Can we make sense of multidisciplinary co-operation in primary care by considering routines and rules?

Although it is widely acknowledged that the complex health problems of chronically ill and elderly persons require care provision across organisational and professional boundaries, achieving widespread multidisciplinary co-operation in primary care has proven problematic. We developed an explanation for this on the basis of the concepts of routines (patterns of behaviour) and rules, which form a relatively new yet promising perspective for studying co-operation in health-care. We used data about primary care providers situated in the Dutch region of Limburg, a region that, despite high numbers of chronically and elderly persons, has traditionally few healthcare centres and where multidisciplinary co-operation is limited. A qualitative study design was used, in which interviews and documents were the main data sources. Semi-structured interviews were conducted with providers from six primary care professions in the Dutch region of Limburg; relevant documents included co-operation agreements, annual reports and internal memos. To analyse the evidence, several data matrices were developed and all data were structured according to the main concepts under study, i.e. routines and rules. Although more research is needed, our study suggests that the emergence of more extensive multidisciplinary co-operation in primary care is hampered by the organisational rules and regulations prevailing in the sector. By emphasising individual care delivery rather than co-operation, these rules stimulate the perseverance of diversity between the routines by which providers perform their solo care delivery activities, rather than the creation of the amount of compatibility between those routines that is necessary for the current, rather limited shape of multidisciplinary co-operation to expand. Further research should attempt to validate this explanation by utilising a larger research population and systematically operationalising the rules existing in the legal and--more importantly--organisational environment of primary care.