Updated: Feb 12, 2021
A reframe that will turn all practice change challenges into wins
The digital age has brought us amazing technological advances, with undeniable benefit and appeal.
There is great hope that this benefit and appeal will be experienced in healthcare, impacting positively on patient care, staff workload and the overall sustainability of the NHS.
This is yet to be proven.
In the context of no absolute proof, GP practices are now contracted to offer digital-first options to patients in terms of how they access services — with the expectation being that this will expand over time to include new ways of data analysis, healthcare pathway design and even treatment provision.
The largest and most challenging system revision(s) for Primary Care in living memory.
The response to these expectations is mixed, with handfuls of practices embracing the challenge and pushing hard to innovate and implement technology at pace. These are often heralded as flagships for the nation and marketed as a future ideal for all.
The reality for most is that these changes have arrived at the most challenging period for Primary Care. The sector as a whole is reporting high rates of staff burnout, unmet demand, staff retention/recruitment issues, and low resource. The task of practice managers and partnership boards being primarily about how to meet demand and keep afloat, in the context of what feels like a burning platform.
The problem is easy to agree on. How to deliver best practice in this context, without burning out or falling apart.
The solution is less clear.
One solution, now contracted in Primary Care services, is the use of online consultation technologies to support patient access and triaging services — based on the rationale that patient need will be better met with less time spent by high demand clinicians dealing with low complex issues. The evidence is light that this is achievable, and the sector is aware of this… which has created a range of negative responses for some teams including disinterest, fear, and anger. This is understandable and should not be ignored.
Online consultation is not for the faint of heart. It is a whole system revision and requires a shift in working for clinical teams, trusting a remote triage model rather than one that requires person-to-person contact with every patient. It requires changes in clinical practice and the models of access to services — a quality improvement challenge that is complex and beyond what many practices have experienced. There is a lack of trust in this approach, in response to how little evidence there is to suggest that this revision is the solution to the problem.
We regularly meet resistance in teams who are being pushed to implement online consultation. There are shared concerns:
will uncapped access lead to increased demand, rather than less demand?
will remote closing create increased risks for patient care?
will digital triage lead to less opportunity to spot other problems patients have, rather than those reported?
will access be equal to all patients (e.g. older patients, those with disabilities)?
will the use of eHubs reduce continuity of care?
These are all valid and are in themselves representations of the problems faced, currently, in healthcare access — and arguably on the increase as the age of the population increases and demand on services increases alongside.
So… how to get past the resistance commonly experienced in teams? Or more helpfully, how to build this resistance into an innovation plan that activates practice buy-in? The answer is in how the change challenge is represented, how your journey towards it is described and what your team agrees to commit to. For many practices, this requires a big shift in how their partnership boards support innovation. More on this below: How to build a learning culture Here we will describe the implementation of online consultation as an opportunity to build a learning culture within your team — which is justified and needed, independent of whether the technology is the solution or not:
1. Create clarity about what the team is signing up to:
Firstly, it is important to realise that a component of the shared challenge for primary care is the fact that online consultation is not a choice — it is now a contracted obligation. This doesn’t reduce the resistance but is a driver if recognised as such. This is not enough but often needs to be restated in team meetings. Resistance now means a larger challenge later when (inevitably) more technology will be coming that needs to plug into innovation successes made now.
For your team, you don’t have to sign up to the idea that online consultation is the solution — rather that you need a solution and that it is worth experimenting with this one, as you are being contracted to and in many cases the technology is funded by the CCG.
The word ‘experimenting’ is key. Your practice needs to recognise that this is a lengthy trial that will reveal what does and does not work. It is not pass or fail, rather a quality improvement initiative that requires you all to get on board with co-creating a plan, trying it, accepting errors and learning quickly — a PDSA cycle (Plan Do Study Act).
It may reveal that online consultation does not work for you — or it may reveal that the model for it to work needs a lot of local adaptation and bending around your existing processes (this is most likely, in our experience).
The practice should consider this an 18–24-month learning project — and not look for wins at a fast pace. We have seen many practices take this long to switch telephone supplier! Change is slow.
Learning to learn as an organisation is key — it will enable you to embrace any change challenge, as change is learning and not threat.
2. Recognise the value of teaming up.
Teaming up is a buzz phrase at the moment, but has real value for practices. Online consultation as a quality improvement initiative will require your practice to pull together an implementation team that are driving the project forward with the backing of the board, but not the total involvement of the board.
