Health and Social Care in the Community (2015) 23(4), 362–370

doi: 10.1111/hsc.12150

Primary care team working in Ireland: a qualitative exploration of team members’ experiences in a new primary care service Norelee Kennedy BSc (Physiotherapy) PhD1, Claire Armstrong 3 2 HRM and Walter Cullen MD MICGP MRCGP

BComm PhD

2

, Oonagh Woodward

BA MSc Strategic

1

Department of Clinical Therapies, University of Limerick, Limerick, Ireland, 2Graduate Entry Medical School, University of Limerick, Limerick, Ireland and 3Kemmy Business School, University of Limerick, Limerick, Ireland

Accepted for publication 10 July 2014

Correspondence Dr Norelee Kennedy Department of Clinical Therapies University of Limerick Health Sciences Building Limerick, Ireland E-mail: [email protected]

What is known about this topic

• • •

Team working is an essential and integral part of primary care provision. Hierarchical team structures can reduce the benefits of team working in primary care. Professional identity and boundaries around professional roles can create conflict in primary care teams.

What this paper adds

• • •

Conflict was not always a feature of team working in primary care. Formal team leadership may not be as fundamental to team working in primary care as previously thought. Varied employment arrangements appear not to be a source of conflict within the teams, nor do they negatively affect the smooth functioning of the team.

Abstract Team working is an integral aspect of primary care, but barriers to effective team working can limit the effectiveness of a primary care team (PCT). The establishment of new PCTs in Ireland provides an excellent opportunity to explore team working in action. The aim of this qualitative study was to explore the experiences of team members working in a PCT. Team members (n = 19) from two PCTs were interviewed from May to June 2010 using a semi-structured interview guide. All interviews were audio-recorded and transcribed. Data were analysed using NVivo (version 8). Thematic analysis was used to explore the data. We identified five main themes that described the experiences of the team members. The themes were support for primary care, managing change, communication, evolution of roles and benefits of team working. Team members were generally supportive of primary care and had experienced benefits to their practice and to the care of their patients from participation in the team. Regular team meetings enabled communication and discussion of complex cases. Despite the significant scope for role conflict due to the varied employment arrangements of the team members, neither role nor interpersonal conflict was evident in the teams studied. In addition, despite the unusual team structure in Irish PCTs – where there is no formally appointed team leader or manager – general issues around team working and its benefits and challenges were very similar to those found in other international studies. This suggests, in contrast to some studies, that some aspects of the leadership role may not be as important in successful PCT functioning as previously thought. Nonetheless, team leadership was identified as an important issue in the further development of the teams. Keywords: leadership, primary care, qualitative, roles, team working

Introduction Ireland’s Primary Care (PC) Strategy, originally published in 2001, outlined a need for a strengthened PC structure. The Health Services Executive (HSE) Transformation Programme, established in 2007, operationalised this policy by establishing a national network of teams. At a time of significant transition 362

and reform in PC in Ireland, it is important to explore the experiences of team members of being part of a primary care team (PCT). Team working is an integral aspect of PC (Shaw et al. 2005). Research investigating the effectiveness of PCTs has identified that there are a number of aspects to successful teamwork in this setting. These include having clear shared objectives (Poulton & © 2014 John Wiley & Sons Ltd

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West 1999) and strong communication (Firth-Cozens 1998, Molyneux 2001) and collaboration between team members (Shaw et al. 2005). Certain factors can, however, hinder effective PCT working including the presence of hierarchical structures within teams, where some members view their roles as superior to others (Riley et al. 2003) and issues with role boundaries, role misunderstanding and changed roles. Hansson et al. (2008) concluded that if teamwork is to be successfully introduced into PC, the general practitioners’ (GPs) self-perception has to be taken into consideration as should be the prestige and status associated with their traditional role and the benefits of teamwork to the profession of medicine. The issues with role definition within PCTs, however, are not limited to GPs; Arskey et al. (2007) also found that there were misunderstandings about ‘core’ and ‘peripheral’ roles within PCTs. This also applied to role boundaries which were not always clear; for example, receptionists might be asked to give feedback of test results to patients on behalf of doctors. Role conflict can be avoided where team members have a better understanding of each other’s roles, and where role boundaries are clear, clinical outcomes are enhanced (Pearson & Jones 1994, Grumbach & Bodenheimer 2004, Arskey et al. 2007). A review of a United Kingdom (UK)-based PCT, 5 years after establishment, identified a number of issues that facilitated successful team implementation. These factors included each team member undertaking a fundamental appraisal of their own role, health professionals relinquishing their attachment to their profession, managers abandoning their traditional models of management and all team members developing new skills and attitudes to fit the new model of working (Lowe & O’Hara 2000). Belanger and Rodriguez (2008), however, suggest that professional identities remain an important barrier to PCT working. The establishment of the new PCTs provided an excellent opportunity to explore PCT working in the Irish context. By the end of 2013, there were 418 PCTs in operation (i.e. holding clinical meetings between GPs and other staff), 86% of the revised HSE target of 484 teams (White 2013). These teams provide PC services to a population of more than 3.4 million with more than 3000 staff and 1592 participating GPs. Thus, the purpose of this study was to explore how team members experience working as part of a PCT, to explore how they have experienced becoming members of that team, how their role is understood within that team and to explore if any conflict has arisen for them in working as part of the PCT. © 2014 John Wiley & Sons Ltd

