The last few years, and particularly since the introduction of the Assisted Roles Reimbursement Scheme (ARRS) general practices have seen a huge growth in the number of allied health professionals (AHPs) working as part of their teams. From paramedics to podiatrists, occupational therapists to physiotherapists, pharmacists and dieticians, the multi-professional team is very much the present and future model of general practice.

With this development, employees as well as employers and patients are all getting used to new ways of working. The typical nature of a diverse general practice team is that AHPs are often one of only a few of their profession (sometimes the only one) in the practice or PCN and we know from research as well as experience this can feel isolating. New systems are having to be developed to support AHPs, supervision and mentoring is also having to adapt to embrace these varied roles. Add in to this that many AHPs are forging new roles often at an enhanced or advanced level, often undertaking additional study or qualification and it is easy to see the pressure that can feel overwhelming.

Paramedics

The Ambulance Staff Charity – TASC’s services | The Ambulance Staff Charity (theasc.org.uk) – financial/well-being

College of Paramedics – Paramedic Mental Health and Wellbeing (collegeofparamedics.co.uk) – well-being

Physiotherapists

The Physiotherapy Benevolent Fund (thepbf.org.uk)  – financial

Pharmacists

About – PBF | Pharmacy Benevolent Fund – financial
Homepage – Pharmacist Support – well-being

Occupational Therapists

Our hardship fund is here to support you – RCOT – financial

Podiatrists

The Royal College of Podiatry (rcpod.org.uk)  – financial

Health and Care Professions Council (all registered professions)

How we can support you | (hcpc-uk.org) – support during fitness to practice

Your health and wellbeing | (hcpc-uk.org) – well-being

Developing resilience | (hcpc-uk.org) – well-being

• Create opportunities for the team to come together to share and learn experiences that bring them closer to their goals
• Remember to analyse any issues from a system perspective rather than blaming individuals for things that haven’t gone quite according to plan
• Encourage open and equal contribution

• Understand that the organisation is a system, not simply a collection of individuals. This means understanding how all the working parts fit together and reviewing and enabling the system as a whole. This can be difficult where there has traditionally been a prevalent hierarchical or blame culture but careful evaluation of the conditions that individuals exist under, together with processes that make it easy for them to do the right thing and difficult to do the wrong thing ,can be helpful
• Build psychological safety within the team. Psychological safety exists when nothing you say or do will be used against you as long as you mean well. Essentially it is a trust that exists between all members of a team that promotes their ability to grow and become their best selves. Remember that achieving safety is not always comfortable, but magic doesn’t happen in the comfort zone. We have to stretch ourselves in order to progress, otherwise we stay as we are. But this has to happen in a positive context, without any evidence of malevolence.

Safety is not the same as comfort

Whether you’re talking about the gym or a team environment, the following hold true:

To build psychological safety the required behaviours need to be encouraged within the whole team, not just in a top-down fashion. Encourage feedback, be authentic, look for learning opportunities, questions, non-judgemental sharing of struggles and mistakes. Don’t ignore anyone, take things personally, punish suggestions that don’t work, dismiss any contributions, or get agitated.

Remember that everyone is approaching their life with a positive intent – always actively look for it.

• Arrange an opportunity to agree a shared purpose across the whole team. When we talk about a shared purpose we do not mean a shared sense of what we do, or why we do it, but of why it’s important to us collectively (watch Simon Sinek ‘Start with Why’)
• Help people think beyond their immediate actions towards that greater purpose
• Understand the problems you are trying to solve, then build a clear picture of what good looks like
• Encourage open discussion – to explore all alternative solutions to any issue, to honestly appraise the pros, cons and trade-offs required for any particular course of action chosen
• Be prepared to keep revisiting and re-articulating both vision and goals to ensure clarity of understanding and commitment across the whole team (particularly important when new team members join)

A positive culture is one in which the environment is collaboratively crafted and nurtured to enable all members to flourish. Unfortunately, more often than not, culture in general practice is aligned with hierarchical structures which does not enable positivity.

The good news is that, with sufficient will, organisations can create a different way of being, a new sense of ‘how things get done around here’. It’s not easy or quick, and requires all members to be involved, but it is definitely possible and ultimately worthwhile because culture eats pretty much everything else for breakfast. It trumps all.

Organisational culture eats strategy for breakfast, lunch & dinner

Real teams with a positive, progressive, learning culture all share the same characteristics:

• They have clear shared objectives
• They have an ability to work interdependently
• They create regular opportunities to meet and regularly review and improve performance

The benefits of this are that both colleague and client satisfaction levels rise, with greater colleague engagement leading to lower levels of errors, stress, injury, sickness absence, intention to quit and turnover. Plus, we see a reduction in bullying and harassment from both colleagues and clients.

The culture of a team is everyone’s responsibility. It cannot be imposed; it needs to be agreed and nurtured by all team members.

Ask each of your team members to consider where they think the team is with regard to each of the following areas:

• ROBUST – solid intention with agility: we know and share our purpose, we have clear goals that align with this and are proactive when obstacles arise
• RESOURCEFUL – optimising resources and processes: we use our individual team member’s strengths and resources to build a culture of continuous improvement
• PERSEVERANCE – persisting despite setbacks: we regroup when setbacks occur and generate solutions. Everyone contributes to the energy required
• SELF-CARE – ensuring sustainable performance: we each take personal accountability for our self-care. We support each other fully in a pre-agreed fashion
• CAPABILITY – delivering in a changing landscape: we seek regular feedback from each other (e.g. by mentoring or peer review) and build on what’s working well
• CONNECTED – having a sense of belonging: we care about each other and each have a sense that we are valued as a person. We co-operate with and support one another
• ALIGNMENT – sharing motivation for success: we maintain good levels of energy and persevere towards our goals. We notice and acknowledge progress and celebrate success

You can download the Team Resilience Worksheet to do this.

