RESEARCH ARTICLE Open Access

The role of boundary spanners in deliveringcollaborative care: a process evaluationCarianne M. Hunt1*, Michael Spence1 and Anne McBride2

Abstract

Background: On average, people with schizophrenia and psychosis die 13–30 years sooner than the generalpopulation (World Psychiatry 10 (1):52–77, 2011). Mental and physical health care is often provided by differentorganisations, different practitioners and in different settings which makes collaborative care difficult. Research isneeded to understand and map the impact of new collaborative ways of working at the primary/secondary careinterface (PloS One 7 (5); e36468). The evaluation presented in this paper was designed to explore the potential ofa Community and Physical Health Co-ordinator role (CPHC) (CPHCs were previously Care Co-ordinators within theCommunity Mental Health Team, Community in the title CPHC refers to Community Mental Health) and Multi-Disciplinary Team (MDT) meetings across primary and community care, with the aim of improving collaboration ofmental and physical health care for service users with Severe Mental Illness (SMI).

Methods: Data collection took place across five general practices (GPs) and a Community Mental Health Team (CMHT)in the Northwest of England, as part of a process evaluation. Semi-structured interviews were conducted with apurposive sample of GP staff (n= 18) and CMHT staff (n=4), a focus group with CMHT staff (n=8) and a surveycompleted by 13 CMHT staff, alongside cardiovascular risk data and MDT actions. Framework analysis was usedto manage and interpret data.

Results: The results from the evaluation demonstrate that a CPHC role and MDT meetings are effective mechanismsfor improving the collaboration and co-ordination of physical health care for SMI service users. The findings highlightthe importance of embedding and supporting the CPHC role, with an emphasis on protected time and continuingprofessional roles and integrating multiple perspectives through MDT meetings. Considering the importance ofphysical health care for SMI service users and the complex environment, these are important findings for practitioners,researchers and policy makers in the field of primary care and mental health.

Conclusion: There is an increasing focus on integration and collaborative working to ensure the delivery of qualitycare across the whole patient pathway, with a growing need for professionals to work together across service andprofessional boundaries. The introduction of a two pronged approach to collaboration has shown some importantimprovements in the management of physical health care for service users with SMI.

Keywords: Boundary spanning, Co-ordinated care, Mixed methods, Severe Mental Illness (SMI), Primary care,Community care

* Correspondence: Carianne.hunt@srft.nhs.uk1NIHR Collaboration for Leadership in Applied Health Research and Care(CLAHRC), Greater Manchester, Salford Royal NHS Foundation Trust, 3rd FloorMayo Building, Stott Lane, Salford M6 8HD, Greater Manchester, UKFull list of author information is available at the end of the article

© 2016 The Author(s). Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Hunt et al. BMC Family Practice (2016) 17:96 DOI 10.1186/s12875-016-0501-4

BackgroundPeople with mental health problems, such as schizophre-nia or bipolar disorder, die on average 13–30 yearssooner than the general population [1, 2–4]. This mor-tality gap has widened in recent decades [5–7] and ap-proximately 60 % is due to physical illness [8, 9].Individuals with Severe Mental Illness (SMI) have in-creased frequency of tuberculosis, HIV, obesity relatedcancer, osteoporosis, stroke, hypertension, myocardialinfarction, diabetes [1]. A greater predisposition to de-velop metabolic abnormalities in combination with themetabolic adverse effects of antipsychotic drug treat-ments can have a negative influence on physical health[10]. It is, however, possible to avoid many of theseproblems if close attention is paid to service users’ phys-ical health [11].Despite many of the physical health issues experienced

by this group, (e.g. cardiovascular diseases and diabetes)being preventable or controllable by chronic diseasemanagement, people with SMI continue to experiencehealth inequalities, particularly in relation to theprovision of physical health care services. There is anenormous gap in physical health outcomes for thosewith mental health problems and, as such, more needsto be done to promote and manage good mental healthand prevent mental ill health [12]. These inequalities areattributed to a combination of factors, one of which be-ing the separation of mental health services from othermedical services [13, 14] and poor clarity regarding re-sponsibility in care co-ordination [15]. When serviceusers do access health services, their physical healthneeds are often ignored or treated as a manifestation oftheir mental health condition, rather than a health issue.This ‘diagnostic overshadowing’ [16] can lead to physicalconditions being undiagnosed and untreated, which canprove fatal. Aligning health services to improve the co-ordination and collaboration of care could lead to im-provements for those in greatest need. The increasedprevalence of cardiovascular disease and its modifiablerisk factors highlights the importance of ensuring thatpeople with SMI are monitored and screened regularly.Terms such as ‘collaborative care’, ‘shared care’ and ‘in-