Participants and methods Design The study, conducted in Ireland in 2010, has a qualitative methodology and is based on semi-structured thematic interviews with participants purposefully selected from two PCTs in the Mid-West region of Ireland. Data were analysed using thematic analysis to identify the participants’ experiences of PCT working and to cluster these into categories and themes (Braun & Clarke 2006). Participants One urban and one rural PCT, based in the Mid-West region of Ireland, were identified through professional contacts, and all 24 team members were invited to participate. The urban team was established in 2009, while the rural team had been established in 2002. Researchers initially contacted via email the Primary Care Development Officer for the region, to explain the study and seek permission to contact members of the team. Contact details of the relevant team chairpersons were obtained and email contact was made with these personnel. Information about the study was given to be disseminated to the other team members and a time to meet with the team members was arranged. At that meeting, the study investigators further explained the study and gave written information to the team members. Team members willing to participate were asked to email the study investigators to arrange a time for the interview to take place. Prior to interviewing, written informed consent was obtained from each participant. Nineteen members of the two PCTs agreed to participate (Table 1). The 19 participants came from a range of professional backgrounds comprising Nursing (n = 5), General Practice (n = 4), Physiotherapy (n = 2), Occupational Therapy (n = 2), Home Help Co-ordination (n = 1), Community Welfare Administration (n = 1), Practice Administration (n = 1), Clinical Psychology (n = 1), Social Work (n = 1) and Counselling (n = 1). Some members were new to team working, while others had worked as part of a team in previous employment. Qualitative interviews Three interviewers (N.K., C.A. and O.W.) undertook semi-structured thematic face-to-face interviews with the participants. The interviews were held in the 363

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Table 1 Professions interviewed in each team

Administrator/clerical officer Clinical psychologist Community welfare officer Counselling Community registered general nurse General practitioner Home help co-ordinator Occupational therapist Physiotherapist Public health nurse Social worker Total

Box 1 Question route for interviews

Team A (n)

Team B (n)

Interview questions

1 – 1 – 1 3 1 1 1 3 – 12

0 1 0 1 0 1 0 1 1 1 1 7

Could you describe your role within the PCT? What distinguishes your practice from your colleagues? What is your unique professional contribution to clients? How does your practice differ in this PCT compared to your previous job? Are there opportunities for your role to develop in the future within this team? What might these opportunities be? Have you experienced role conflict within this PCT? How did this team establish role boundaries? Did you formally communicate your role to one another? How did you determine/agree other team members’ roles? What organisational structures/personal factors/training and education help you to work effectively with your colleagues? From your own experience can you describe any barriers to effective team working?

participants’ places of work or in their offices. One interview was held at the University of Limerick. Nineteen semi-structured interviews over an 8-week period in May and June 2010 (12 in team A and 7 in team B), lasting 30–45 minutes each, were digitally recorded. An interview guide was used for each interview to maintain consistency between interviews while allowing participants the opportunity to raise issues of importance to them. The interview questions were generated based on literature review (Box 1) and through discussion and reflection among the research team.

