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Dear Editor
“Positive psychology” is useful in teams that have many routine tasks but there is a significant minority of conditions where the evidence base is limited, for which curiosity and candour - “active communication” - are essential for better practice. From this kind of teamwork, which is not always comfortable, comes new learning about each other’s perceptions and skills, for example in the care of adults who have both type 1 diabetes and an eating disorder, a high risk condition more effectively managed by one team. Some of these patients can have a powerful emotional impact on experienced clinicians, “provoking a reaction such as needing to rescue, or adversely to reject, the patient who fails to respond to treatment. These crucial unconscious communications from the patient can become enacted within the team, causing significant splits, or disagreements on management of the case, and in some cases a breakdown in the treatment” (1). Open exploration of these conflicts in regular facilitated case reviews strengthens the team's ability to work collaboratively with disturbance and complexity.
A second example is carefully planned case discussions in the management of Long Covid, where “teams made sense of, and planned for, each case through multidisciplinary dialogue. This dialogue typically began with one staff member presenting a detailed clinical history along with a narrative of how it had affected the patient’s life and what was at stake for them (e.g. job loss), after which professionals from various backgrounds (nursing, physical therapy, occupational therapy, psychology, dietetics, and different medical specialties) joined in a discussion about what to do” (2).
Though he does not specify the means required to achieve it, Ara Darzi’s timely report (3) repeatedly calls for better integration of care at the front line. “As the disease burden has shifted towards long-term conditions, multidisciplinary team working has become more important. Yet NHS structures have not kept pace” (32, p 47). He notes also that that "training in silos impairs teamwork which compromises patient safety. This is partly a result of divergent curricula for different staff groups that damage attitudes and a lack of focus on learning the skills for teamwork” (7b, p 40). These skills can only be learned through practical experience, enriching our capacity for real professional partnerships that benefit patients. There are trainings in team dynamics and leadership at the NHS and third sector Tavistock organisations (4, 5, 6), who have together developed group relations conferences and related consultancy courses over the past seven decades (7), but whose work is not cited in Darzi’s report.
(1) Ismail K, Turner T, Brown, J Rosenthal M, Ayis S, Oliver N, Liu Y-K, Harrison A, Garrett C, Hopkins D, Treasure J, Valabhji J, Thomas S, Stadler M. An integrated diabetes and mental health intervention for people with type 1 diabetes and severe disordered eating: a prospective proof-of-concept cohort study. The Lancet Diabetes & Endocrinology 2024: 12:7, 442 – 444, https://www.thelancet.com/journals/landia/article/PIIS2213-8587(24)00123-2/fulltext
Competing interests:
Is promoting the (neglected) work of my alma mater a conflict of interest? I have nothing financial to gain from my comments, but do hope that the Tavistock & Portman NHS Trust and the Tavistock Institute of Human Relations may gain wider recognition from them.
05 January 2025
Sebastian Kraemer
Honorary Consultant Child and Adolescent Psychiatrist
Conflict in multidisciplinary teams is sometimes needed for better outcomes
Dear Editor
“Positive psychology” is useful in teams that have many routine tasks but there is a significant minority of conditions where the evidence base is limited, for which curiosity and candour - “active communication” - are essential for better practice. From this kind of teamwork, which is not always comfortable, comes new learning about each other’s perceptions and skills, for example in the care of adults who have both type 1 diabetes and an eating disorder, a high risk condition more effectively managed by one team. Some of these patients can have a powerful emotional impact on experienced clinicians, “provoking a reaction such as needing to rescue, or adversely to reject, the patient who fails to respond to treatment. These crucial unconscious communications from the patient can become enacted within the team, causing significant splits, or disagreements on management of the case, and in some cases a breakdown in the treatment” (1). Open exploration of these conflicts in regular facilitated case reviews strengthens the team's ability to work collaboratively with disturbance and complexity.
A second example is carefully planned case discussions in the management of Long Covid, where “teams made sense of, and planned for, each case through multidisciplinary dialogue. This dialogue typically began with one staff member presenting a detailed clinical history along with a narrative of how it had affected the patient’s life and what was at stake for them (e.g. job loss), after which professionals from various backgrounds (nursing, physical therapy, occupational therapy, psychology, dietetics, and different medical specialties) joined in a discussion about what to do” (2).
Though he does not specify the means required to achieve it, Ara Darzi’s timely report (3) repeatedly calls for better integration of care at the front line. “As the disease burden has shifted towards long-term conditions, multidisciplinary team working has become more important. Yet NHS structures have not kept pace” (32, p 47). He notes also that that "training in silos impairs teamwork which compromises patient safety. This is partly a result of divergent curricula for different staff groups that damage attitudes and a lack of focus on learning the skills for teamwork” (7b, p 40). These skills can only be learned through practical experience, enriching our capacity for real professional partnerships that benefit patients. There are trainings in team dynamics and leadership at the NHS and third sector Tavistock organisations (4, 5, 6), who have together developed group relations conferences and related consultancy courses over the past seven decades (7), but whose work is not cited in Darzi’s report.
(1) Ismail K, Turner T, Brown, J Rosenthal M, Ayis S, Oliver N, Liu Y-K, Harrison A, Garrett C, Hopkins D, Treasure J, Valabhji J, Thomas S, Stadler M. An integrated diabetes and mental health intervention for people with type 1 diabetes and severe disordered eating: a prospective proof-of-concept cohort study. The Lancet Diabetes & Endocrinology 2024: 12:7, 442 – 444,
https://www.thelancet.com/journals/landia/article/PIIS2213-8587(24)00123-2/fulltext
(2) Greenhalgh T, Darbyshire JL, Lee C, Ladds E, Ceolta-Smith J. What is quality in long covid care? Lessons from a national quality improvement collaborative and multi-site ethnography BMC Medicine 2024:22:159 https://doi.org/10.1186/s12916-024-03371-6 https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-024-03371-6
(3) Darzi, A. Independent Investigation of the National Health Service in England https://assets.publishing.service.gov.uk/media/66f42ae630536cb92748271f/... 2024
(4) Group Relations Conferences in partnership with the Tavistock Institute https://www.tavinstitute.org/group-relations Tavistock Institute of Human Relations
(5) Group Relations Conferences https://tavistockandportman.ac.uk/about-us/group-relations-conferences/ Tavistock & Portman NHS Trust
(6) Team Effectiveness https://tavistockconsulting.co.uk/team-effectiveness/ Tavistock Consulting
(7) Kraemer, S. What to do with appraisal: an idea whose time has come, BMJ 2020;370:m3102 doi: https://doi.org/10.1136/bmj.m3102
Competing interests: Is promoting the (neglected) work of my alma mater a conflict of interest? I have nothing financial to gain from my comments, but do hope that the Tavistock & Portman NHS Trust and the Tavistock Institute of Human Relations may gain wider recognition from them.