FROM THE THIRD GENEVA CONFERENCE ON PERSON-CENTERED MEDICINE: THE TEAM APPROACH IN PERSON-CENTERED HEALTH CARE
The Team Approach in Person-centred Health Care: The Social Work Perspective
Terry Bamford OBE MA(Oxon) Dip(Soc Admin) FRSA
International Federation of Social Workers; Former Chairman, British Association of Social Workers, London, UK.
Social workers bring to the multidisciplinary team skills in direct relationship work, experience of group work and an awareness of wider social factors affecting the patient. They have a particular role in working with relatives and carers to establish a network of support which is critical after discharge from hospital. If the traditional ambivalence of social work towards medicine and the medical model can be overcome social workers can improve the overall effectiveness of team functioning.
Teamwork, Equality, Participation, Empowerment, Authority, Leadership, Recovery, Relationship, Social Work
Terry Bamford, Flat 2, 19 Inverness Terrace, London W2 UK. E-mail: firstname.lastname@example.org
Accepted for publication: 19 January 2011
‘No man is an island’ wrote John Donne in 1624. Today we all claim to be team players and recognize that what we are able to achieve depends on the contribution of many others.
The nature of the interaction of clinicians and social workers with their patient or client will in large measure be shaped by the contribution of others. A friendly welcome from the receptionist, comfortable chairs, and something to read while waiting to see the doctor or social worker set the tone for the consultation. They also enhance the prospects of a useful interview and mutual understanding. At the other extreme the theatre porter, nursing staff and anaesthetists are essential components of the multi disciplinary team in surgery.
Social work operates at the boundary between the individual and their environment. It tries to reduce the pressures caused by poverty, poor housing and fractured relationships and the impact which these have on health outcomes. Social workers have to work through others to achieve positive outcomes for those with whom they are working.
Modern medicine places the patient at the heart of the process. There has been a transformation in the nature of the doctor-patient relationship. The NHS Alliance affirmed “The relationship between GPs and patients should be an equal one, to empower the patient to be ‘fully engaged’ (in the Wanless Report’s terminology) in caring for their own health as much as they can” . This welcome endorsement of patient participation has been reflected in increasing openness in the communication between clinicians and patients.
The rapid development of the internet has been a major driver of change with a proliferation of web sites enabling patients to research their own condition, to establish mutual support networks and sometimes to challenge clinicians with details of new clinical trials of which the doctor may be unaware. The power balance is shifting and in a way which is not always comfortable as knowledge ceases to be the exclusive prerogative of the professional.
But welcoming increasing self-management of long-term conditions and greater patient participation is not enough. Equality between doctor and patient means that it is important unequivocally to accept the patient as a full member of the multi disciplinary team. If we practice person-centred care then by definition the patient is the core member of the team and should be involved in all decisions about treatment.
Of course not all team members have equal status. As Napoleon said in Animal Farm ‘all pigs are equal, but some are more equal than others’ . Status comes from experience, age and professional discipline. Historically medicine has been viewed as the leading profession within the team with others in a subordinate role. That view is still widely held. Tuso in an American context asserted “the future success of our physicians, as leaders of their teams, will depend on how well we identify and train physicians in the art of leadership. Our growth and success will depend on strong leadership developing a culture of strong leadership. The physician as leader carries responsibility” . Person-centred medicine stands this on its head by asserting that the person with most authority in the team is the patient.
There is a distinction between leadership and authority. Decisions about care and treatment should not be taken without the agreement of the patient. This is not to pretend that patients have the same knowledge and experience of other professionals in the team, nor the same understanding of risks and consequences. But the responsibility of other team members is to ensure that their understanding is fully shared with the patient so that an informed decision can be made about management and treatment of the condition.
Social work values are wholly congruent with this approach. They emphasise both self-determination and participation.
“1. Respecting the right to self-determination - Social workers should respect and promote people’s right to make their own choices and decisions, irrespective of their values and life choices, provided this does not threaten the rights and legitimate interests of others.
2. Promoting the right to participation - Social workers should promote the full involvement and participation of people using their services in ways that enable them to be empowered in all aspects of decisions and actions affecting their lives” .
So what does this mean for the role of social workers in multi disciplinary teams?. Social workers have a crucial role in the team in ensuring that the views of the patient are heard at every stage of the process. How they do this will vary from team to team. Sometimes no more may be required than gentle encouragement to the team to involve the patient. At other times where patients lack mental capacity or are unable clearly to articulate their views they may be acting more in the role of advocate for the patient seeking to act in their best interests .
Often it is in arrangements for discharge from hospital that social workers will become involved. This is where their knowledge of social welfare benefits, accommodation and employment comes into play. Adequately heated and clean accommodation suitable for the needs of the discharged patient is essential if discharge is not to be swiftly followed by readmission. Arrangements need to be made with the employer or in the absence of work with social security to ensure an adequate income. Carers whether through the family or the social network need to be mobilized and supported with a clear understanding of their role and where they in turn can seek support and assistance.
Relatives and carers have a crucial role. While they are not directly involved as part of the team they have equally to be involved and informed about the treatment plan, its risks and its consequences. The relatives and friendship network can be viewed as an outer circle of support helping the team achieve successful outcomes. By virtue of their links with the family and carer network social workers will be particularly active in helping them to understand and deal with the fear and anxiety which surrounds any medical intervention.
