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Case scenarios

Case1.

You join a 3 doctor practice as a principal. The practice has a "telephone request" book. Patients can ring and ask for a prescription rather than seeing the doctor as an "emergency". Most of the requests are for children or young adults with "cough" who are requesting antibiotics. The other partners prescribe without seeing the patient but you are not happy to do this. You decide it is time for change! At the next opportunity you raise the subject with one of your partners who says, " yes, I was the same when I came here, you’ll learn". What do you do now? How can you try and change your partner’s practice?

Case 2.

You return from a weekend meeting on evidenced-based medicine. You want to use some of the skills you have learnt. You feel that a good way to start would be to run a jornal club in which each of the members of the team would critically appraise a topic of their choice. At the first meeting you find that only one of the nurses turns up. The rest of the team doesn’t. Why? How could you manage this situation to improve the turn out?

Case 3

You perform an audit looking at the recording of body mass index in women on the combined oral contraceptive. You present the audit. The practice performance falls well below the standards you set based on national guidelines. One year on you repeat the audit. There has been no improvement. Why?

Case 4

At a practice meeting the partners decide that they will start charging for holiday vacinations. The practice manager writes a memo to the practice nurses telling them of the change in policy. Two weeks later one of the practice nurses resigns. Why??

Activity.

For each of the above:

Look at the cases from the perspective of the incoming partner and the practice team.

Discuss these with you peers, trainer and probably most useful of all your practice manager!

Think back to the last time you were asked to do something new, how did you feel??

Notes:

"the only thing constant about the NHS is change"

Anon…….I think??

Change is inevitable but its management is often haphazard. In order to facilitate change we need to:

Reaction of individuals and organisations to change.

In order to change you have to leave you past behind! You might have been very happy with the past and so the reaction to change is often compared to a grief reaction.

The reaction to this "perceived loss" may include:

" I don’t drop players. I make changes."

Bill Shankly 1914-81.

The perceived loss or anxieties may be related to:

Rsistance may be due to:

  1. Self interest
  2. Lack of trust
  3. Different assessment of the situation or priorities
  4. Low tolerance of change.

But equally it may be due to:

  1. Lack of information and Poor communication
  2. Stress, increased levels of stress reduce desire for new changes
  3. Resource concerns e.g. time, workload

A behavioural model of change recognises the following stages.

Pre-contemplative no reason for change has been given

Contemplative information about need for change is available e.g. benefits

Preparation plans for change

ACTION

Maintenance reminders of change and why it was instituted.

Tips for effective change management.

Ask

Why change?

Motivation may be external e.g. FHSA demands an annual report from you, or internal. The motivation may or may not be shared by your partners or team members.

Why now?

What is my/our vision for change?

This vision may be your own or the practice’s. Share your thoughts with your partners. This can be done informally initially to gauge their thoughts. General practice’s are like a marriage, at times you have to test-the-water with your spouse before revealing your plans to go away for a weekend of golf!! Your partners are noe different. Watch children do it with their parents……they are experts.

Find out your partners vision. What do they perceive your role in the practice to be. Do you feel on equal ground with them at present? Identify the innovative individuals in the practice as these are most likely to be interested in change.

How far are we away from our vision?

How did we get here?

The practice is made up of a number of personalities and has a history. Don’t ignore this. Find out if the change has been tried before, what happened? But don’t be put off by "failures" but use these as learning experiences!

Now you are in a better position to start the change process by:

Agreeing a topic for change

Explore barriers to change

Look for incentives for change

Ensure good communication

Provide support

Monitor and evaluate change and report back

When faced with resistance to change you can:

The first three take time.

The Key messages from the management Gurus are:

  1. Involve people involved from an early stage
  2. Have a good reason for change
  3. Put a respected person in charge
  4. Plan the change throughout the organisation
  5. Train if necessary
  6. Install systems to manage change
  7. Acknowledge and reward people
  8. Provide clear leadership

References:

Pringle M, Hayden J, Procter A. A guide for new principals. Oxford University Press. 1996. 90-101.

Risdale L. Evidenced based Pracitce in Primary Care. Churchill Livingstone. 1998. 180-183.

Effective Health Care Bulletin. Getting Evidence into practice.

Try Yahoo and search on "change".

Francisco Machado 1999.
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