tegrated care’ are often used interchangeably, however, acommon theme running through all definitions is afocus on developing closer working relationships be-tween primary care (family doctors or GPs and practicenurses) and specialist health care (such as CommunityMental Health Teams). Collaboration between mentalhealth care providers and GPs is important, particularlyas many patients with SMI are treated as outpatients.Collaboration should be organised around systematicand structural collaboration between GP and mentalhealth care services, including clearly defined responsi-bilities, with a focus on a patient centered, holistic and

tailored approach to caring for patients with SMI [17].Further research in this area is needed to improvethe co-ordination of care for patients with complexneeds and long-term illness, which is currently de-scribed as poor [18, 19]. It is important for the healthand wellbeing of service users with mental and phys-ical multimorbidity that future research explores howintegrated care models can be translated into routineprimary care [20].Physical health care of SMI service users does not

occur as a single or isolated event, rather as a complexseries of linked incremental activities which can involvea diverse range of occupational groups and span a rangeof organisational boundaries. The evaluation presentedin this paper accepts the complexity of this area and fo-cuses on understanding how a boundary spanning rolecan assist healthcare professionals in improving the col-laboration of physical health care for SMI service users.Boundary spanners help to “facilitate transactions andthe flow of information between people or groups who ei-ther have no physical or cognitive access to one another,or alternatively, who have no basis on which to trust eachother” [21]. Despite the emergence of the concept of‘boundary spanners’ and the potential of this role, theprocesses by which they can make improvements inknowledge sharing and integration in healthcare are yetto be determined. There is limited empirical research ex-ploring the function of such individuals in healthcaresystems, particularly examining how boundary spannersperform (or should perform) their role to improve qual-ity of care [22]. The findings presented in this paper de-scribe how a CPHC role and MDT meetings can workacross the boundaries of primary and community care,facilitating the sharing and integration of informationwithin and across services.

MethodsThe aim of the evaluation presented in this paper was tounderstand the function of the CPHC role as a boundaryspanner and how the role was operationalised alongsideMDT meetings, with the aim of combining and integrat-ing multiple perspectives.The research was conducted by the Collaboration for

Leadership in Applied Health Research and Care,Greater Manchester (CLAHRC GM) between June2012 and December 2013. Two members of staff fromthe CMHT were seconded on a part time basis to theproject as CPHCs, both secondees worked part time asCare Co-ordinators (CCs) within the CMHT. The inter-vention described in this paper was designed to imple-ment a CPHC role and to co-ordinate MDT meetingsbetween primary and community care to improve thephysical health management of people with SMI, forexample, managing lifestyle issues and disease reviews.

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A purposive sample of key informants was chosen be-cause of their involvement in the programme and to rep-resent a range of views based on the care of SMI serviceusers. Participants were interviewed from all participat-ing GP practices and included medical, nursing and ad-ministrative staff.The authors confirm that formal ethical approval was

not required for the study since it was classified by Na-tional Health Service (NHS) governance procedures asservice evaluation. All participants received a participantinformation sheet and consented to the recording oftheir interview and use of their data.

Data collectionEighteen semi-structured interviews were conductedwith a range of medical, nursing and administrative staffacross primary care and four semi-structured interviewswith staff from the CMHT. A focus group was con-ducted with CCs (n=8) and a survey administered withCCs (n=13) (see Table 1).Prompt sheets were prepared prior to the semi-