PCT, primary care team.

and delve deeper into answers given. The authors independently analysed data and then reached consensus by comparing and discussing the findings. To ensure rigour, all participants were invited to check a summary of the analysis of their interview to confirm that the findings accurately reflected their perspectives and experiences via email. No amendments to transcripts were made by participants. Power relationships

Data analysis All interviews were transcribed verbatim and thematic analysis undertaken (Braun & Clarke 2006). NVivo 8.0 software was used to store and organise the data. Stage 1 of data analysis involved repeated reading of the transcripts to enhance familiarity with the data. Stage 2 involved identification of initial codes through line by line coding. Stage 3 involved identifying five main themes by grouping codes with similar meaning. In the fourth stage, all themes were reviewed and discussed by members of the research team to ensure all themes had internal homogeneity and external heterogeneity. In the fifth phase, the five themes were named and defined. Rigour To establish credibility in the phenomenon under investigation (Guba 1981, Graneheim & Lundman 2004, ), two PCTs from different locations and different stages of development were invited to participate in the study. Depth and richness in the interviews were ensured by asking follow-up questions to clarify 364

The researchers considered power relationships within the study at the following stages. Recruitment: Both teams agreed to participate and highlighted their willingness to participate as they recognised and welcomed the opportunity to describe their experience of PCT working. Interviews: Along with the initial team meetings, interviewers built rapport with interviewees at the start of the interview. Data analysis and production of the report: Following data analysis and the emergence of themes, we presented the findings to both teams. There was strong agreement and positivity to the themes and the teams endorsed our study findings. Team members acknowledged their positivity towards having had the opportunity to describe their experience of PC working in a forum outside their work environment. Ethical considerations Approval to undertake the study was given by the HSE Midwest Research Ethics Committee. Written and verbal information about the study was given to © 2014 John Wiley & Sons Ltd

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all participants and written informed consent was obtained prior to the interview. Confidentiality was assured to participants by the use of pseudonyms and changing of any identifiable data. Participants were assured that they could withdraw from the study at any time.

Findings Five main themes emerged that described the experiences of team members of working as part of a PCT. The themes were support for PC, managing change, communication, evolution of roles and benefits of PCT working. Quotes are used to illustrate the themes, and pseudonyms are assigned to each quote. Support for primary care Participants gave their views on PC and described their experiences of working within PC. There was significant positivity towards PC, with people describing the benefits of team support, particularly with managing difficult clinical cases. Participants also described how PCT working is less isolating and thus, more enjoyable: I would be very pro-Primary Care [team working]. I do think it is a very good way of working. I think we were far too isolated before. (Joan)

extent, of the people who are being treated by the team. It has added some extra layers, but it hasn’t made any difference from my point of view, to be honest. (James)

Managing the change to PC working Expected difficulties associated with transitioning to a PCT structure were clear to the interviewees involved. However, there does not appear to have been a standard approach to implementation of the teams, with differing levels of training provided to both teams at start-up. Also, newer team members reported a different experience to those involved from the start. Participants described how the nature of their practice had changed with working in the PCT from their previous way of working: [my previous way of working was] Quite isolated and I suppose the only communication I really felt I had with anybody was a piece of paper. So, yeah I got a referral and even to the extent that they pushed them under the door. There was very little face-to-face contact. (Joan)

Participants described their previous practice and the improvements in their practice that came with PCT working: When you were on your own trying to get everything organised, it was very difficult. You couldn’t get anything done . . . And there was no co-ordination, and there was no hub on which to hang the various spokes. (Colm)

The essence of the vision of the PCT structure is summed up by team members who felt positively about what they could achieve with a cohesive, multidisciplinary approach and how this benefitted the communities in which they worked:

While participants were on the whole positive about PCT working, they cited a number of problems with how the teams were set up. Their experience was that a lot of expectation was placed on them to simply ‘get on with it’, with very little assistance in implementing the team structure:

It’s all meant to be client-centred and it is and it just means that at the end of the day that the main beneficiaries are the clients and they are being given every possible input. (Jennifer)

I would have huge questions about how PCTs are set up. I think people have been put into posts, and they have been sent to a meeting and are part of a team. (Joan)

Participants described how the focus of their practice was about the client: [it] is all about the client really and being the advocate for the client and looking after their whole needs and looking at them holistically . . . I think it’s good for the client as well, because every service that they have is here, locally based. (Sadie)

While the general consensus has been one of support for PC, some members expressed their reservations about PC while still describing benefits from it for their patients: So it hasn’t made a huge difference to my practice other than maybe it has improved the quality of care, to an

© 2014 John Wiley & Sons Ltd

Participants discussed the varying nature and sometimes lack of training received at team set-up. In some cases, participants did not receive any relevant training to give them an understanding of teams and team working, conflict management or team building. While there was clear evidence of training at the implementation stage for some (but not all) PCTs, there was little provision for those who joined postimplementation, although it did depend at what stage they joined; the earlier they joined the more likely they were to have received training to support their new role. Participants who were with the PCT from the initial implementation stage were more positive about their experience as they were more likely