If they record their rating on a scale of 1 to 10 (where 0 is agree completely and 10 is disagree completely), you can record a collective rating on this spider diagram for the team’s current position. You can also agree with the team a preferred rating on each axis.

By doing this you can start to see where the team might need the most support and develop a strategy to deliver improvements. This may include some ideas from the section on Culture Setting.

The point about this two-part questionnaire is to supply you with the means to take both a subjective and a more objective look at your relationship with time. Once the two parts are completed, it’s useful to compare them and to talk over noticeable differences with someone helpful that you know or maybe even a paid professional.

Part 1 you fill in yourself.
Download the GP Time Questionnaire – Part 1

Part 2 should be filled in by someone who knows you well.
Download the GP Time Questionnaire – Part 2

PART 1. To be filled in by you

1. General approaches to time

   • I am generally very laid back
   • I sometimes feel the need to hurry
   • I frequently feel the need to hurry
   • I often feel rushed / under pressure of time

2. Punctuality for things – appointments etc

   • I am often late for things
   • I am sometimes late for things
   • I am generally on time for things
   • I am invariably punctual unless there’s a good reason

3. Others’ use of time

   • I am not generally bothered when people are late
   • I am occasionally irritated when people are late
   • I am usually irritated when people are late
   • I get very stressed when people are late

4. Capacity for speed at work.

   • I could easily speed up what I do
   • I might be able to speed up what I do
   • I have little capacity to speed up what I do
   • I am working flat out and cannot go any faster

5. Prioritisation

   • I find it very hard to rank tasks in order of urgency
   • I am only fair at ranking tasks in order of urgency
   • I am quite good at ranking tasks in order of urgency
   • I have no problems with ranking tasks in order of urgency

6. Memory under pressure

   • I usually forget things when I am under pressure
   • I sometimes forget things when I am under pressure
   • I rarely forget things when I am under pressure
   • I almost never forget things when I am under pressure

7. Setting boundaries

   • I find it impossible to say No when I am asked to do something
   • I have trouble saying No when I am asked to do something
   • I find it fairly easy to say No when I am asked to do something
   • I have no problem saying No when I am asked to do something

8. Addressing workload with colleagues

   • I find it impossible to approach my colleagues about my workload
   • I rarely discuss my workload with colleagues
   • I sometimes discuss my workload with colleagues
   • My colleagues and I frequently discuss workload issues

9. Setting boundaries with patients

   • I find it impossible to say ‘No’ to patients’ requests or demands
   • I can say ‘No’ to patients, but this is rare and I find it difficult.
   • I am reasonably good at saying ‘No’ to patients but find this uncomfortable
   • I have clear boundaries with my patients

PART 2. To be filled in by someone who knows you well

1. What is his/her general approach to time?

   • Generally very laid back
   • Sometimes feels the need to hurry
   • Frequently feels the need to hurry
   • Often seems rushed / under pressure of time

2. Punctuality for things – appointments etc

   • He/she is often late for things
   • He/she is occasionally late for things
   • He/she is generally on time for things
   • He/she is invariably punctual unless there’s a good reason

3. Others’ use of time.

   • He/she is not generally bothered when people are late
   • He/she is occasionally irritated when people are late
   • He/she is usually irritated when people are late
   • He/she gets very stressed when people are late

4. Capacity for speed at work.

   • He/she could easily speed up what they do
   • He/she might be able to speed up what they do
   • He/she has little capacity to speed up what they do
   • He/she is working flat out and cannot go any faster

5. Prioritisation

   • He/she finds it very hard to rank tasks in order of urgency
   • He/she is only fair at ranking tasks in order of urgency
   • He/she is quite good at ranking tasks in order of urgency
   • He/she has no problems with ranking tasks in order of urgency

6. Memory under pressure.

   • He/she usually forgets things when under pressure
   • He/she sometimes forgets things when under pressure
   • He/she rarely forgets things when under pressure
   • He/she almost never forgets things when under pressure

7. Setting boundaries.

   • He/she finds it impossible to say No when asked to do something
   • He/she has trouble saying No when asked to do something
   • He/she finds it fairly easy to say No when asked to do something
   • He/she has no problem saying No when asked to do something

What is it about the patient’s behaviour that you feel to be inappropriate? If your discomfort is around perceived unrealistic expectations by patients of you or the processes or services you provide, please see the ‘Managing expectations’ section.

When it appears that the patient wants to simply hand their problem to you, you are being drawn into a variant of the child-parent consultation model. It is important to always try and maintain an adult-adult interaction. As clinicians we need to help the patient understand that their health is our concern, but their task/responsibility. The aim should be for the patient to accept that their health is the result of their decisions and actions, and that the clinician is there to inform and support this process but not to take it over. Occasionally patients have a deeply ingrained external “locus of control” which can be difficult to change.

It is worth spending some time developing common boundaries for clinicians within the practice to observe in any consultation. What behaviour is appropriate, and what is not? Do we expect patients to call us by our professional names, and do we reciprocate by calling them Mr., Mrs., etc., or do we not? Do we agree that this is how we will all behave on all occasions, or are we willing to allow a degree of deviation? In order to be successful, the agreed ways of working should be observed and upheld, without deviation where possible. Patients are more likely to recognise boundaries if they are consistent across the organisation and, to this end, wider considerations for patient-staff interactions overall should also be set.

You might wish to consider the following:

• Practice Workload Philosophy