structured interviews to guide data collection and in-cluded the following themes: relationship with CMHTand primary care, the role of the CMHT and primarycare teams, knowledge of physical health care for SMIservice users, the role of the CPHC, collaborative and in-tegrated care across the CMHT and primary care. Theprompt sheets were used to guide and focus discussion,however the interviews were flexible and participantswere able to discuss any relevant issues. The semi-structured interviews enabled participants to reflect ontheir individual roles and provide key information in re-lation to the co-ordinating role and the MDT meetingsand specifically the process of facilitating collaborativecare. The focus groups were an important source of in-formation as they provided an opportunity for CMHTstaff to discuss themes from the perspective of commu-nity care and from their individual experiences of work-ing with service users in the community. All interviewswere conducted at the participants’ place of work, GPsurgery, CMHT team offices, or over the telephone,whichever was most convenient. All interviews wereaudio-recorded and transcribed verbatim.Alongside the interviews, quantitative data was col-

lected to show the number and type of MDT actions

performed and completed (see Fig. 3) and anonymisedcardiovascular risk data (based on the indicators re-quired for QRISK21) for each service user under the careof the CMHT and the pilot practices (see Table 2). Thisdata focussed on the QRISK2 key measurement criteria,i.e. weight/body mass index (BMI), blood pressure, chol-esterol and recorded smoking status, for the previous12 months. Baseline data was collected between Juneand July 2012 and a re-audit at 9 months (March andApril 2013).

Framework analysisA coding scheme was designed based on the topic areaspreviously discussed and data was analysed using ananalytic hierarchy approach. The stages of this approachincluded identifying themes and concepts related to theco-ordination of care and the implementation of theCPHC role. Data was then labelled by themes, sum-marised and refined, any new categories were also iden-tified. Explanations of the data were then developed,looking specifically at how and why [23]. As interviewtranscripts were produced they were read by the authorswho made notes of emerging themes and concepts, thesewere then labelled and sorted by theme. Categories werethen identified and any patterns were recorded alongsideexplanations of the data.

ResultsAnalysis identified three main components of the CPHCrole and MDT meetings, the importance of embeddingand supporting the role in practice and facilitating theintegration of multiple perspectives, below we elaborateon each of these areas.

The CPHC an embedded boundary spannerPrior to the CPHC role communication between pri-mary and community care was ‘patchy’, ‘sporadic’ and‘disjointed’, which led to limited co-ordination across ser-vices. Individual electronic patient records are held bymultiple organizations, however there is no interoper-ability between the systems, and the sharing of patientrelated information is limited. The current mechanisminvolves the sharing of a paper based Care Planning Ap-proach (CPA) document between the services; howeverthe physical health information held within the CPA isoften limited, insufficient and outdated.Table 1 Data collection

Data collection Participants Number

Interviews GP staff 18

Interviews CPHCs 2

Interviews CMHT Managers 2

Focus group CMHT staff 8

Questionnaire CMHT staff 13

Table 2 Cardiovascular risk data

Service users Practices

Baseline 186 5

Re audit 1725 55Numbers differ due to natural flux in the case load of the CMHTs. All resultswere adjusted accordingly

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“I think historically, there could have been a bit oftension, GPs wanted us to do things, we wanted GPs todo it and it would end up nobody doing anything. Ithink in most surgeries we work with, that has gone. Sothat’s really good.” (CPHC, CMHT)

The CPHC acted as a co-ordinator across primary andcommunity care, spanning service boundaries, with afocus on improving communication and collaboration.The role was pivotal for facilitating information sharingbetween the GP practices and CMHT, which helped toimprove working relationships between services and pro-moted a greater understanding and respect for profes-sional roles. CPHCs provided a key link between primaryand community care which enabled CCs to provide amore holistic care plan for service users. CPHCs wereseen as a channel or conduit for transferring and integrat-ing service user knowledge, which helped to establish aclear path for maintaining communication and sharing in-formation, as the following quotes illustrate.

“Yes I do think care is more co-ordinated, just throughattending the meetings, we’re now aware what patientsare being seen, what care is being given to thosepatients, and we’re more aware of those patientsourselves.” (Practice Manager, Primary Care)

“Liaison with the [community physical healthco-ordinator] is time saving for Care Co-ordinatorsand enables a better package of care for the client.”(Care Co-ordinator, NW CMHT)

“I think the GPs understand who people are and Ithink they understand the roles of people better. Ithink there was almost a light bulb switched on in onemeeting when they realised the breadth of the CMHT,and also the individuals who look after it.” (PracticeManager, Primary Care)

The two CPHCs were assigned to the position for 0.4Whole Time Equivalent (WTE) (each), the remainder ofthe time they continued in their CC role. This split func-tion was crucial for embedding the CPHC role in prac-tice as it allowed CPHCs to retain their CC skills, retainaccess to appropriate service user and organisational in-formation, meetings and discussions and importantlyhelped to maintain trust and respect from peers.