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to have received appropriate training and support and to have developed with the team:

ment and supporting team members in addition to facilitating better communication:

It’s been good to have been there from the beginning because there were issues and it’s good to see it develop and put them behind you and move forward and yes, I think it’s been very good. (Fiona)

So that is why the team meeting is useful for that kind of thing. You can thrash out ideas and you can say ‘hang on a minute now, what’s causing the anxiety or are there any underlying things going on?’ (Caroline)

Team communication

Evolution of roles

Communication among team members is critical and requires specific skills and techniques, while poor inter-professional communication can prevent effective team functioning and strengthen unhelpful stereotypes and perceptions (Sargeant et al. 2008). When asked about barriers to effective teamwork, most respondents in this study cited communication as one of the main barriers:

A strong theme throughout the interviews was the issue of roles. Participants described their own roles, how these have changed with membership of the PCT, how their role might develop in future, areas of role distinction, how they came to understand other team members’ roles and individual discipline roles compared to their team role. Participants described their current practice within the PCT. References were made by some participants to how each team member understood their own area of practice. Some also referred to their team role reflecting on the dual nature of their involvement in the team, i.e. having a clinical and a team role:

Lack of communication, not communicating at the best level that you could [is a real barrier]. (Paula)

As well as being acknowledged as essential for effective teamwork, some PCT members made the observation that communication was the main difference between working as an individual practitioner and working as part of a PCT. The team meetings were seen as the main vehicle for ensuring ongoing, effective communication: Communication is fairly good in this team and I do think that it’s the frequency of the meetings [that aids this]. (Annette)

. . .one of my biggest roles is to be a team member. (Alison)

Participants described how they came to understand each other’s roles and their own roles within the PCT. For some participants, particularly, newer team members, this role understanding started with formal documentation outlining other team members’ roles:

Infrastructure to support communication was identified by team members as an important enabler for communication:

There is a sheet that went around that described what everybody did and everybody wrote their own. So I think that was kind of helpful. (Joan)

The ease of communication through the email. You’ll have it sent in a moment and you’ll have a reply back. (Sadie)

For others, the team meetings provided an opportunity to clarify roles which occurred through discussion of a clinical case:

However, some participants referred to the lack of supporting information and communication technology, such as laptops, etc. which they felt could make communication between team members more effective and efficient, particularly because their roles were mobile and not desk bound: If we had some better kind of IT communication which didn’t depend on phone calls. (James)

Team meetings were identified by the majority of participants as having a key role in how the team operated and were one of the key differences and advantages of being part of a team. While some did refer to the time commitment in attending the meetings and having to forego clinical time to attend, there was general positivity towards the meetings and the role they played in better patient manage366

So when I first started, we had a business meeting where I was able to give them just a little more detail of what I cover within the service. (Ann)

Role understanding also occurred through working with other team members on individual cases or on team projects: I hadn’t an idea of the role of the [profession] until I saw him in action. (John)

Benefits of team working A number of subthemes emerged within the area of team working and work relations. These centred on how the teams were working, issues of conflict and conflict resolution and team leadership. All © 2014 John Wiley & Sons Ltd

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participants indicated that their teams are working well and were extremely complementary towards their colleagues: I think the team works quite well and I think we resolve problems, and I suppose the bottom line is patient care and it has worked very well. (Helen)

Participants highlighted the significance of community projects involving all team members and the value they provided for the team and the people in the community: We did an initiative [in] the local day care centre here and the [profession] went in and we spoke about incontinence . . . we got the Fire Officer to talk about safety in the home, we got the dietician to talk about diet and whatever, the OT came in and spoke about her role within the team and it was a way also of promoting the team . . . all the team were very willing to co-operate and give of their time and it was a way of promoting as well. (Sadie)

Projects, like that referred to in the above quote, were outside the day-to-day remit of PCT members’ roles, but were hugely beneficial to team members in terms of understanding the breadth and scope of each other’s roles and developing strong working relationships built on mutual respect. These benefits may have been less obvious than the advantages that the projects brought to the community, but their contribution to a successfully functioning PCT was very positive. Interestingly, conflict was not a major issue for participants. Where conflict arose, it was minor and easily resolved. Participants described misunderstandings about roles as examples of conflict; however, conflict where it existed was resolved easily. Role overlap, which has been shown in other studies to be a source of conflict, was not a significant issue in this study: So yeah, there has really been no real role conflict. Maybe a bit of argy-bargy about who is going to do letters and things like that, but nothing that I can give you a good example of really. (Jill)

