The findings are structured around the themes that emerged that related to: (a) the two relationship factors of power dynamics and trust, and (b) the patient experiences of the impact of these interprofessional relationships. Quotes are used selectively to give voice to the participants and to illustrate the meanings.
Use of power by health professionals to protect their autonomy
Government policies have extended the gate-keeping role of GPs to allied health professionals, and hence their access to resources. Increased GP referrals through TCA provide allied health professionals with an additional source of clients and income.
"We see more Medicare side of things now where patients with diabetes who are having difficulty with regular exercise as a consequence of osteo-arthritic changes in their lower limbs." (Physiotherapist)
The power of GPs over allied health professionals, however, is limited. Patient referrals and TCA involve a low level of professional interdependency and involve few risks to the professional autonomy of allied health professionals as they have other sources of income (e.g. fee-paying self referrals) over which GPs have little influence. Despite these constraints to the authority of GPs, they implicitly asserted their medical dominance in other ways. They rarely developed MDC plans in consultation with other providers, there was very little two-way communication and the information that they shared varied considerably.
" If we get a very brief care plan it's very hard to sort out exactly what the doctor's and patient's expectations are from the consultation. If you've got a good care plan that outlines exactly what the goals are, it's so much easier." (Podiatrist 5)
Power dynamics between private and public sector providers
Collaboration between GPs and public sector health professionals was more complicated and both groups strived to maintain their authority over what they considered their area of expertise. GPs had little formal authority or responsibility for the management or care coordination of patients in public sector health services. Most public sector nurses and allied health practitioners relied on referrals from other practitioners within the area health service and client self-referrals. In this context, the gate-keeping role and medical dominance of GPs were circumvented, and the professional status of non-medical practitioners protected as indicated by the following quote:
" The literature from the diabetes educators' association says that if you are newly diagnosed it is still best practice to be educated by a diabetes educator and dietician. When discharging clients, we make it clear to them that if they feel they need to return, they don't have to come back through a doctor's referral. They can refer themselves." (Diabetes educator 1)
Practice nurses together with GPs were running diabetes clinics in two of the larger general practices in the study. These nurses carried out much of the routine diabetes monitoring and patient education that was traditionally undertaken by diabetes educators (who were nurses by profession). The concerns about the consistency of care being provided, as illustrated in the following quote, could be a reflection of threats to the professional standing of the diabetes educators posed by less trained practitioners taking on these roles.
"There was concern from the diabetes educators: how are GPs and practice nurses delivering this information? If they're going to be supporting newly diagnosed diabetics, .....are they giving them consistent messages or are the diabetes educators going to get the patients three months down the track and have to address the inconsistency of messages." (Manager, Division of General Practice)
Health professionals maintain their power by reducing their dependency on selected health professionals
Health professionals minimised the threats to their autonomy and independence through two major approaches: (a) choosing partners with whom they had cooperative relationships, (b) reducing their collaboration with health professionals outside their organisation. The introduction of financial subsidies for some allied health care gave GPs a broader range of affordable referral choices outside the public sector, which they preferred to use. The relationship was mutually beneficial to both parties and involved little conflict or threats to existing power relations.
" (GPs) should work with a practice nurse to manage diabetes.. and refer patients to private sector dieticians, podiatrists, and optometrists. So we can do it within in the private sector that way." (GP 1)
Access to medical practitioners working at the area health service meant that public sector nurses and allied health professionals could limit their collaboration with GPs, and they used a mix of strategies to achieve this: applying their own criteria to gauge the priority of GP referrals, maintaining self-referral relationships with patients and declining to participate in TCAs, for example:
"There has been some resistance....The GPs have wanted us to sign off as a second care giver, but we haven't ... for some reason we weren't happy about it ... I don't know whether you'd call it professional jealousy or what." (Community nurse 1).
Larger general practices reduced their need to collaborate with external practitioners by developing their own skills and capacity to provide diabetes care. Some general practices also entered into co-location arrangements with allied health professionals, although the latter remained independent practitioners and maintained their own patient records. Through the opportunities for informal communication, co-location contributed to the development and maintenance of cooperative relationships, however this did not result in shared decision-making.
Trust based on role perceptions
The level of trust was positively related to the extent to which roles and role boundaries were accepted. This was relatively straightforward in relationships between GPs and private sector allied health providers where the roles of the latter complement those of GPs and the TCAs limit the numbers of allied health consultations that can be reimbursed in any one year. There were more risks and uncertainties associated with collaboration between general practice and the diabetes centre, which in part was to do with an overlap in their roles. Both groups expressed strong identification with having a central role in diabetes care. Improvements in the quality and capacity of some general practices meant they were shifting into areas previously the domain of more specialist diabetes services. This is at times a complex and unpredictable environment with considerable variation in the levels of trust and mistrust. Some GPs reported a reluctance to refer patients to the diabetes service as: "...they take over their care."(GP 1), although another GP reported that "They don't pinch clients, they don't take them over, they always send them back." (GP 4) These different perceptions illustrate the subjective nature of trust.
