Innovating under pressure: Primary Care, COVID-19 and online consultation.

What primary care teams need to support rapid innovation to meet the current crisis


There is mounting evidence that COVID-19 will pose a significant threat to health systems around the world. Not only the increased demand for services for the unwell and the potentially worried well but also the real likelihood that health care staff themselves are likely to need time off sick during the crisis. A health service model that is reliant on face to face, where patients wait together in small rooms for consultations — seems ill-prepared for a highly contagious virus. This much is apparent.


There is a contender in the digital technology arena to support a change in services that could be of great value in this context — online consultation. The shift from face to face consultations with all patients, to a remote digital triage that affords services the ability to remotely identify which patients are best served, in the health service. There is anecdotal evidence that this model speeds up access to services, provides more immediate responses to patient requests for assessment and could quickly funnel those at risk of spreading COVID-19 (or other conditions) to specialist service sites. This solution appears to be rising as the innovation goal for Primary Care — at pace.


This could provide a quick sense of relief. However, the introduction of online consultation is not new and has been a priority for the NHS for some time now — with contractual obligations on primary care to meet this innovation shift, that few primary care teams have embraced or succeeded with. This is a problem and is not a representation of stubbornness in the system.


The challenge of large scale change

For Primary Care teams, the task of adapting their access models to support full-triage online consultation is not a small challenge. It is a full system revision. This is difficult for any team, in any organisation, where systems or processes are long-established. Particularly for medicine, where processes and practice is trained into all of the team as a part of their professionalisation. Everything about Primary Care teams has been pre-built to host staff who meet patients, who come in person (or telephone).. and the whole system is familiar with this (including patients).

Change always raises fear and resistance in systems. Nobody really likes a change, unless the merits of it are really obvious or really desired. Online consultation has not proven that yet. In fact, patients often react against it as a concept — feeling that a loss of contact with clinicians is a second rate service… and many clinicians feel the same. COVID-19 may create an appetite for service change, as many might agree that meeting each other and sitting in small spaces with coughing / sneezing people is a bigger fear than a change in the model. Others may feel that there is just no choice and the crisis will push the change through quickly. But this cannot be assumed and needs support.


Change at pace?

The NHS is not famous for its ability to change rapidly. There are many references to how good ideas can take 5–7 years to implement across the system. The system rarely has to change at a large scale in a short time to meet a pandemic, and so its capability to do so is not tested. Appetite may be present, but it is feasible that many staff don’t believe the rapid change is possible. Even in a world where all teams say yes, there is the issue of the ‘soft stuff’ that underpins success in most change programs.

There is enough written in the change management sector to demonstrate that the psychological and organisational structures around change challenges are crucial in the success of innovation. Most change projects that fail, fail for these reasons. If the correct environment of support, engagement and skill development is created — the chances of success are much higher.

Currently, Primary Care is already in the context of staff shortages, staff burnout, unmet demand and increasing pressures to innovate. This has not gone well, with repeated publications relating to the sustainability challenge for Primary Care and the exodus of staff. If the government decides on rapid change as a goal and is prepared to “spend whatever is needed”, it will want to put change capability on the top of its list.


Change capability Need

Rather than trying to define this, here is a list of red flags in the narrative of innovating in a crisis, that are potentially problematic for change.

This is a call to those at the top to hold in mind a number of ideas relating to change, when pushing for pace:


Pressure does not equal pace.


Simply having a need for fast change does not create fast change. The pace of change is dependent on many, many factors and teams are at different stages in relation to this. High resource teams who are already on the path to digitisation will change much quicker than low resource teams, with ill staff, long waiting lists and problems within their own teams in terms of leadership. Pressure simply puts further strain on these cracks and can crack a team.


The scale of needed change will be preset, the pace will not. CCGs need to recognise that each team will have its own pace and will need bespoke support. Witnessing teams trying is worth celebrating!


Unachievable targets create apathy


Teams need high-performance goals that are both achievable and safe to reach for. When targets are made too difficult to achieve (either by scale or deadline), there is a risk that teams simply detach from the narrative. Either failing to see any reason to start the impossible or feel that the agenda is set outside of the awareness of the challenge being set. This creates a real sense that failure is likely, which will reduce a team’s willingness to risk the challenge — particularly when they have experienced blame many times over in the media, for getting it wrong.


Communicating and being visible in supporting the challenge teams face, in relation to pace and capability of each team, is essential. Getting close to them and understanding where their rate limits are will be essential to combat a broader sense that teams will either lose or win in this endeavor.


Buy-in is the key


Change management is dependent on engagement. Teams and leaders need to agree on the goal, the narrative and the method of innovation. This is built on a range of variables including the safety for the project to fail and learn, the project goals being compatible with existing systems it needs to fit alongside and the vision of the project connecting with the drivers of the team. When engagement is not there, teams don’t work hard to solve problems but see failure or innovation pain as evidence that the solution is a bad fit. No matter the sense of urgency, without engagement from the team (and public) change will not be easy.


COVID-19 cannot be assumed to create engagement for patients and teams in any health service change model. Both need clear communications about the benefits, the support available, the scale of the challenge and the rationale for the fast pace. When teams feel that patients are on board and their commissioners are supportive, buy-in emerges — and buy-in creates pace.


One size fits all does not create buy-in


At the local level, teams need help to find their reasons to change at pace. This is beyond the national pandemic threat and more attuned to the culture of the team and its journey of innovation in the past. Receptionists may not connect the same understanding of the broader threat as GPs, but there are likely shared narratives that can be explored. Rapid change needs whole team buy-in. Online consultation is a whole team approach and the changes needed are substantial at all levels.


To meet this need, the models of online consultation on offer need to have adaptability at their core in some part. One size does not fit all — and ownership/adaptability will increase the ability of teams to buy-in. This may need to be restricted to small adaptations, to support scale — but small adaptations are better than no adaptations.


Attend to the soft stuff!


In the best scenario, investment is needed in these areas to support the teams. In the absence of such investment, recognition is needed that teams are being pushed in the worse scenario for change to happen.


Ideally, additional staff are needed to support the above, the soft stuff… which is in fact the ‘hard stuff’ for teams.


In our experience, spend should be directed to:


  • increased visible and accessible project management support in implementation.

  • increased change management support that is creative and remotely accessible.

  • increased local and regional comms support (for patient and team buy-in)

  • collaborative spaces for teams to interact (share learning) and debrief (offload stress) — which can be online digital spaces.


Finally


As the pressure mounts and innovation potentially emerges as the solution, don’t blame any part of the system for failing. CCGs might struggle, teams might struggle, individual staff might struggle. Respond to challenge, resistance, defeat, apathy, stress etc with an open willingness to support and meet need. All of this is to be expected and the model needs to be designed to listen for and then meet the need.


Humans evolved to be curious, to grow, to want to improve… but only when the environment invites and nurtures this. Let’s not forget that, even in a crisis.


Good luck to the staff who potentially face this challenge!


Ready


Steady