ers who are employed directly and solely by the HSE, and counsellors and psychologists, many of whom are employed part-time by the HSE and also maintain a private practice. However, when interviewees were asked about conflict in general, this was not raised as an issue and when specifically probed on this unusual feature of Irish PCTs, team members admitted that they had never really thought about it, but were generally content with the advantages brought by their own employment arrangement. One of the chairpersons believed that the fact that they were not employed by the HSE was a distinct advantage for the team because they were in a position to challenge the HSE without any fear for their future employment: I was chosen as chairperson as well. The reason for this was that I was not a HSE employee, so I could say things which would not be politically acceptable for an HSE employee to say. So it gives the team an independent voice by having me as chairperson of the team. (John)

Participants acknowledged the lack of a formal leader in each team, while acknowledging that each team did have an unofficial leader/chair. The advantages and disadvantages of this approach were discussed with some favouring the appointment of an official manager, while others described how this would not be their choice: At the moment it seems to work OK because somebody is chairing the meetings and things are getting done. (Jill)

The lack of definitive, official leadership was considered, by some participants, to be a barrier to more efficient outcomes: I mean, our team doesn’t even have a manager, and it works reasonably well but there are probably issues which are shoved under the mat and not addressed because of that. (Alison)

Where conflict had occurred, people described how it was resolved on an informal basis:

Participants acknowledged the current situation where a team chairperson is in place. However, the differentiation between a chairperson, who chairs a meeting and a team leader with a wider remit, was noted. One chairperson described their role as:

Basically we met and had to sit down and try to decide what the best way of doing this is. And just through talking, I suppose, about it and then, yeah, you know, we had to agree on something. (Jill)

[giving] the team an independent voice by having me as chairperson of the team. It also gives a figurehead to the team and gives a point of contact for other people. (John)

Specifically, in Ireland, GPs are not employed by the HSE (the commissioning and oversight body for PCTs). Instead, most GPs are sole traders and are not under the authority of the HSE. This differs significantly from other team members such as social work© 2014 John Wiley & Sons Ltd

Discussion Five key themes were identified from this qualitative study to describe two Irish PCT members’ 367

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experiences of working together: support for PC, change and organisational change management, communication, roles and team working. Participants were generally supportive towards the model and suggested that the resulting improved communication between team members may enhance patient care. The opportunity to manage complex cases and conditions as part of a team was identified by the majority of the members as a key aspect of this enhanced patient care. The benefit of a PCT approach in the management of complex cases has been previously identified (Sargeant et al. 2008, Kringos et al. 2010) and is a positive aspect of this approach to patient care. While team members described the personal and professional benefits of PCT working, they also highlighted difficulties with this approach. Barriers to effective PCT working included issues associated with multiple sites/locations for team members. Co-location was identified as a key factor in high-performing PC team working in the United States of America (Bodenheimer et al. 2014). Communication was hindered by the inability of people to meet on a regular basis and as such, opportunities to discuss complex cases and to resolve minor misunderstandings were reduced. Similar issues around location have been reported in other studies (Xyrichis & Lowton 2008, Oanadasan et al. 2010). Team meetings thus were highly important in providing opportunities for communication, clarification of issues and discussion on complex issues. While team members identified the difficulties in attending team meetings (due to multiple locations, timing of the meetings), they recognised the importance of attending them. The value of team meetings in enhancing closer working relationships by leading to greater rapport and improved team working has been reported elsewhere (Jones & Jones 2011). Although previous research suggests clarity regarding leadership is key to the success or failure of team working (Zaccaro et al. 2001, Day et al. 2004, Taplin et al. 2013), it is noteworthy that this role is not formally established in Irish PCTs. For example, chairpersons are identified for the purpose of chairing and organising meetings. They do not, however, have a formal role in relation to, for example, acquiring resources for the team, setting team direction, monitoring team performance, or even providing performance feedback to team members. In our study, participants generally felt that having a team leader would be advantageous, particularly to advocate on behalf of the team, especially in respect of negotiating improved resources. Our findings did not report significant conflict within teams as has been reported in other studies 368

