Interprofessional education took root in the UK during the late 1960s, driven by developments in primary and community care. Teamwork became the cornerstone for effective collaboration as primary care centres were established, but no panacea. Relationships between professions which may have worked well enough at arms length became fraught at close quarters. GPs were enthusiastic about the work of the district nurses, but critical of health visitors whose role some failed to understand. Others understood well enough, but felt that the advice given by the health visitors was at best unnecessary and at worst ill-conceived to the point of being harmful.1,2
These women stood accused of being interfering, even officious and impertinent towards patients, giving medical advice, often incorrect or in conflict with the GP's treatment, and undermining their authority with their patients.3
As for social workers, GPs regarded them as relatively junior employees of the local authority, whose main functions were to find home helps, sort out financial problems, and rescue battered babies. Neither GPs nor health visitors thought that social workers were trustworthy. They were hard to contact and slow to take action, did not offer a 24-hour service or remain long in the same post, never made time to discuss individual cases, and never provided feedback.1
Comments about GPs were scarcely less critical. According to the health visitors and social workers, they were difficult to contact, did not understand the work of other agencies, and withheld information of importance. Better cooperation between professions could not be achieved without major changes in both attitudes and working arrangements, but change was uncomfortable and threatening.2
Retired GPs who recall those days assure me that relations with their colleagues from other professions were invariably cordial and constructive, but there is evidence that doctors can be unaware of the stress which colleagues from other professions are experiencing.4–6
The same tensions were rehearsed during numerous workshops and conferences convened to help resolve the problems. The first was a 2-day symposium on ‘Family Health Care: the Team’ convened in London in 1966 by Dr Ekkehard Kuenssberg (1967) and sponsored, among others, by the Royal College of General Practitioners (RCGP).7,8
The RCGP with the health visitors and social work training bodies then recommended ‘regional arrangements’ for interdisciplinary meetings. The ‘Windsor Group’ discussed cooperation and conflict in community care and convened a 2-day seminar where GPs and social workers concluded that one of the most emotive issues was the extent and nature of future relations between their respective professions following the creation of social services departments in the wake of the 1969 Seebohm Report.9,10
Freeing social workers from medical control had, according to delegates, led to problems, but improving working relations would need also to include health visitors, whose role was seen to overlap with those of both GPs and social workers.11
That debate prompted a 5-day seminar at Cumberland Lodge in Windsor Great Park where recently qualified practitioners from the three professions explored each other's roles and identities, dissipated prejudices, and acknowledged stresses in their working relations. GPs had reportedly failed to understand that health visitors had become independent practitioners with skills in preventive medicine, which in some ways went beyond their own. Neither GPs nor health visitors had yet accepted social workers' claims to their own specialist field. Many GPs preferred to pass social problems to health visitors when referrals to social services departments reportedly led to rejection, rationing, or delay. The core knowledge and skills of each profession, said delegates, had to command the respect of each of the others before liaison could be effective, and services become flexible and responsive. The roles of all three professions had broadened. Increasing overlap between them argued for common studies during pre-qualifying education.
A national conference held at the then Middlesex Polytechnic in 1984 was a landmark. It was organised by Michael Carmi (general practice), Valerie Packer (nursing) and Ann Loxley (social work) who had been running interprofessional short courses jointly for some time. Delegates backed a proposal to establish a permanent central organisation to support and coordinate interprofessional learning.12
Further conferences followed, leading to the founding in 1987 of the Centre for the Advancement of Interprofessional Education in Primary Health and Community Care (as CAIPE was then known).13
John Horder, who had recently retired from general practice and completed his term of office as President of the RCGP, agreed, despite a recent health crisis, to take the lead and became CAIPE's first Chairman and later President.
Concurrently in Scotland, Ken Calman, then Professor of Clinical Oncology at the Glasgow Medical School, was the driving force behind ‘Interact’, a rolling programme of conferences for interprofessional activists moving from city to city. The interprofessional movement owes much to his support throughout his long and distinguished career in medicine and academe, notably his proposals as Chief Medical Officer for England for ‘practice professional development plans’ in primary care which put teamwork and interprofessional education at their heart.14
Back in London, Patrick and Marilyn Pietroni were pioneering interprofessional education with the Marylebone Centre Trust. Jungian analyst and Freudian psychotherapist respectively, they introduced psychodynamic insights to cultivate a holistic understanding of interprofessional education and practice within which the complementary therapies were assured of a place.15
Applying Jung's theory of archetypes, Patrick saw the doctor as ‘the hero-warrior god’, the nurse as ‘the great mother’, and the social worker as ‘the scapegoat’, a role inherited from the medieval witch via the midwife who had successfully escaped such stigma. A fourth archetype was ‘the trickster’, like Hermes and Mercury bearing Caduceus' staff as they carried messages between God and man. Slippery and cunning, the trickster for Patrick resembled not medicine but psychotherapy. If some of us struggled to distinguish between archetypes and stereotypes, which interprofessional learning existed to challenge, we joined in the fun when participants at one workshop were invited to caricature themselves and others. The social work students saw themselves as Guardian readers into health foods; medical students as beer drinking rugby players; and nursing students as caring but unimaginative. The medical students saw social work students as left wing, self-opinionated but intellectual, driving deux chevaux; nursing students as having chips on their shoulders; and themselves as naïve and (agreeing with the others) arrogant.16
The Trust launched the Journal of Interprofessional Care in 1992, with Patrick as its first editor, and destined to become the dedicated channel for national and later international exchange of scholarship in interprofessional education, practice, and research. It was also instrumental in bringing interprofessional education into universities, mounting the first interprofessional masters' programme, validated by the University of Westminster.
The seeds of university-based interprofessional education were also being sown at Exeter where Denis Pereira Gray, then Head of the Postgraduate Medical Education, with Rita Goble from occupational therapy, instigated postgraduate and masters programmes to secure firmer academic and research foundations for non-graduate entrants to nursing, social work, and the allied health professions, with an interprofessional twist.17
Shared learning between health and social care professions during pre-registration studies was developing in parallel, but minus medicine and interprofessional learning.18
It was the 1980s before the first examples were reported, in Bristol, where medical students shared modules with nursing and social work students.19,20
Numerous initiatives were bringing together newly qualified practitioners, for example, one by John Hasler in Oxford21
and by Oliver Samuel in London,22
while Bob Jones was running ‘novice days’ in Exeter.23
GPs were also writing teamwork texts.23–28
By the 1980s interprofessional education was no longer preoccupied with introspection about problematic relationships; it was more positive, more outward looking, more intent on exploring how the professions together could be more effective in improving services and promoting healthier lifestyles. Problematic relationships could be dealt with if and when necessary.
in Liverpool led a 5-year primary healthcare development programme during which facilitators worked with their fellow GPs and nurses to break down isolation between practices, to promote the employment of practice nurses, and to encourage a reorientation from one-off treatment of disease to participation in health. Among a plethora of activities, mentors were designated to support the rapidly growing number of practice nurses, but the initiative which I relished especially was the one where interviewers discussing healthy lifestyles with patients in the waiting room dispensed daffodils in exchange for cigarettes!
Nationwide, Deryck Lambert30
was injecting much the same energy into health promotion in primary care during a travelling circus of workshops mounted by the Health Education Authority. ‘Triads’ were invited from the same primary health care team, each of which selected a health promotion priority to translate into a training strategy during the workshop and implement ‘back at the ranch’, reporting progress during a recall day.