By Dr. Terry Maguire, a Northern Irish Community Pharmacist, senior lecturer at School of Pharmacy (Queens University Belfast) and Belfast LCG member.
Nothing stays the same so it’s ironic how steadfastly committed we are to the status quo; adversely opposed to new ways in spite of clear evidence that new ways bring benefits. Change is mostly viewed as risky and risk we are hardwired to avoid. Beechy Colchey, a Belfast-boy, famous in the 1990s for saving the stars from their passions and desires, was the first business/self-help guru I heard talk about change.
“If you keep doing what you do you’ll keep getting what you’ve got”
This was his mantra and he was right. The old ways will not give us better outcomes no matter how much we wish they would. Einstein thought this a form of madness.
But it was Machiavelli in the 14th Century who had, back then, a full insight to the threat change presents;
“………..there is nothing more difficult to carry out nor more doubtful of success nor more dangerous to handle than to initiate a new order of things;……….” (The Prince)
And he goes on to explain why.
“Because the innovator has for enemies all those who have done well under the old conditions, and only lukewarm defenders in those who may do well under the new.”
And so it remains today. People, it seems, just don’t like change, they don’t want the unk
nown, they are not easily convinced that getting to a new place is worth the effort as the benefits promised are not guaranteed. We just do not trust a new future; we prefer the devil we know.
And yet the change journey is well understood. Charles Handy in the 1980s identified a change model by studying organisations that had undertake major change programmes and succeeded. First step define your mission; what the organisation does that improves things for society. Next, set out your Vision; where you want to get to and lastly, plan your strategy; how to get there. Mission and Vision are easy. Where most change projects fail is in executing strategy; the hard work of forging public belief in the programme and then leading the faithful to the new land.
I should know this. Vision 2020 was the change programme set up by the Pharmaceutical Society of N. Ireland in the late 1990s to transform community pharmacy. Sadly it largely failed as too few pharmacists were persuaded of the benefits of change. My leaderships skills stink it seems. Rather than transform what we do by paying pharmacists to dispense fewer medicines we stuck with the script-volume model and now poly-pharmacy – a bad thing when I was a pharmacy student – is common practice. Something is deemed clinically amiss if you’re over 50 and not taking at least 4 medicines daily ; my current poly-pharmacy champion is a 53 year old in 27 medicines daily.
Failure to change the funding model for pharmacy has pushed the old model to its extreme and to a point of collapse as predicted in the Charles Handy change model. Now that we have successfully achieved mass mediation the next move is to massive dispensing factories where the multiple pharmacy chains will dominate and efficiencies required will eliminate a big proportion of independent pharmacists. Community pharmacy NI – our negotiating body – delibertly refused to buy into Vision 2020. By refusing also to set out their own vision they have no direction of travel merely responding to the ups and downs of the status quo.
Transforming Your Care (TYC) is the change management programme that hopes to transform the health and social care system in N. Ireland and allow the service to do three things; improve public health, be financially efficient and maintain high standards; the DHSSPS’s Triple Aim Agenda. TYC had set out a clear mission and vision and had sought a commitment to this in a well defined strategy.
TYC is under pressure. Three years in there is little evidence of a transformed health and social care system. There is little evidence that people are taking more care of their own health and are being supported to stay in their own homes rather than being treated in hospital. Closure of statutory residential homes was the first real challenge for TYC. When Trade Unions heard closures were planned they rallied their troops and we have spent three years fighting a high profile public battle which in Belfast affects only 16 elderly people and their families. There is no need for statutory residential homes as we move to more humane ways of supporting our elderly such as through supported housing and other innovations. But the unions – only concerned about the jobs of their members – are having none of it. In a change programme when you fail to get everyone into the tent… well you know the rest.
At a recent workshop to reinvigorate TYC it was clear the enablers for change are well know, less well known is how confident we are in applying these enablers. The system is big and complex and has ways of punishing those who try to interfere and it’s not only in statutory residential homes and the commitment of the trade unions that the problems lie, never underestimate consultant physicians.
A&E is frequently under pressure because of a failure to transform but rather than change through transformation, consultants want to keep the status quo by adding more emergency beds and increasing the number of emergency care consultants. But this is not transformation. Transformation would involve getting fewer people to arrive at A&E because they should be treated elsewhere in the system, at the GP for example, and we need to get people out of hospital sooner so that beds are not blocked. To do this we need good support systems in the community. This requires investment but no one seems willing to risk this investment in case it doesn’t work.
When I heard John Galbraith, another change guru, speak some years back I thought he was making a joke when he said.
“When faced with a choice between changing and proof that change is not necessary most of us get busy with the proof”
John was not joking he was deadly serious; this is the irrational part of our brains at its best and the reason why change is so difficult.
