Implementing change within a General Practice can often be quite challenging. It’s a curious thing because General Practice is subject to frequent change in terms of the expectations of outside agencies such as their clinical commissioning group, primary care network, possibly external funders, NHS England, etc. One could even argue that General Practice is a great example of an organization that most often does a great job at responding to change very rapidly because they are asked to do it so often.
However, because of the high-pressure environment created by the constant demand to adapt to change very quickly and frequently, the way a practice adapts can often be a very reactive process rather than something that’s very considered. There often isn’t time taken to carefully plan ahead and consider what might work best under which conditions and scenarios and for whom, including consideration for what might be most effective for both staff and patients. The difficulty is in finding the time to plan meaningful change as well as deciding how best to measure the impact.
Quality Improvement (QI) offers a model for implementing change called the “Plan, Do, Study, Act” Cycle (PDSA Cycle). This approach encourages General Practice to take the time to carefully consider and implement what changes might work best as well as to think about what measures they might introduce to monitor that change in order to observe and measure the genuine impact. This model is very much a “what” to do that begs the all-important question of “how” to do it, which is where psychology has a lot to offer.
I would define the “what” in change, for any organizational or institutional change, as the plethora of theories and models that claim to tell us exactly what to do to get the changes we want. We are spoiled for choices in terms of pictures and diagrams and models claiming to tell us exactly what actions to take to lead us to those changes. Of course, the bit that’s missing from all of that is the all-important implementation process of method, I.e. “how” to do it.
I like to use a cooking analogy to explain the difference between the “what” and the “how”. In this analogy the ingredients listed in a recipe represent the different theories and models (the various “whats”) we have at our disposal—all of which are valuable! But without the method (the “how”) we won’t really know how to put those ingredients together to create the delicious dish we want. We need guidance on how to combine the ingredients, how to cook them, how long to cook them, and whether we need to add the onion to the pan before adding the tomato, for example. Otherwise, we’re just left with a list of ingredients that nobody really knows what to do with.
It is unavoidable that, as people, we simply don’t know what we don’t know. There are a lot of good intentions behind the suggestion of various models and theories in an effort to help people understand how to implement change, without the full realization that we’re still within the realms of “what” when what we really need is the “how”. Health and social care, and other such organizations, can often be guilty of trying to reinvent the wheel when we could probably do better to draw from the learning and expertise of psychologists who have known a lot of these things about implementation processing in change for over 60 years at least.
Some people call it sharing good practice but I like to call it stealing really good ideas, and psychologists have got really good ideas about how to implement change. In the QI community we haven’t yet really capitalized well enough on that skill base and that area of expertise and knowledge. Certain models like Experience-Based Design and Appreciative Inquiry are starting to build momentum in in the QI world, but even those are more “what” with not enough of the “how”. That’s why, for me, Xytal are real pioneers of this kind of thinking because we are starting to utilize learning from psychology to help deliver the “how” —and not at the expense of the “what”.
From this perspective, the “how” is very much a way of being with one another; a true partnership. Motivational Interviewing (MI) is a great example of a person-centred approach to communication which is highly collaborative. Everything is done in partnership; nothing is done “too”, everything is done “with”. It centres around questions like: How do we show empathy? Might we be listening more reflectively? Might we be using more open questions instead of closed ones? To really understand the perspectives of others, instead of simply telling them why change has to happen, are we asking them what they think about this change? What’s in it for them? How might we find something within this change that they might find beneficial or enjoy?
So, what outcomes can practices expect to see when they choose to focus on the “how” in this way? A good example might be higher rates of satisfaction at work, the feeling amongst staff of being included, potentially even a positive impact on overall personal well-being at work. Impact can also be felt in the leadership style of the management and other leaders within the practice. Has it become much more inclusive rather than direct? If so, these are all areas in we can learn a lot from psychology and therapeutic learning. These outcomes, though perhaps difficult to measure and quantify, can make a real impact with regard to how successfully a General Practice is able to navigate change. As Bananarama would say: “It ain’t what you do, it’s the way that you do it. And that (really) is what gets results!”
This blog was written by Dr Charlotte Hilton.