(Riley et al. 2003, Shaw et al. 2005, Brown et al. 2011). This may be related to the willingness of people to ‘get on with it [the job]’ as described by one participant. The researchers have considered how power relationships and researcher positionality within the interview process may have contributed to this. While participants in this study did describe incidents of disagreement between themselves and colleagues, it was not considered conflict. Disagreements, when they did arise, were typically addressed on an informal basis. Participants did not express concerns around confidentiality before, during or after the interviews or when the study findings were presented to both teams that may have contributed to them not describing issues of conflict. When the lack of conflict was highlighted to the teams and discussed with co-researchers within and connected to our research group, cultural influences were considered the preferred reason for this finding. Conflict is considered a strong term used to describe a sustained period of clashes between parties. When asked specifically if conflict had been experienced during their work, interviewees referred instead to what they considered minor examples of disagreements between colleagues that were invariably ‘sorted out’ in a nonformal manner. Participants described how they came to understand each other’s roles and the value of ‘seeing people in action’ in providing role clarity. While formal education about roles is important in facilitating inter-professional collaboration, the value to be gained from experiential learning should not be underestimated. Both teams reported the need for continuing investment in education to improve teamwork and patient care. The need for inter-professional education and continual investment in the professional development needs of PCTs has been identified (Chan et al. 2010, Royal College of General Practitioners 2011). Similarly, investment in newly established teams is imperative as the process of establishing new teams is challenging (Rodriguez and Pozzebon 2010). Strengths and limitations of the study In the Irish context, this study is novel. PCTs are a relatively new phenomenon in Ireland and little research has taken place into their development and specifically, the change from individual to team-based clinical practice. The use of a qualitative methodology allowed the voices of the PCT members to be heard. This is particularly appropriate, given the exploratory nature of this study. The © 2014 John Wiley & Sons Ltd

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study also gave team members the opportunity to reflect on the positive aspects of PC and to remember the original rationale for the move towards PC. Within the two teams, members from a wide range of professions were interviewed, which encompassed all disciplines within a standard PCT, as well as some others (Table 1). Our findings should be interpreted with some caution. Although this qualitative approach provides an in-depth understanding of the PCT members’ perspectives of team working, generalisability is not obtained from sample representativeness, but from the themes that are applicable to other PCTs (Green 1999). Recruitment of PCTs through personal contacts may have led to an uncharacteristically engaged sample of healthcare professionals. Although we were able to gain multiple perspectives within a team, a sample of two teams is small, which again potentially affects generalisability. Finally, the study was undertaken in 2010, hence the findings are 4 years old. However, PC has not changed substantially in that timeframe and we are confident that the findings are relevant to the current PC service. Implications for future research or clinical practice Our findings suggest that more emphasis be placed on developing team working skills for the team members. Designation of a formal team leader, who is responsible for the team’s performance, answerable to the HSE and with sufficient authority to drive the team and deal appropriately with issues of underperformance among team members as well as advocating on behalf of the team might be useful, although this was disputed by some team members who were content with the status quo. As well as re-organising team structures, the infrastructure within which PCTs operate also needs to be examined. For example, physically locating teams within the same building and ensuring all its members have sufficient capacity (e.g. protected time, training and information access) are likely to enhance communication and effectiveness. This study, as the first study to explore team members’ experiences of working in PC in Ireland, was an important start point in a larger evaluation of PC in Ireland that is currently underway involving some members of the teams who participated in this study and some of the co-authors of this paper. Future research into PCTs should examine team functioning from the perspective of all stakeholders and the development/use of a quantitative instrument would enable a wider examination of this issue. © 2014 John Wiley & Sons Ltd

The development of health services interventions which optimise PCT working are a priority.

Conclusion This qualitative study highlights the benefits (better team and clinical support, better patient care) of being part of a PCT and barriers/enablers to their successful establishment (physical infrastructure, training/education, communication). Two issues are particularly noteworthy. Despite the significant scope for role conflict due to the varied employment arrangements of the team members, neither role nor interpersonal conflict was evident in the teams studied. In addition, despite the unusual team structure in Irish PCTs, general issues around team working and its benefits and challenges were very similar to those found in other studies. This suggests, in contrast to some studies, that some aspects of the leadership role may not be as vital a factor in PCT functioning as previously thought. Overall, this study provides an insight into the issues that arise in developing PCTs in Ireland and may apply in other systems where PC has parallel private and public systems.

Acknowledgements We thank the Irish College of General Practitioners Research and Education Foundation, Dublin, Ireland who funded this study. We thank our colleague at the University of Limerick, Ms Mary Gamble, who commented on early drafts of the protocol. We also thank the staff in both participating PCTs, especially chairpersons Dr Ray O’Connor and Dr Michael Tangney who advised on the original protocol and introduced us to the two teams.

Conflicts of interest No conflicts of interest exist for any of the authors.

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