Some diseases carry particular fears for both patients and their carers. Cancer has a special resonance with its associations of death, physical decay and pain. Social workers are used to helping people face up to often painful realities. They do so fortified by the practice knowledge that acknowledging a problem is the key to being able to deal with it making the problem more manageable. Social workers have to work with the psychological impact of life-threatening conditions and can help the patient to address their fears.
In terms of physical recovery after surgery or illness these social factors are well recognized. They are however even more true for mental well being where the individual needs sensitive help to build upon strengths and develop resilience. Again this is where social work has a distinctive contribution. Social workers mediate between potential stresses in the environment and the patient to ensure that difficulties are minimized and strengths are built upon and reinforced.
Mental health recovery is not a clinical absence of symptoms. A broader conceptualization is needed. The recovery model has been widely adopted. Within this approach recovery is viewed as a personal journey. Hope, a sense of self-worth, supportive relationships, empowerment, social inclusion, coping skills, and finding meaning in life are the component elements. In a joint statement the Royal College of Psychiatrists, Social Care institute for Excellence and Care Services Improvement Partnership offered this definition  “Recovery is the process of regaining active control over one’s life, accepting and coping with the reality of any ongoing distress or disability , resolving personal, social or relationship issues that may contribute to one’s mental health difficulties, taking on satisfying and meaningful social roles, and calling on formal and/or informal systems of support as needed .
These areas are the territory in which social workers operate.
Social workers have expertise in working with relationships. This is both the personal relationship with their clients but also helping their clients with their own troubled and difficult relationships. They have experience of working with users and carers to strengthen support mechanisms.
This expertise in direct relationship work with the patient is a key skill which social workers bring to the multidisciplinary team. They will often be the only professional in the team with explicit training in group work and can use that knowledge to help the team address conflicts and difficulties.
The pre-conditions for effective teamwork are well recognised. These are:
· Clear shared aims and goals
· Focus on results
· Competent team members
· Unified commitment
· Collaborative climate and mutual respect
· High standards and clear expectations
· External support and encouragement
· Principled leadership 
Clarity about the aims of the team is essential. But too often these are implicit. As Sir Kenneth Calman wrote about aims “they need to be hammered out, discussed, debated and by joint agreement put into practice”.
Mutual respect cannot always be assumed. Historical professional rivalries or personal conflicts can destabilize a team. High functioning teams need a mechanism for resolving differences. Team members bring different skills but they should be valued equally. While respecting the individual skills of the disciplines represented in the team, the best teams have a flexibility which allows some blurring of boundaries. Teams supporting people with mental health problems are a good example where the psychologist, nurse, social worker or psychiatrist may at times have interchangeable roles.
Information is power but that is true only if information is freely shared within the team. Good teams pay attention to their internal communication mechanisms. That does not just mean the distribution of information but also the opportunities to reflect and discuss the significance of the information. In a health care setting confidentiality and how it is handled can be a source of tension. Clarity is needed about who are the team members, what stays within the team and what can be shared outside.
All team members have a shared responsibility to promote open communication
Teamwork does not come naturally. It has to be worked at and constantly reinforced. Social work can help the team work to the benefit of the patient. There are three key roles; as an advocate for the patient, as an interpreter of the patient’s views to the team and of the team’s views to the patient, and in using negotiating skills to help the team communicate effectively.
Social work’s relationship with medicine has been characterized by ambivalence. The clinical model of diagnosis-prescription-treatment-recovery does not accord with the experience of social workers who tend to take something closer to a public health model looking at the wider determinants of health- poverty, bad housing, poor nutrition, and unemployment- as contributing to poor health outcomes. That perspective can assist the multidisciplinary team in taking a wider view.
Teamwork is not easy. Sharing decision making with patients is not easy. But a team working effectively can bring real gains for the patient both in terms of outcome and the positive effect of being taken seriously as a co-producer in the health care enterprise.
 NHS Alliance press release 2/6/09 at launch of Patient Participation Group programme.
 Orwell, G., (1945). Animal Farm Secker and Warburg, London.
 Tuso, P., (2003). The Physician as Leader, Geriatrics Winter Permanente Journal 7, 1.
 International Federation of Social Workers and International Association of Schools of Social Work, Ethics in Social Work, Statement of Principles.
 Mental Capacity Act 2005, Deprivation of Liberty Safeguards.
 A Common Purpose, Recovery in future mental health services (2007) Care Services Improvement Partnership (CSIP), Royal College of Psychiatrists (RCPsych), Social Care Institute for Excellence.
 Faulkner, A. and Layzell, S. (2000) Strategies for living: A report of user-led research into people’s strategies for living with mental distress, London: Mental Health Foundation.
 Leibrich, J. (1999) A gift of stories: Discovering how to deal with mental illness, New Zealand: University of Otago Press.
 Larson, C. and LaFasto, F. (1989) Teamwork: what must go right/what can go wrong, Newberry Park, Sage Publications.
 Calman, Sir K., (1994). Working together, teamwork, Journal of Interprofessional Care 8, 95–9.