“Because there’s the side to it that you’re stillembedded in the team, and still carry a carecoordination case load, which as an individual, they’vesaid, keeps their skills at the right level, but it alsolends a credibility to their role in the team, becausethey are a part of that team.” (CMHT Manager)

“They (CPHCs) have the knowledge and contact they’vehad with that patient, and they can explain clearlyabout what the patient is going through, what thepatient needs, and any actions can be agreed prettymuch immediately” (Practice Manager, Primary Care)

Primary and community care staff suggested thatcontinuing to be embedded in the team was an im-portant aspect of the role for maintaining trust andaccessing relevant service user information, both ofwhich were crucial to the successful implementationof the role.

Supporting boundary spannersManagement support and active engagement were seenas critical elements to success in terms of understandingthe CPHC role and providing support, guidance andsupervision. It was imperative for CMHT managementto have an understanding of the commitment requiredto perform the role and the ability to make necessarychanges to individual caseloads. Indeed, the importanceof protected time for this role was noted by one of theCPHCs, a colleague and two managers:

“It is key to the CPHC as a separate, dedicated role,and to give the role protected time and reduced caseload.” (CPHC, CMHT)

“Yeah, I think it’s a full-time job but I think like […]and […] have probably struggled to do it around othercommitments and I think if it’s a permanent role Ithink that should just be their job.” (CC, CMHT)

“it would be very important to have that [CPHC role]as a distinct role because again, bolting that onto acare co-ordinator without the allowance of the amountof time that kind of role would take would be…again itwould be one of those things that gets lost as a priorityin terms of that liaison with the GP practices and for thegeneral medical sort of side.” (CMHT Manager)

“I think people would struggle to do it as a tag on tothe care coordinator …they [CPHCs] have thatdedicated time to go to the GP practices, and to do allthe follow up around that. So they’re not carrying afull case load and then having to do it on top of it,because with prioritisation, the link worker role wouldnaturally go to one side if you carry a full case load,because we have that many competing priorities, andultimately a lot of the priorities is around ourperformance” (CMHT Manager).

Commitment to the role was important for provid-ing the CPHCs with an official mandate to perform

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their responsibilities, which also added legitimacy tothe role, the importance of this should not beunderestimated.Evaluation findings suggest that providing protected

time for the role enabled the CPHCs to develop sys-tems to improve the flow of communication and in-formation within and between services. CPHCs wereself-organising in that they worked with and acrossteams to design ways of working that were tailoredto the local setting, for example, designing MDTmeetings based on the GP setting (i.e. size of prac-tice), small practices held small MDT meetings withGPs. Community and primary care staff workedtogether to develop a flowchart of responsibilities forthe CPHC role which helped to provide someconsistency and continuity across different teams.This helped to ensure that processes were tailored tothe individual setting, rather than taking a generalapproach to implementation. CPHCs designed anddeveloped a method for identifying service users fordiscussion at the MDT meetings. This identificationprocess was accompanied by a method of trackingactions from the MDT meetings, ensuring that theCPHC, CC and primary care staff were fully awareand informed about what had been discussed andagreed at the meeting and what outcomes requiredactions.

“The feedback from the surgeries is fantastic. Theyreally like the form that we’ve come up with in the lastmonth or two, with the colour coding about whetheractions have been completed or not, with all the clientsthat we’ve discussed.” (CPHC, CMHT)

