affected development of psychosocial maladjustment
and stigma.
1 Levine R, Banks S, Berg B. Psychosocial dimensions of epilepsy: a review of
the literature. Epilepsia 1988;29:805-16.
2 Dodrill CB, BreyerDN, Diamond MB, Dubinsky BL,Greary BB. Psychosocial
problems among adults with epilepsy. Epilepsia 1989;25:168-75.
(Accepted 12 March 1992)
Managing Change in Primary Care
Learning from the past
Justin Allen, Andrew Wilson
This is the second in a series of
articles looking at how to
manage change in general
practice
Countesthorpe,
Leicestershire
Justin Allen, general
practitioner
Department of General
Practice, University of
Leicester, Leicester
LE2 7LX
Andrew Wilson, senior
lecturer
Correspondence to: Dr
Wilson.
Series edited by:
Dr M Pringle.
BMJ 1992;304:1418-20
1418
Doctors in a three partner practice do all their own on
call out of hours work in an equal rota of nights and
weekends. The senior partner is aged 56. He has given
vague hints that he is planning to retire at 60 but has
never confirmed this. His two junior partners have
been in the practice for three and four years respectively. At a partners' meeting he announces that he is
proposing to give up his night work as he is finding this
increasingly irksome, and has done it uninterrupted
for the previous 27 years. He is proposing that the
change should take effect from the beginning of the
next quarter, in six weeks' time. His proposal is that
the junior partners would take over his responsibility
and in return would share all the income received for
night visists. Much to his surprise he is met with an
angry refusal. Hurt and rejected by this response, he
gets angry and threatens to dissolve the partnership
and the meeting breaks up in uproar.
Most practices will be able to recall similar examples
of proposed change going wrong. But most can also
point to changes that have been successfully implemented and found to be beneficial. Change, or the
possibility of it, is with us all the time. This ranges
from the major externally imposed upheavals that have
been a feature of general practice over the past few
years to minor adjustments within the practice. All
practices, therefore, have a wealth of experience of
change. Can they use these experiences to improve
their management of change? According to Socrates,
experience has taught our best flautists, but it has also
taught our worst. The following questions allow a
practice to review its changes over recent years.
How much have we changed?
Has the practice been either too stagnant or too
unstable? The degree of change and its frequency
should be considered. One major change, such as the
breaking up of a partnership, might have prolonged
repercussions. However, frequent small changes may
also have an impact. In industrial settings frequent
environmental changes have been shown to boost
productivity (the Hawthorne effect). In contrast,
general practitioners often complain about the frequency of minor changes, such as to standard referral
forms or protocols for child health surveillance.
Have changes been in response to external events or
have they been initiated internally? Changes resulting
from a perceived need are clearly more likely to be
* Much can be learnt from practices' experience both
of proposed change going wrong and of successful
change
* Changes resulting from a perceived need internally
are more likely to be welcomed than those imposed
from outside
* Practice members will have a wide range of different skills to offer and different attitudes towards
change
* There must be a workable structure for decision
making and style of management
* The way a change is implemented is important to its
success
* The effect of change should be evaluated
welcomed and are less traumatic and frustrating than
those imposed from outside. This also applies within
an organisation; although some members of a practice
might feel in control of internally generated change,
this does not necessarily apply to others.
What is our attitude to change?
It is unlikely that all members of the practice feel the
same about the benefit or otherwise of change. In any
group some will be good at having new ideas, others at
analysing positive and negative features of proposals
for change, and others at actually initiating change and
making it work. As well as there being such a range of
skills, attitudes to change will also differ. Some may be
naturally conservative and difficult to persuade that
any change is better than the status quo. Others may
resist change for more pragmatic reasons and argue
that it is not worth the disruption it would cause. At the
other end of the spectrum some may enjoy the process
of change and respond to problems by suggesting a
change to the system rather than by trying to make
existmg arrangements work.
Such a mixture is beneficial to an organisation-if
everyone excelled at new ideas but not at following
them through little change would occur and all would
be frustrated. The benefit of such a mix of skills and
attitudes, however, can be realised only if individuals
are aware of their own attributes and those of others.
Practices may wish to explore this in a formal way
by using recognised psychological tests or informally
BMJ
VOLUME
304
30 MAY 1992
BMJ: first published as 10.1136/bmj.304.6839.1418 on 30 May 1992. Downloaded from http://www.bmj.com/ on 6 June 2020 by guest. Protected by copyright.
We are grateful to the British Epilepsy Association Research
Fund for sponsoring this research and to the National Society
for Epilepsy for their assistance in making the research
possible. The medical aspects of the national general practice
study of epilepsy have been generously supported by Action
Research and the Brain Research Trust. We also acknowledge
Dr J W Sander and Dr Y M Hart for their assistance.
3 Shorvon SD. The temporal aspects of prognosis in epilepsy. J Neurol
Neurosurg Psychiatry 1984;47:1157-65.
4 Hart YM, Sander JW, Johnson AL, Shorvon SD. National general practice
study of epilepsy: recurrence after a first seizure. Lancet 1990;336:1271-4.
