In part four of this blog series, Ruth Glassborow continues to explore resistance to change, turning now to explore what enables and hinders primary care engagement with change.

Back in 2011 my job included leading work across Scotland to increase the number of people being diagnosed with dementia. In parallel, I was completing a Masters in Public Administration. As primary care had a key role to play in this work, I decided to focus my dissertation on understanding more about the factors enabling and hindering primary care engagement in this national improvement initiative.

This blog shares the insights I gained from interviewing 11 GPs and 2 Practice Managers. Although the sample size was small and non-random, I picked up some useful insights which I would like to share here.  

First things first, all my interviewees highlighted the vital importance of involving primary care in the design of changes which impact on them. Whilst this may seem a statement of the blindingly obvious, in my work I still come across secondary care initiated change initiatives which impact on primary care but have not involved them in any way. And then we wonder why they resist!

Related to this, a key point raised by eight respondents was the importance of personal contact by the individual initiating the change. Why do they want personal contact? Because this recognises that primary care is not a single entity, but rather many different organisations each with their own unique histories, cultures and ways of doing things. Personal contact enables a joint exploration of why the change is considered important and how it might need to be tailored for any individual practice.

Which leads me back to another key issue highlighted in earlier blogs: the importance of change adopters being dissatisfied with the status quo and believing that there is a better way of doing things. In other words, being convinced of the case for change. My interviews identified that there are essentially three elements that make up the case for change in primary care:

  1. Agreement that there is a problem that needs addressing which requires action within primary care
  2. Agreement that the changes being proposed will deliver benefits to the individual practice
  3. Belief that the benefits justify the costs.

This immediately leads to the question: what benefits matter most to primary care? The following table highlights the type of benefit mentioned in the interviews and the number of respondents who mentioned it.

Table: Classification of benefits

I think it is important not to gloss over the first: benefits to patients. Every single interviewee highlighted this as a critical factor in deciding whether to engage in a change initiative. Indeed this aligns with my own experiences over the last three decades of working in healthcare. The vast majority of clinicians are motivated to provide high quality patient care and they will resist change which they think will have a negative impact on patient care. Personally, I take comfort from this knowledge, as I would hate to work in a system where clinicians willingly implemented changes which they thought would have a negative impact on the quality of care being provided.

The other benefit mentioned by all interviewees was whether implementing the change would increase practice income. In my experience, this can get translated into an unhelpful stereotype that GPs won’t do anything unless they are paid for it. In reality it is more complicated than that.

The finances do matter, particularly for GPs who are self-employed and running their own business. If those of us working outside primary care had to pay out of our own pockets for a locum to cover our work when we were attending a meeting, I am sure we would either not attend or ask the organisers of the meeting to pay for the locum cover. This is the day-to-day reality for many of our colleagues in primary care. Furthermore, if you ask them to make a change that increases workload to the extent that they have to pay additional hours to their staff, the financial costs of that ultimately comes out of their pockets. So no wonder they want compensating for it. I think most of us would too if we were in their shoes.

However, my interviewees highlighted that it is not just about the money – overall the benefits of the change must outweigh the costs and there is often a complex relationship between the two that can vary between practices. The water is then further muddied by the role that evidence plays in the overall cost-benefit analysis. This is something we will explore further in my next and final blog in the series.

This fourth blog in the series has highlighted insights gained from interviewing GPs and Practice Managers. The next and final blog in the series on resistance to change highlights some of the specific factors that need to be taken into account when working with primary care.

Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.