The increasing prevalence of T2DM and workforce shortages also influenced perceptions of vulnerability and risk. In response to the volume of work, one specialist medical practitioner was shifting routine follow up and screening to an allied health profession, whilst acknowledging that:
"..people will protect their income.... and if you're working really hard then you're not actually trying to do that, you're just trying to get through the workload. If you didn't have anything to do then you'd want to get people back." (Medical specialist 2)
Trust is based on demonstrated competence
Respect and trust were intertwined and related to a mix of professional and personal factors. Recognising that other health professionals have complementary skills and competencies which can enhance and not duplicate care was a necessary precondition of respect and a willingness to collaborate, as the following quote illustrates:
"I believe that good primary care requires collaboration. I don't hold either the knowledge or the mortgage on the right ways to support patients." (GP 3).
The second aspect was confidence in the competency of other professionals. For some health professionals, this was demonstrated through the quality of referral feedback information and patient feedback. GPs in particular judged the competency of allied health professionals from the relevance of the information contained in their reports and the timeliness of their communication. GPs preferred to refer patients to those practitioners who met these expectations. Allied health professionals who relied on TCA for an increasing proportion of their business recognised this and responded accordingly.
Confidence in other health professionals reduced the uncertainty of collaborating. A tacit knowledge and understanding of how other health professionals worked helped to reduce this uncertainty. Greater effort was required to establish and maintain relationships where the ground rules were not well known, or where there were different expectations.
"I find with the private guys I send people to I usually get information back quite quickly and know exactly what's been covered, and if there are any gaps I need to fill. I feel like it's quite a team approach. Whereas with the diabetes educators and others at the area health service... they don't often give me a great deal of information about what they're actually doing with people." (GP 5)
This quote also highlights the relationship between confidence and communication in the development of trust.
Trust develops over time with good communication
Direct communication, usually by telephone, provided opportunities for the development of rapport, respect and trust in ways not afforded by referral letters and feedback reports. This, however, depended on the nature and tone of the communication. Communication characterised by a lack of respect could have the opposite effect. The receptivity and responsiveness of other health professionals was an important indicator of the quality of the relationship, mutual respect and trust. The following quotes illustrate the variation that existed:
" We generally have a good rapport with the referring doctors and we are able to contact them easily and discuss things if need be. I think that rapport has been built up over many years of treating patients and them getting to know us and what we do." (Dietician 2)
"...when we do have problems and we write to the GP, for example asking them to review a wound, we often don't hear back. That's very frustrating!" (Community nurse 2)
Opportunities for social interaction and the development of personal relationships help to foster trust and respect [10
]. The rural context was a major enabler and most health professionals knew one another through a web of personal and professional linkages. Interprofessional and interdisciplinary education and training activities were important ways for different practitioners to come together and learn more about each other's roles, contributions and ways of working.
"I think what we've found is that the practice nurses have been a real bonus.... They've worked well with us and quite a lot of them have come to the diabetes course we run and we've got to know them, build up the rapport and they're comfortable about ringing us about anything." (Diabetes educator 2)
The effect of power and trust relations between health professionals on patient experiences related to their access to health services and the continuity of care they received from multiple providers.
Access to health services
Most patients recalled being referred by their GP to the diabetes centre for education when they were first diagnosed and for stabilisation when first commencing insulin. This finding indicates that despite the reservations expressed by GPs about the diabetes centre, they acknowledged the centre's role in these two areas. Patients who reported being on MDC plans were receiving care from a broad range of allied health professionals many of whom they had never or seldom seen before. This contrasted with other patients, not on these plans, who were referred to few allied health services, suggesting that these GPs were less willing to collaborate. The preference of GPs to refer patients to private sector allied health professionals was also evident in patient experiences.
"I get my eyes checked every 12 months, I've been to a podiatrist for my feet and I did a 10 week program with a dietician and exercise person at a health clinic that they run at a local gym." (Patient 5, aged 67)
Continuity of care
Aspects of continuity included timely communication and information exchange which facilitated consistent and complementary care over time. Patients' experiences varied. Patients who were not on MDC plans and TCA experienced a less connected and continuous form of primary health care, with each health professional providing their own care with little interprofessional communication and information sharing that patients were aware of. It was left to the patient as they saw fit to inform their main health provider of other care they were receiving. Patients on MDC plans and TCA experienced a greater continuity of care. The care plan was identified by patients as the common focus of consultations by the multiple providers. The reporting back by allied health professionals to the referring GP facilitated information sharing and consistency of care.
"the podiatrist sends a report after each meeting, and the practice nurse told me she'd entered it into the computer. (Patient 8, aged 65)
Patients who required a higher intensity of collaboration when their diabetes was unstable spoke about the direct two-way communication between the various health professionals during this short term period of more intensive management. This suggests that despite a lack of trust between GPs and the diabetes centre, their concerns about patients could override their disinclination to collaborate.
"I can't think why I went to the diabetes educator, but my readings were up and she suggested I see my GP and that I might need to go on insulin. She contacted him and he started me off on insulin. And because I started on insulin I also went to see the medical specialist at the diabetes centre as well and my GP was conversing with him and they agreed that it was important to see both Drs at that time." (Patient 3, aged 67)