5 Sander JW, Hart YM, Johnson AL. Shorvon SD. National general practice
study of epilepsy: newly diagnosed epileptic seizures in a general population.
Lancet 1990;336:1267-71.
6 Hart YM, Sander JW, Shorvon SD. National general practice study of epilepsy
and epileptic seizures: objectives and study methodology of the largest
reported prospective cohort study of epilepsy. Neuroepidemrioloy 1989;8:
221-7.
7 Chaplin JE, Yepez R, Shorvon SD, Floyd M. A quantitative approach to
measuring the social effects of epilepsy. Neuroepidemiology 1990;9:151-8.
8 Nunnally JC. Psychometric theory. New Delhi: Tata McGraw-Hill, 1981.
9 Wright GN. Rehabilitation and the problem of epilepsy. In: Chigier E, ed.
New dimensions in rehabilitation. Tel Aviv: Gomeh Scientific, 1978:492-6.
10 Rodin EA. Medical and social prognosis in epilepsy. Epilepsia (Amsterdam)
1972;13:121-31.
pilot or trial period? Some new initiatives are bound to
fail. What safeguards have been constructed so that if
this should happen chaos does not result? It may be
worth demonstrating the feasibility of a new system
before irrevocably abandoning the old.
through discussion. As well as differences in attitude,
the reaction to change at both individual and practice
level will be determined by previous events and current
morale. An unsuccessful attempt at change or low
morale might leave members feeling bruised and
defensive.
How are changes initiated?
However good the mix of talents, change can be
successful only if a suitable structure for decision
making and management exists. If the past has been
too turbulent a practice might conclude that this is
because change is initiated too readily, without proper
consultation. Alternatively, a practice might decide
that too much consultation and attempt to consensus
have occurred, resulting in any innovation being
squashed. Each practice needs to establish its own style
of management and to find a method that suits
participants. However, the style has to be agreed;
problems will arise if some members think the chosen
style is democratic and consultative, while others are
working to a more hierarchical system.
As well as style of management, practices should
consider whether decisions about change are made at
the appropriate level of organisation. Should a practice
manager have the sole responsibility to select reception
stafRf Should a partner's proposal to change the hours
of a surgery be discussed with receptionists only after a
decision has been reached? Problems may arise if
decisions are made at an inappropriate level, or more
commonly because no policy has been established on
the mechanism to be used.
How has change been implemented?
The implementation of change raises similar issues.
Some members of the practice are likely to be better
than others at implementing an agreed proposal. The
way a change is implemented is a major determinant of
its success. How are those not involved in the initial
decision informed of the proposal? How much modification is acceptable? How are the fears ofithose against
the proposal dealt with? Changes implemented
gradually are less likely to be disruptive but more likely
to be frustrating to those in support. Should there be a
BMJ VOLUME 304
30
MAY
1992
What experiences of change can we learn from?
The scenario at the beginning of this article is an
example of how a proposed change failed. Failure may
also arise at a later stage. As well as reviewing change in
general, as suggested above, specific attempts at
change, successful or unsuccessful, may give further
insights into how the practice can work best.
The first consideration is the background to the
change-what was the morale of the practice and
individuals? Were individuals defensive or confident?
Who introduced the proposal, and why, and with what
prior consultation? How was the idea introduced, how
was it negotiated, and who was consulted? How
was a decision about the proposal made and was it
unanimous? How was the change implemented and
evaluated?
EXAMPLES
Below we describe how this process might work,
starting with the scenario at the beginning of this
article. We can perhaps see why this proposal went
wrong. Examining the process in detail, in the light of
the factors mentioned above, may provide further
insights that could help this practice in the future.
Past experience
Looking back to the recent past would show that
change in the working arrangements in this practice
had always proved difficult. Many other proposed
changes had been blocked by the senior partner, whose
attitude to change had always seemed to favour the
status quo. The partners, who were being expected to
cover the extra nights on call, had not perceived a need
for this change and therefore were unlikely to be keen
on it, particularly in the light of their previous
experiences. The overall impact of the proposal, the
advantages and the drawbacks, had not been considered
or discussed, and none of the parties had looked at the
issues from their colleagues' point of view. In an
attempt to rush things through, the normal decision
making rules had been bypassed and actual implementation of the change proposed with immediate and
apparently permanent effect.
1419
BMJ: first published as 10.1136/bmj.304.6839.1418 on 30 May 1992. Downloaded from http://www.bmj.com/ on 6 June 2020 by guest. Protected by copyright.
How has change been evaluated?
The most neglected aspect of change, particularly by
those who enjoy the process, is the assessment of
whether the change has been successful. If changes
found to be counterproductive are not withdrawn the
organisation will rightly become resistant to future
initiatives. Evaluation is possible only if there has been
a clear statement of the purpose and content of a
proposed change. The ultimate objective of a change
may be immeasurable-for example, a practice would
not be able to show the effect of its new diabetic clinic
on mortality and morbidity. However, process and
intermediate outcomes are measurable-for example,
it would be possible to audit who was invited to the
clinic, who attended, and whether designated procedures were followed during the attendance. It is
important to consider unpredicted effects of change,
and those produced elsewhere in the organisation -the
new diabetic clinic may have been very successful in
achieving its objectives, but due to overrunning led to
unacceptable waiting times in the surgery session
which followed it.