Integrating multiple perspectives around the service userWhile the CPHC was seen as a conduit for informationsharing and communication, the MDT meetings weredesigned as a vehicle for processing this information,with an aim of integrating and building effective actionplans for service users. MDT meetings were conductedin a variety of ways across the teams (see Fig. 1). Thegeneral consensus, however, was to involve, at a mini-mum, a GP, practice manager/administrator, practicenurse/health care assistant and CPHC and to hold themeetings monthly or bi monthly. The importance oflocal requirements and delivery were taken into account,with some MDT meetings designed as a standalonemeeting and others forming part of a wider integratedcare meeting, for example, integrated into existing pallia-tive care or long term conditions meetings. Figure 1 pro-vides an illustration of the various aspects of the caremodel described in this article, highlighting the keymethod of collaboration, the MDT meeting and the vari-ous health care professionals who are required to inputinto these meetings and the various information thatthey are required to provide.Gathering multiple perspectives and sharing informa-

tion across services enabled the teams to provide a co-ordinated approach to the care of service users. MDTmeetings were designed to be a mechanism to share in-formation with an action orientated focus, with all meet-ings producing some form of action plan for eachservice user discussed. These actions included referringservice users to lifestyle programme, medication reviews,disease reviews, for example repeat blood investigations,diabetes checks (see Fig. 3). Attendees at the MDTmeetings designed an action plan for the service users

Fig. 1 The MDT meeting

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based on their integrated knowledge; this action planwas then communicated to relevant professionals acrossand within services.Actions plans were then discussed and reviewed at

MDT meetings. The processes, which were designed tohelp facilitate the flow of communication, were achievedthrough the CPHCs working with CMHT staff and pri-mary care to design local solutions to meet local require-ments. For example, one GP practice found that theMDT action plans were not used effectively, to addressthis issue the team used the plan-do-study-act (PDSA)2

cycle to test new ways of working. The process wasadapted to include a colour coded MDT traffic light sys-tem as a way to clearly decipher the responsibility for ac-tions arising from the MDT meeting. These codes wereused alongside scheduled phone calls with the practicemanager to provide progress updates between MDTmeetings. CPHCs shared information from the MDTmeetings through the traffic light form, or similar docu-mentation, which provided an overview of the actionsdiscussed during the MDT meetings and the individ-ual(s) responsible. The traffic light system was used todenote the status of action: actions are complete (green),action performed but needs following up (amber), actionneeds to be performed or the existing action is outstand-ing (red). CPHCs produced a clinical guidance docu-ment to assist future CPHCs, particularly in relation tothe process of preparing, attending and following up ac-tions from MDT meetings.Engagement with MDT meetings was important for

developing an improved understanding of service user’sphysical health care needs which was a key facilitator fordesigning and delivering appropriate physical health care

management plans. The MDT meetings provided pri-mary care and community staff with a space to shareand acquire knowledge concerning service users’ phys-ical and mental health in a supportive environment. Themeetings were an important opportunity for staff to re-flect on the care of service users and update other keyprofessionals, identifying the availability of, and gaps inknowledge. The primary care team were able to providedetailed information about service users’ physical health,for example, the severity of their physical condition andany recent assessments or screening and the CPHCsprovided information on other factors impacting phys-ical health, such as medication adherence and lifestyle.This collaboration and co-ordination of knowledge facil-itates a holistic approach to care, which is essential forSMI service users as their physical health may be deteri-orating because of a lifestyle issue which may be exacer-bated by their mental health. The MDT meetingsprovided an opportunity for staff to understand the rela-tionship between mental and physical health; under-standing how physical health impacts on mental healthand vice versa. Knowledge integration was focused oncombining knowledge about service users from multipleperspectives around a key objective, rather than simplymaking information and data available. Figure 2 and thefollowing quotes illustrate how knowledge was combinedin the MDT meetings to improve the provision of care.

“The service user had raised cholesterol, I identifiedthat the literature that had been provided to the clientregarding healthy eating had not helped. Followingdiscussion in the MDT it was agreed that he would beappropriate for one to one healthy eating advice from

Fig. 2 Service user case study – CPHC perspective

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the practice nurse. Appointments made and clientattended.” (Care Co-ordinator, CMHT)

“They [CPHCs] have the knowledge and contactthey’ve had with that patient, and they can explainclearly about what the patient is going through, whatthe patient needs, and any actions can be agreed prettymuch immediately” (Practice Manager, Primary Care)

“Increased knowledge about the client: I think you findout things about service users that you and the careco-ordinator and the consultant weren’t aware of andvice versa.” (CPHC)

