Growing pains

1
Growing pains

• Thoughts about change, mourning professionals,
  groupthink and leadership in primary healthcare

Based on experiences in the field, common
sense, soap series and good books
2
Growing pains

• Ron van t Land
• Former GP
• Quality management for outpatient anticoagulant
  services
• Consultant PHC for Kenniscentrum Eerstelijn (KC1
  / Knowledge Centre PHC)
• Director regional Medical Coordinative and
  Diagnostic Centre

3
Growing pains

• Thoughts about change

4
Need for change

• Dutch working force will not be able to provide
  for future healthcare needs if we go on like this
• Quality is to be controlled, proven and improved,
  more than it is now
• Possibilities grow faster than budgets and
  knowledge grows faster than brains

5
The government approach

• Introducing a market system within an unchanged
  overall budget, thereby accepting
• Increasing cost of transaction
• Pursuit of profit
• Bankruptcies
• Introduction of fortune-seekers
• Steering the interactions between the insured,
  the healthcare insurers and the healthcare
  providers with money, laws and surveillance
• Forcing complex change using the
  unfreeze-move-freeze method by introducing a lot
  of pressure and a certain level of chaos

6
What GPs are forced to do

• Profiling, negotiation, contracting
• Efficiency
• cost-sharing, centralizing purchase, combining
  competence and redesign processes
• Accounting for quality
• System, process and outcome
• Increasing chain participation with other
  healthcare providers
• Professional, financial, strategical

7
What makes it so difficult ?
8
What makes it so difficult ?

• Doctors in general have been trained to be alone
  and lonely in a tricky profession. They tend to
  rely only on their own judgement, even in matters
  that dont match with their own competence. They
  forget to ask for help and support

9
What makes it so difficult ?

• When you Google for managing complex change,
  this is what you get

Dr. Mary Lippitt / 1987
10
What makes it so difficult ?

• Struggling With the Demon Perspectives on
  Individual and Organizational Irrationality

11
What makes it so difficult ?

• As explained by Manfred Kets de Vries
• Ongoing change needs
• Social support
• A strong (internal) locus of control
• Change implicates loss and all the elements of
  mourning are applicable
• Denial, anger, depression
• Acceptance

12
What is the GPs loss ?

• Romantic picture
• Based on very ancient rol models but containing
  very important values
• But also
• Freedom
• Getting limited because of quality transparency
• Monopoly
• Very much affected by the introduction of an more
  or less open market

13
What happens to GPs ?

• Some of them get inspired and creative, but
• Many of them get confused, scared, angry and
  depressed, resulting in
• Territorial behaviour
• Victim behaviour
• Weariness, demotivation and inactivity

14
The GPs challenge

• Try to understand what is happening and the
  impact it has on you. Ask for help if you dont
• Dont victimize yourself. Accept, adapt and make
  what is important for your profession survive in
  a new kind of world

15
Keep it safe and motivate

• Be more careful about introducing market
  mechanisms at regional level where health care
  providers need time to learn how to compete and
  cooperate at the same time
• Ask GPs and other providers for help instead of
  trying to manipulate them. Helping is what is in
  their genes, what they are trained to do and what
  they like to do most

16
Create proper incentives

• Dont simplify by focussing on outcome, but
  reward process improvement
• Pay for ambition, quality focus and patient
  orientation. This is more effective, more fun and
  less threatening
• Leave them part of the profits for further
  improvement

17
About social support

• Good social support is about learning, sharing
  difficulties and celebrating success. But beware
  of groupthink !

18
What leadership must do

• Create safety and trust in the process of change,
  rather than mobilizing fear and anger
• Coach on developing a solid locus of control and
  new points of view

19
Independent leadership

• The GPs own leaders
• The groupthink obstacle
• The question of mandate and trust
• Selling the message to the work floor
• Or outsourcing to a trusted extra party
• Independent towards government, insurers and GPs
• Knowledge of the work field
• Understanding change at all levels

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Take home thoughts

• Part of the difficulty of changing PHC is caused
  by mourning GPs
• Groupthink and territorial behaviour are easily
  induced and very much obstruct the change we all
  need
• To much pressure leads to some improvement and a
  lot of resistance
• Results might be better using independent
  leadership that is coaching on the process of
  change
• Even a GP is just another human being

21
Growing pains

• Dont forget to read The alchemist by Coelho