The board needs to agree that this 18–24 month project requires a team to deliver and that this team needs some autonomy. This team should reflect the skills and insight needed, so a mix of key people across the practice (project manager, clinical lead, admin, nursing). A group who can meet together often, to review learning and co-create solutions at pace.
They need clinical oversight, yes — but should not need every decision ratified by the partners board or to have vito powers activated regularly in response to partner anxieties or resistance. Agreement that this is the plan is the start of this work — the board needs to agree and to see this innovation team as the conduit of feedback in and out of the project, for fast adaption and learning.
The PDSA cycle becomes:
Plan: the project leader(s) plan the activities into the next period of time
Do: these plans become actions through the team — with tracking to be sure everyone does as they agree.
Study: the innovation team look at the data and feedback and tweak the model with a new plan to solve issues
Act: the actions are shown to the partners for oversight (not for knee jerk input). If there are no real risks or concerns, the green light is given and the planning restarts.
Beyond your own practice, recognise that shared learning benefits all. So team up with other PCN practices and share what you are learning. Hold a regular virtual meeting or a Whatsapp group just for this — this will reap major returns for all.
3. Crash, don’t burn
The project will fail. It will fail again and again. This is the route to getting it right for ALL innovation. Don’t mistake these fails as indications that the solution is wrong, in the early days — realise that it is needed to learn.
WD-40, the famous can of spray stuff that seems to loosen off bolts, fix cars etc.. is called WD-40 (‘water displacement 40) as this was the 40th chemical composition the company tried before the ‘stuff’ was effective. 39 fails before a result. Somewhere in their organisation, the leaders accepted 39 fails on the way to success. And it paid off!
Your board should expect things to sometimes feel harder or less tolerable, but trust the innovation cycle to hear their concerns and make adaptations in an effort to fix this. Trust in learning and don’t blame the innovation team if things feel wrong. Ask yourselves how many fails are ok, what types of fails are ok and what types of fails are not. Build this into your plan so that the whole team know that failing is fine, but fails such as increased risk etc are not — this will reduce resistance as the model will not feel like it has the ability to run wild.
Do not blame any of the team for things going wrong! I can’t overstate this. This blame culture will kill innovation — as your team needs to risk failure to find a win. Embrace the effort, accept the fails and strive for the win.
This is the hardest step for partnership boards, I realise. But the most essential. Partners are not always the best people to lead change — they often don’t even have the capacity. Being distant to the project can make it feel risky, but this emotional response is not a reason to micromanage and sabotage. The board should reflect on this, with support if needed.
4. Reflect and learn
Take the opportunity, as often as possible, to capture the data that you need to see to assess if you are progressing. Continuity of care, patient experience, staff experience, workloads, QOF income trends etc… what data will inform the model’s development.
The board needs to know that this is all being considered, to feel reassured. The practice needs to know what tweaks to the model are steering the outcome towards or away from your overall vision. The innovation team can then justify re-tweaking of the model in the context of this learning… “we are changing X, as we have seen Y and hope to achieve Z”.
The practice should want to embrace this as a learning culture — as this is going to be needed long past online consultation. Innovation is the norm for the NHS and the pace is increasing faster than ever seen before. Being a learning team is being fit for change.
Don’t shy away from the emotions of team members. Ask for them. Validate if people are disappointed, angry, afraid, etc. This is not an attack on the model, but real team feelings. These are data too and should be valued. When this is noticed and captured — recognised in the ongoing planning and tweaking — the resistance in the team is often much less.
Learning not winning is the guaranteed win
Eventually, you will learn what model of access works for you — or if this does not work. This learning is valuable, as it will reveal so much more about your processes, pathways and team issues that, if addressed, will better your existing practice setup. The secondary gains out of change management programmes are always huge — as the pressure of change will reveal cracks and gaps that need attention to move forward. Put succinctly, there are three big wins for your practice if you can embrace this approach to innovation:
you will discover what model of online consultation works for you, in a way that enables your team to get fitter in terms of learning to change quickly.
your team will get additional gains from the learning culture promoted, in terms of understanding why a change programme is hard for you and what you need to attend to.
this method will serve you in the future for any innovation challenges or desires you face. This is how change happens best and the better you are at it, the better your team will fare at the level of engagement and capacity.
Practices that work in this way describe feeling less pressured, more in contact and more aware of what else they need to work on, which has often been left unattended to for many years.
Learn to win
Find out about how we at aim-you can support your practice.