In the last part of this blog series, Ruth Glassborow highlights some of the specific factors that need to be taken into account when working with primary care.
In part four of my blog series on resistance to change, I started to share my findings from interviewing 11 GPs and 2 Practice Managers around what helps and hinders their engagement with change initiatives. I highlighted:
- the importance of the individual initiating the change making personal contact with practices
- the necessity of being able to demonstrate the benefits for patients
- the reason why attention does need to be given to the financial case for change, and
- that 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.
This is the new bit. In addition to the above, evidence that change will lead to better outcomes was highlighted as important by a number of the GPs I interviewed. One GP went as far as saying that, for a current change initiative, he was deliberately avoiding the evidence in case it persuaded him that he needed to do something he didn’t want to do.
However, in practice, GPs consistently engage with change initiatives where there is limited evidence. Why is this? Why does evidence matter in some situations but not others?
My interviews highlighted that GPs do not need a strong evidence base when they can intuitively see the benefits of a proposed change and the change fits within current cultural/professional norms. However when either of the reverse apply then evidence becomes a key issue.
Further, the issues around evidence and finance interface with each other. So to help change initiators to think through how well their idea is likely to be received, I’ve summarised the role of finance and evidence in making the case for change in primary care in the following flow chart:
You can find more information about the findings behind this.
A very practical example of this is our current work in Scotland to develop and roll out approaches which reduce the amount of time GPs spend reviewing documentation. Following initial prototyping work with practices, we are now running a national programme to spread the work to further practices. We’ve had enormous interest from primary care as they can intuitively see the benefits of a change which reduces the amount of time they spend on paperwork (in one of the prototyping practice by on average 5 hours a week). It is a change that fits with current professional and cultural norms (who doesn’t want to do less paperwork?) and we’ve resourced the roll out alongside providing the evidence that once implemented, the change will save GP time on an ongoing basis. When you work that scenario through the above flow chart, you end up at a green box; a change that is ready for implementation. Which explains the level of interest we’ve seen in participating in the spread programme.
Where the flow chart is perhaps more useful is when a proposed change ends up at an amber or red box, as this highlights that the change may not yet be appropriately designed for successful implementation. From a practical point of view, it also provides ideas about adaptations that may be necessary to overcome the potential resistance.
In summary, this final blog in my series on resistance to change has highlighted some of the specific factors that need to be taken into account when working with primary care. I am conscious that these findings were based on a small non-random sample. Further, in Scotland the new contractual arrangements in primary care have bought a different context that may also impact on their validity. So I share them as insights to spark some further debate on how we can effectively engage primary care in the current modernisation agenda, and hopefully, to help with thinking through how to design improvement initiatives that are likely to succeed.
I would love to hear the views of those working in primary care whether any of the above resonates with your experiences and what you think about my analysis of the role of funding and evidence.
Resistance to Change – Blog Series Links:
Ruth Glassborow is Director of Improvement at Healthcare Improvement Scotland.