The MDT meetings provided a forum to discuss anarray of physical health care needs, Fig. 3 shows thebreadth and frequency of issues discussed during MDTmeetings. The figure illustrates the level of integrationacross MDT meetings, highlighting the range of differentactions, from improving the recording of clinical infor-mation and following up with lifestyle service referralsto ensuring that CCs are engaged in the process of help-ing to engage service users. Engagement is particularlyimportant for ensuring service users have critical diseaseand medication reviews and attend for crucial tests orinvestigations. These MDT actions show how CPHCswere able to act as a key conduit of information and acrucial point of engagement across primary and second-ary care, ensuring that these important actions werefollowed up and reviewed. Disease reviews (n=43; 26 %)were the most frequently discussed issue, closely

followed by actions relating to physical health checks inboth primary care (n=32; 20 %) and in the community(via Rethink community physical health assessment(CPHA) n=5; 3 %). Medication reviews, changes and dis-cussions around adherence levels were also prominentin MDT meetings (n=15; 9 %). These findings demon-strate the focus of MDT meetings and the importance ofsharing information across services. To understand howMDT actions were performed and the process involved,we collected accountability data which showed who wasresponsible for each MDT action. Encouragingly, wefound an equal division of responsibility for actions (GPn=34; 21 %, Practice Nurse n=19; 12 % and combinedn=53; 33 %) and the CMHT (CC n=58; 36 %), with anumber of these actions requiring joint responsibility(n=47; 29 %). This shows that primary and communitystaff worked together to implement MDT actions, whichdemonstrates a collaborative approach to physical healthcare management and suggests that collaborative carewas extended beyond the MDT meetings.Alongside the qualitative data, GP practice clinical sys-

tems were re-audited to investigate any changes to re-ported cardiovascular risk clinical information (usingQRISK2 indicators). The data showed that there was amarked improvement of 25.7 % in the quantity of infor-mation recorded. During the start-up of the projectthere was ‘data rich’ QRISK2 scores (‘data rich’ =QRISK2 scores in which the following four factors werealways recorded: systolic blood pressure, HDL: choles-terol ratio, smoking status and body mass Index) for38 % of service users (n=115), post project this had

Fig. 3 MDT actions

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improved to 58 % (n=79).3 At the point of data collectionnot all of the service users had been discussed at an MDTmeeting. As the meetings continue we expect that thenumber of service users discussed will increase and inturn there will be an increase in the follow up QRISK2data. Service users were required to attend the GP practicefor the GP and/or nurse to perform the relevant QRISK2assessments, completing this information helped to estab-lish a clearer picture of service users’ physical health.Despite improvements in knowledge sharing, respon-

dents commented on the continued problem of accessinghard to reach groups. Suggesting that the role of theCPHC had helped to improve care for some serviceusers, however, further work was needed to access moredifficult to reach groups, arguably those in more need ofa co-ordinated approach.

“I think we probably have made contact with somepatients, who we wouldn’t ordinarily have seen. Butthere are still the hard-core that we don’t get throughto” (GP, primary care)

DiscussionIndividuals who occupy boundary spanning roles facili-tate the communication and sharing of expertise, linkinggroups who might be separated in terms of location, div-ision, or function [24]. There are generally two types ofboundary spanner, the first are those who have a dedi-cated role to work as a boundary spanner across organi-sations or settings and connect different groups [25] andthe second are those individuals who undertake bound-ary spanning activities as part of their mainstream job.The CPHCs described in this paper were embedded inthe community care team with dedicated time to per-form the role. The key function of their role was to actas a bridge between professionals and services, spanningthe boundaries of primary and community care. Bound-ary spanning activities focused on improving the sharingand co-ordination of communication, with an emphasison mobilising a shared willingness to collaborate. In es-sence, the role was designed to facilitate knowledgetransfer and integration, allowing each group of profes-sionals to present their specific knowledge in a structureand format that could be integrated with individuals oneither side of the boundary. CPHCs were able to transferknowledge from primary and community care and applythis to each service user, which provided an opportunityfor emergent and shared meaning [25]. The CPHC rolewas developed through “learning by meeting”, as attend-ance at MDT meetings was a crucial opportunity forbuilding personal and collective practice [26, 27].Protected time was a key factor for success and en-

