Greenwich, 

CT: JAI Press. 

Smith, K.G., Locke, E.A. & Barry, D. (1990). Goal setting, planning and 

organizational performance: An experimental simulation. Organizational Behavior 

and Human Decision Processes, 46, 118-134. 

Sommers, L.S., Marton, K.I., Barbaccia, J.C. & Randolph, J. (2000). Physician, nurse 

and social worker collaboration in primary care for chronically ill seniors, Archives of 

Internal Medicine, 160, 1825-1833. 

Stein, M. (1996). Unconscious phenomena in work groups. In M.A. West (Ed.), 

Handbook of Work Group Psychology, pp. 143-157 Chichester: Wiley. 

Stemberg, R.J. & Lubart, T.I. (1990) Defying the Crowd. Cultivating Creativity in a 

Culture of Conformity. New York: Free Press. 

Stevens, M.J., & Campion, M.A. (1994). The knowledge, skill and ability 

requirements for teamwork: Implications for human resource management. Journal of 

Management, 20, 

503-530. 

Stevens, M.J. & Campion, M.A. (1999). Staffing Work Teams: Development and 

Validation of a Selection Test for Teamwork Settings. Journal of Management, 25, 

No 2 207 - 228. 

Sundstrom, E., De Meuse, K.P. & Futrell, D. (1990). Work teams: Applications and 

effectiveness. American Psychologist, 45, 120-133. 

Tajfel, H. (1978). Differentiation Between Social Groups: Studies in the Social 

Psychology of Intergroup Relations (European Monographs in Social Psychology, 

No. 14). London:Academic Press. 

Tajfel, H. & Turner, J.C. (1979). An integrative theory of intergroup conflict. 

In W. G. Austin and S. Worchel (Eds), The Social Psychology of Intergroup 

Relations. Monterey, CA: Brooks/Cole.

Tannenbaum, S.I., Beard, R.L. & Salas, E. (1992). Team building and its influence 

on team effectiveness: An examination of conceptual and empirical developments. 

In K. Kelley (Ed.), Issues, Theory and Research in Industrial/Organizational 

Psychology (pp. 117-153), London: North Holland. 

Tannenbaum, S.I., Salas, E. & Cannon-Bowers, J.A. (1996). Promoting team 

effectiveness. In M.A. West (Ed.), Handbook of Work Group Psychology, (pp 503- 

529) 

Chichester: Wiley. 

Taylor, M.F. (Ed), with Brice, J., Buck, N. & Prentice, E. (1995). British Household 

Panel Survey User Manual. Colchester: University of Essex. 

Tjosvold, D. (1982). Effects of approach to controversy on superiors' incorporation of 

subordinates' information in decision making. Joumal of Applied Psychology, 67, 

189-193. 

Tjosvold, D. (1985). Implications of controversy research for management. Journal 

of Management, 11, 21-37. 

Tjosvold, D. (1991). Team Organisation: An Enduring Competitive Advantage. 

Chichester: Wiley. 

Tjosvold, D. & Field, R.H.G. (1983). Effects of social context on consensus and 

majority vote decision making. Academy of Management Journal, 26, 500-506. 

Tjosvold, D. & Johnson, D.W. (1977). The effects of controversy on cognitive 

perspective-taking. Journal of Educational Psychology, 69, 679-685. 

Tjosvold, D., Wedley, W.C. & Field, R.H.G. (1986). Constructive controversy, the 

Vroom-Yetton model, and managerial decision making. Journal of Occupational 

Behavior, 7, 

121 -138. 

Toon, P.D. (1994) What is Good General Practice? A Philosophical Study of the 

Concept of High Quality Medical Care. 

Tziner, A.E. (1988) Effects of team composition on ranked team effectiveness. Small 

Group Behaviour, 19, 363 - 378. 

Vroom, V.H. (1964). Work and Motivation. New York: Wiley. 

Wall, T.D. & Lischeron, J.H. (1977). Worker Participation: A Critique of the Literature 

and some Fresh Evidence. Maidenhead, UK: McGraw-Hill. 

Walsh, J.P. & Fahey, L. (1986). The role of negotiated belief structures in strategy 

making. Journal of Management, 12, 325-338. 

Walsh, J.P., Henderson, C.M. & Deighton, J. (1988). Negotiated belief structures 

and decision performance: An empirical investigation. Organizational Behavior and 

Human Decision Processes, 42, 194-216. 

Watson, W.E., Kumar, K. & Michaelsen, L.K. (1993). Cultural diversity's impact on 

interaction process and performance: Comparing homogeneous and diverse task

groups. Academy of Management Journal, 36, 590-602. 

Weldon, E. & Weingart, L.R. (1993). Group goals and group performance. British 

Journal of Social Psychology, 32, 307-334. 

West, M.A. (1990). The social psychology of innovation in groups. In M.A. West & 

J.L. Farr (Eds), Innovation and Creativity at Work (pp. 309-333). Chichester: Wiley. 

West, M.A. (1994). Effective Teamwork. Leicester: British Psychological Society. 

West, M.A. (1996a). The Handbook of Work Group Psychology. Chichester: Wiley. 

West, M.A. (1996b). Reflexivity and Work Group Effectiveness: A conceptual 

Integration 

in M.A. West (Ed) Handbook of Work Group Psychology (555 - 580), John Wiley & 

Sons Ltd. 

West, M.A. (1997). Developing Creativity in Organisations. Chichester: Wiley. 

West, M.A. (2000). State of the art: Creativity and Innovation at work. Psychologist, 

13, 9 460 - 464. 

West, M.A. & Anderson, N.R. (1996). Innovation in top management teams. Journal 

of Applied Psychology, 81(6), 680-693. 

West, M.A., Borrill, C.S. and Stride, C.B. (1998). Strain as a moderator of the 

relationship between work characteristics and work attitudes. Journal of Occupational 

Health. Vol 4, 

No 1, 3 - 14. 

West, M.A., Borrill, C.S. & Unsworth, K. (1998). Team Effectiveness in Organisations. 

In C.L. Cooper & I.T. Robertson (eds) International Review of Industrial 

Organisational Psychology. Vol 13. Wiley & Sons: Chichester. 

West, M.A. & Field, R. (1995). Teamwork in primary health care. Perspectives from 

organisational psychology. Journal of Interprofessional Care, 9, 2, 117-122. 

West, M.A., & Poulton, B.C. (1995). Primary health care teams: Rhetoric versus 

reality. Paper submitted for publication. Institute of Work Psychology, University of 

Sheffield. 

West, M.A. & Slater,J.A. (1996). The Effectiveness of Team Working in Primary 

Health Care. London:Health Education Authority. 

West, M.A. & Wallace, M. (1991). Innovation in health care teams. European Journal 

of Social Psychology. Vol 21, 303 – 315. 

West, M.A. & Pillinger, T. (1995). Innovation in UK manufacturing (Research report). 

Institute of Work Psychology, University of Sheffield. 

Wood, N., Farrow, S., & Elliott, B. (1994). A review of primary health care 

organisation. 

Journal of Clinical Nursing, 3(4), 243-250.

Worchell, S., Wood, W. & Simpson, J.A. (eds) (1992). Group Processes and 

Productivity. Newbury Park, CA: Sage. 

Yeatts, D.E. & Seward, R.R. (2000). Reducing turnover and improving health care in 

nursing homes: The potential effects of self-managed work teams. The Gerontologist, 

40 (3), 

358-363. 

Zimmer, J.G., Eggert, G.M. & Chiverton, P. (1990). Individual versus team case 

management in optimising care for chronically ill patients with dementia. Journal of 

Aging and Health, 2 (3), 357-372.

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