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Team approach

Building the team is another critical area for practices to develop. Everyone in the team is equally important, from the receptionist to the business owner. Find out how other teams have changed their way of working so that everyone feels valued, heard and contributes to transforming the work environment.


Why is teamwork important for delivering self-management support?

Patients’ knowledge, attitudes and behaviours impact on their health outcomes in important ways. How well a patient “self-manages” is influenced by their healthcare experiences. When patients have negative experiences, such as being ‘told off’ for failing to lose weight or remembering to take their medicines, they often respond by non-adherence, loss of confidence and inertia.


Simply telling people what to do isn’t an effective way to help them improve their health outcomes. Patients often receive mixed messages from healthcare providers, which leave patients confused and less able to engage in their own health care. Many people will trust others to provide them with information and support and increasingly people are seeking help and information via the internet and their own social networks.


To achieve better outcomes, primary care teams need to support patients and help them become better managers of their own health. Self-management support is a collaborative process that enables patients to take better care of themselves. To do this effectively all members of the practice team need to be ‘on the same page’. This is true not just for the core practice team but should also include other clinical disciplines that are involved with a persons’ care as well as their wider social network and people who are important in their lives.


Working as a team facilitates effective delivery of self-management support by improving patients’ involvement in their care, building skills and confidence, and helping people to change their behaviours.


All of this contributes to better health outcomes and higher patient and health provider satisfaction.

  • Are you wondering if your teamwork supports people to self-manage?

  • Thinking of improving your teamwork and don’t know where to start?


Try doing one of the assessments:

What do we mean by 'team' and what makes good teamwork?

As Ed Wagner has eloquently described “the traditional image of a solitary family doctor – concerned, vigilant, thoughtful – seated at the bedside of a desperately ill child …bears little resemblance to modern medicine, and not just because house calls are a thing of the past. Modern medical care involves complex, rapidly changing interventions and treatment plans, and the activities of multiple people, disciplines and institutions.” 


Research has clearly demonstrated that one of the key enablers of safer, more effective medical care is teamwork. Studies have also shown that simply working together in a clinic for a number of years does not automatically ensure that the group functions as an effective team.


McKinlay and Pullon wrote about the challenge of teamwork within primary care in New Zealand and have since identified what they

describe as ‘tips for teamwork – NZ solutions for the wicked problem’.

  • Requires shared goals, training, leadership and resources.

  • Making time to build a team.

  • Persistence and patience: an effective team will not happen overnight.

  • Geographical location: working in close location helps build teams.

  • Social connection: having fun together.

  • Regular team meetings at a time when everyone can attend. Clear purpose, agenda and leadership.

What does a primary care team that delivers self-management support look like?

Much has changed in recent years as our understanding, about self-management support grows. We now know that we need a more holistic approach that includes cultural, social and behavioural skills.


A recent Commonwealth Fund report identified as one of the key recommendations that care ‘move away from disease-specific care delivery and toward more patient-centred approaches, or away from the single-provider model and toward cooperation and teamwork’. 


For most general practices in New Zealand, delivering a care model that is person-centred and provides people with holistic self-management support will require a change of service delivery style and structure.


Changing staff roles and workflows is hard, disruptive work. It doesn’t happen unless practice leadership is motivated to change, and the practice team has the same vision and goal around what they want to achieve. However, there is a lot to be gained by making these changes. Practices that have made some of these changes have seen improvements in, clinical quality/patient health, patient experience, reduced hospital and ED admissions, and less staff burnout and greater career satisfaction.

Who are the people – what could the team look like? 

A modern general practice team in New Zealand is usually made up of the traditional GP and practice nurse and admin/reception staff. There are usually links to a broader group of clinicians such as a pharmacist, hospital specialist, psychologist, allied health etc. In some cases, this has been formalised into a multidisciplinary team which is supported by structures such as regular team meetings, case conferences etc.


In New Zealand, in recent years we have seen a growth in interest and investment in lay or non-regulated workforce. Roles such as kaiawhina, peer support worker, community health worker and health coaches are becoming increasingly acknowledged as critical components of a person-centred care delivery model and important conduits in the delivery of self-management support.


Why is it important to rethink the role of the primary care nurse?

The role of nursing in primary care has evolved significantly in the last 50 years. Nurses provide a unique set of clinical and management skills, that when used to their fullest potential, can enhance the primary care team and improve patient care. Primary care nurses are uniquely placed to provide care coordination and management for patients who have complex or chronic health problems.

Case Studies – examples of how a nurse leads in a practice

Expanding the team and new roles

The health needs of communities are changing and the model of care needs to change accordingly. Read about some of the new roles that are appearing in primary care teams and how others are working at the top of their scope as primary care nurses, community health workers, pharmacists and more


Case studies


Pacific Health Navigator Team

The Pacific Health Navigator (PHN) team are employed by Compass Health PHO and work in Porirua and Wellington. The service was formed in 2012 as a result of a review of the Pacific services provided in Wellington region. Read about the team, the challenges they've overcome and their work with Pacific families. 


Porirua Community Health Services


Porirua Community Health Services (PUCHS) is a not for profit, incorporated Society serving a very high needs population based in Porirua. They have worked hard at developing a broad team to meet the many varied needs of their population. 

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Robyn, Community Health Worker, Hora Te Pai

Robyn is a Community Health Worker at Hora Te Pai Health Services, based at Paraparaumu on the Kapiti coast just north of Wellington. Robyn’s role has a wide scope and she is encouraged to support people in their health and wellness. She is clear about boundaries and doesn’t do any clinical assessment or answer clinical queries. She has completed the Health Care Assistants paper and has over 20 years experience working in the health system in a range of roles.

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Team building Cook Islands style

Tivaevae (means patchwork in Cook Island Maori) and is a traditional Cook Island quilting method done by women. Read how this was used to as an innovative health promotion and team building exercise to promote cervical screening. 

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West Coast Navigators

The West Coast Health Navigator programme was first funded in 2007 as part of a Ministry of Health project supporting people with cancer. The initial project was very successful and now the PHO funds the service from the LTC programme and has extended the service to include other long terms conditions (CVD, diabetes and respiratory) plus people who have complex social problems.



  1. Wagner, EH. (2004) Effective teamwork and quality of care. Medical Care. 42(11):1037-9.

  2. Pullon, S. McKinlay E, et al. 2011. Patients’ and health professionals’ perceptions of teamwork in primary care. Journal Prim HCare, Vol 3, No.2.

  3. Owens J, Entwistle V 2017 Was that a success or not a success?”: a qualitative study of health professionals’ perspectives on support for people with long-term conditions.

  4. Whitelaw S, Thirlwall C, Developing and implementing a social prescribing initiative in primary care: insights into the possibility of normalisation and sustainability from a UK case study.

  5. Designing a High-Performing Health Care System for Patients with Complex Needs: Ten Recommendations for Policymakers, Expanded and Revised Edition, The Commonwealth Fund and the London School of Economics and Political Science, September 2017.

Explore the other sections in Implementing Self-Management Support

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