abled the CPHCs to be self-organising. They were re-sponsible for liaising with teams from primary and

community care to design a method of working whichwas appropriate, relevant and locally tailored to theneeds of the service. By appointing an individual to thisrole, rather than simply implementing a set of guidelinesand protocols, a process was developed whereby changesand improvements were designed and embedded intopractice. An example of this self-organisation was thedesign of the MDT meetings, which was based on theGP setting (i.e. size of practice), small practices heldsmall MDT meetings with GPs, practice managers,CPHCs and occasionally practice nurses, larger practicesheld more traditional ‘integrated care’ meetings includ-ing a wide variety of healthcare professionals, such asspecialist nurses and teams (see Fig. 1). The CPHCswere self-organising, adapting their processes in linewith the local needs and requirements of the service,relying on existing interdependencies, i.e. the relation-ships and interconnections between staff. The CPHC fa-cilitated the MDT meetings by leveraging existingrelationships and forging new relationships between pri-mary and community care. CPHCs maintained their CCrole which was critical for developing credibility, a find-ing supported by the literature which highlights the im-portance of boundary spanners acting as legitimateperipheral participants in the communities with whichthey are working and maintaining a strong professionalidentification [28, 29]. As Wenger (1998: 109) states, therole “requires enough legitimacy to influence the develop-ment of a practice, mobilize attention, and address con-flicting interests. It also requires the ability to linkpractices by facilitating transactions between them, andto cause learning by introducing into a practice elementsof another.” [25].While the CPHC was seen as a boundary spanner and

conduit for sharing communication, the MDT meetingswere viewed as a mechanism by which multiple perspec-tives could be shared and integrated to develop andbuild effective management plans for service users.Knowledge integration was focused on combining ser-vice user data and information from multiple perspec-tives around key objectives with an action orientatedfocus, rather than simply sharing information in a pas-sive way. As this was a new process the team were ableto co-evolve and develop new ways of working and newprocesses to communicate, share and integrate know-ledge to improve the physical health care of serviceusers. The role of the CPHC and MDT meetings werenot simply to provide a ‘mechanistic’ passing and pro-cessing of information from one service to the other, butto find a way to develop what Carlile [30] describes as athree stage process of representation, learning and trans-formation. Health care staff had direct contact with theMDT meetings (through attendance), or by indirect con-tact (providing updates and information to the CPHC).

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The information gathered prior to the MDT meetings wasused to build layers of understanding of service users’physical health care needs [12]. The information was thendiscussed exploring different perspectives and developinga holistic picture of the service user and their care needs.This sharing and developing of knowledge was a criticalpart of the process which facilitated transformation, whereexisting knowledge was refined and individuals worked to-gether to collaboratively develop ‘new’ knowledge. Theprocess of representation, learning and transformation,which concluded in the creation of ‘new’ service userknowledge, helped to tailor engagement and care to theservice users’ needs. CPHCs facilitated the process of inte-grating knowledge by coordinating service user informa-tion, personal know-how and experience of individuals,with a focus on problem-solving [31]. Integrating diverseknowledge from multiple sources, often across organisa-tional boundaries, is challenging, but imperative for deliv-ering collaborative care. The MDT meetings providedprimary and community care staff with a space to discussthe availability of information and highlight significantgaps in knowledge.

Strengths and weakness of the researchConsidering the complexity of the environment and theimportance of collaboration and co-ordination of care,this research is an important addition to the extant lit-erature. The research focused on understanding howphysical health care of SMI service users could be im-proved, rather than focusing on specific physical healthoutcomes, such as BMI. The research emphasises theimportance of recognizing “that we are dealing with is-sues of complexity and that there is no ‘one-size-fits-all’solution to the challenge of knowledge translation inhealthcare” [32], by illustrating how a co-ordinating rolecan be used to facilitate the process of communicationand co-ordination across service boundaries. Althoughthe study was focused on one region of England, thefindings can be generalised to other primary and com-munity health care settings, however it is important tounderstand self-organisation within each setting to ap-preciate the variation across local contexts [33]. Thefindings presented in this paper provide some of thiscontext by showing how the CPHC work with primaryand community care to facilitate the process of collabor-ation. Rigour was addressed by collecting data from avariety of healthcare professionals across primary andcommunity care and adopting a mixed method ap-proach to data collection, to extend understanding andadd depth and breadth to the analysis [23]. Data ana-lysis was conducted by more than one person in theproject team and the framework analysis method en-sured that there was consistency in the data collectionand analysis process.