7S.
Improved methods
Moving along a few years we can see the same
partnership approaching another major change
differently. On this occasion the proposal was to
reduce the number of partners in order to improve
earning potential. This was made possible by the
withdrawal ofan existing partner. Early in the deliberations one of the remaining partners suggested that the
partnership should consider the advantages of not
appointing a replacement. The practice had adopted
some quite radical changes in the previous year or so
and had coped with them without difficulty. A clear
evaluation of the pros and cons was prepared for the
partnership meeting, with an analysis of the likely
increase in income and a management plan indicating
how the extra Work was to be dealt with, and this was
discussed fully. The impact on individual members of
the practice, as well as the whole group, was also
considered. An immediate decision was not demanded,
and the decision was taken over two or three meetings.
A trial period of six months with a full evaluation was
proposed from the outset, and the upshot was that the
change was implemented without a hitch. Interestingly,
the partnership concerned, on reviewing that decision
at the end of the trial period, changed its mind and
agreed the need for a replacement partner, again
without a problem.
Conclusion
In all organisations change is occurring all the time.
It may go smoothly, but it may cause problems. If it
goes badly wrong it can cause a great deal of stress,
often needlessly. By looking back at the way changes
have occurred in the past it is possible to identify where
things have gone wrong. If lessons can be learnt and
then applied the process will be much smoother.
A PAPER THAT CHANGED MY PRACTICE
Loss of naivety or innocence
I lost my innocence, or some of the vestiges thereof, as I
read Roy Meadow's article on Munchausen syndrome by
proxy in 1982. It described how an apparently normal
parent would fabricate illness in her or, rarely, his child
and how that parent would sit back and watch as the
medical profession abused the child with countless invasive
tests, performed in good faith. Two of Roy Meadow's
original 19 children had already died. Like many another
doctor I had a sinking feeling as I tried to think of those
children I had seen with bizarre and unexplained
symptoms.
One of them was 9 months old when I first saw her. Her
parents had had a baby who died at birth and still visited
the grave every day. The little girl was reported to have
had fits since the age of 3 months, but whenever we saw
her she looked in the pink of health. Her mother gave a
graphic description of her grand mal convulsions, but
then the mother's handicapped sister had convulsions
as a child. The electroencephalogram was normal but,
convinced by the history, we had started her on phenobarbitone. As I read Roy Meadow's paper I realised that
we had never witnessed a convulsion. I wrote to my
consultant at the time expressing my concerns. He wrote
back to say that the child had been admitted extremely
drowsy and was found to have a high serum pheno-
1420
barbitone concentration. A case conference had been held
and the girl's mother had burst in screaming that they
could not take her baby away from her.
Since then I have seen children failing to thrive because
of a parentally imposed restrictive diet for imagined food
allergy. I have seen children with recurrent septicaemias
with multiple organisms caused by a mother injecting
faeces into the child's vein. I have heard of a girl with
recurrent glycosuria despite normoglycaemia, who had
been coached by her mother to squeeze a concentrated
glucose solution from one eye of her doll into urine
specimen pots.
Now, whenever I hear of a child with unusual symptoms
I consider the possibility of Munchausen syndrome by
proxy. Probably this is good medicine. Perhaps it was my
naivety that I lost rather than my innocence in 1982. But
each time I contemplate the diagnosis of Meadow's
syndrome, as it is now often called, it is with immense
sadness at the child's suffering and the suffering of parents
who could be so disturbed as to harm their own child by
proxy in such a bizarre ritual. -DAVID ISMCS, head,
department of immunology and infectious diseases, Royal
Alexandra Hospital for Children, Sydney, Australia
Meadow R. Munchausen syndrome by proxy. Arch Dis Child 1982;57:92-8.
BMJ VOLUME 304
30 mAY 1992
BMJ: first published as 10.1136/bmj.304.6839.1418 on 30 May 1992. Downloaded from http://www.bmj.com/ on 6 June 2020 by guest. Protected by copyright.
Introduction ofthe idea
What might have happened if the factors outlined
previously had been taken into account by the partnership concerned? It is, of course, not possible for them
to change their recent past. The abruptness of the
proposal, however, might have been better handled if
the senior partner had introduced the idea at a previous
meeting, suggesting its discussion next time. This
would allow them all time to get used to the idea of the
change. If, in addition, he had given the reasons for the
request-he was having problems coping with night
calls, particularly since a recent illness-then his
partners could start to consider things from his point of
view. At the definitive meeting the impact of the
proposal could then have been evaluated from all
points of view. If any of the parties still had doubts
a trial period could be proposed, followed by an
evaluation and possible renegotiation. This would
allow them all to be reassured that in agreeing to the
change they would not prejudice their current position
too much. In the event, the partners concerned finally
agreed to a plan very similar to this, but only after a
further meeting to resolve all the ill feeling previously
generated. This partnership decided that in future,
when making a major change, they should look at their
previous experiences and by planning things better
they would not make the same mistakes again.