The data clearly indicates improvements made inknowledge sharing and service user care management,however respondents commented on the continuedproblem of accessing hard to reach groups. Therefore,further work is needed to explore access issues for moredifficult to reach groups.The CMHTs were provided with funding for the two

CPHCs (0.4 WTE each), therefore their views may notbe typical of other CMHT staff in practices that did nottake part in this work.

ConclusionsData indicates that the introduction of a two prongedapproach, through a CPHC role and MDT meetings, hasimproved the management of physical health care forpeople with SMI, particularly through sharing of infor-mation, co-ordination of actions, and proactive deliveryof care. The findings suggest that a a co-ordinating role,alongside MDT meetings can help to improve commu-nication and collaboration across primary and commu-nity care. Collaboration of care for SMI service users hasled to the design of joint action plans for the physicalhealth management of service users which can now bediscussed and appraised at MDT meetings. This is animportant finding considering the gap in physical healthoutcomes and evidence that suggests co-ordinated andintegrated physical care of patients with SMI has thegreatest chance of improving physical health care out-comes [34].

Endnotes1QRISK cardiovascular disease risk algorithm (QRISK2)

provides an accurate estimate of cardiovascular risk in pa-tients from different ethnic groups in England and Wales.It relies on the following clinical indicators:a) age, b) gen-der, c) ethnicity, d) smoking status, e) diabetes status, f)family history of angina or myocardial infarction, g)chronic kidney disease, h) atrial fibrillation, i) blood pres-sure treatment, j) rheumatoid arthritis, k) cholesterol/HDLratio, l) systolic blood pressure, and m) body mass index

2The Plan Do Study Act (PDSA) cycle is part of theInstitute for Healthcare Improvement Model for Im-provement. It is a simple tool for accelerating quality im-provement www.ihi.org

3Numbers of service users differ from baseline to auditdue to natural flux in the case load of the CMHTs. Allresults were adjusted accordingly.

AbbreviationsCC, Care Co-ordinator; CLAHRC GM, Collaboration for Leadership and AppliedHealth Research and Care Greater Manchester; CMHT, Community Mental HealthTeam; CPHA, Community Physical Health Assessment; CPHC, Community andPhysical Health Co-ordinator; GP, General Practitioner; MDT, Multi-DisciplinaryTeam; NHS; National Health Service; NIHR, National Institute of Health Research;NWCMHT, North-West Community Mental Health Team (NWCMHT); PCT, PrimaryCare Trust; SMI, Severe Mental Illness; WTE, Whole Time Equivalent

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DeclarationsThis project was funded by the National Institute for Health ResearchCollaboration for Leadership in Applied Health Research and Care (NIHRCLAHRC) Greater Manchester. The NIHR CLAHRC Greater Manchester is apartnership between providers and commissioners from the NHS, industryand the third sector, as well as clinical and research staff from the Universityof Manchester. The views expressed in this article are those of the author(s)and not necessarily those of the NHS, NIHR or the Department of Health.

FundingThis work was funded by the NIHR Collaboration for Leadership in AppliedHealth Research and Care Greater Manchester.

Authors’ contributionsCH, MS and AM collected data; all authors were involved in the analysis andin writing this paper. All authors read and approved the final manuscript.

Competing interestsThe authors declare that they have no competing interests.

Ethics approval and consent to participateFormal ethical approval was not required for the study since it was classifiedby National Health Service (NHS) governance procedures as serviceevaluation. However, all participants received an information sheet andconsented to the recording of their interview and use of their data.

Author details1NIHR Collaboration for Leadership in Applied Health Research and Care(CLAHRC), Greater Manchester, Salford Royal NHS Foundation Trust, 3rd FloorMayo Building, Stott Lane, Salford M6 8HD, Greater Manchester, UK.2Manchester Business School, University of Manchester, Room E26, BoothStreet East, Manchester M15 6PB, UK.

Received: 24 February 2016 Accepted: 21 July 2016

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