General Practitioners the Boundary Specialists Martin Marshall Professor

General Practitioners; the Boundary Specialists Martin Marshall Professor of Healthcare Improvement, University College London Lead, Improvement Science London NHG Annual Conference 2014 Amsterdam

About 60 per cent of the problems that patients present in general practice cannot be understood in terms of recognised disease processes

Plan 1. Introduction to the boundary role in general practice 2. The origins and evolution of the role 3. Examples of boundary activities 4. Implications for quality improvement

Can I get it when I need it? Is it good value for money? Will it make me better? Is it safe? Framework for quality Will I like it? Is it fair?

Elizabeth’s boundary problem Illness Unhappy relationship Elizabeth’s view of the world Self-care Treat the problem Disease Depression Professional care Prescribe Prozac The boundary specialist’s view of the world A doctor’s view of the world

Mohamed’s boundary problem Illness None Mohamed’s view of the world Individual need Affordable food Place to socialise Disease Poor diabetes control Collective need Close chicken shop The boundary specialist’s view of the world A doctor’s view of the world

The Boundaries Health Illness and Disease Individual need Self care Collective need Professional care

Plan 1. Introduction to the boundary role in general practice 2. The origins and evolution of the role 3. Examples of boundary activities 4. Implications for quality improvement

'Surgeon and Apothecary. Prescriptions and family medicines accurately compounded. Teeth extracted at one shilling each. Women attended in labour, two shillings and sixpence each. Patent medicines and perfumery. Best London pickles. Fish sauces. Bear's grease. Soda water. Ginger beer. Lemonade. Congreve's matches and Warren's blackening. ‘

Defining General Practice/Primary Care first point of access provision of comprehensive care whole-person orientation commitment to families and communities • provide continuity of care • act as advocates on behalf of patients • • ‘The general practitioner’s job is to witness people’s suffering’ Heath, 1995 ‘General practice is the specialty of diseases without names’ Marinker, 1995

“In the varied topography of professional practice, there is a high, hard ground overlooking a swamp. On the high ground, manageable problems lend themselves to solution through the use of research based theory and technique. In the swampy lowlands, problems are messy and confusing and incapable of technical solution. Donald Schon The Reflective Practitioner, 1987 The irony of this situation is that the problems of the high ground tend to be relatively unimportant to individuals or society at large, however great their technical interest may be, while in the swamp lie the problems of greatest human concern. The practitioner is confronted with a choice. Shall he remain on the high ground where he can solve relatively unimportant problems according to his standards of rigor, or shall he descend to the swamp of important problems where he cannot be rigorous in any way he knows how to describe. ”

Plan 1. Introduction to the boundary role in general practice 2. The origin and evolution of the role 3. Examples of boundary activities 4. Implications for quality improvement

Health Illness and Disease Health: A state of complete physical, mental and social well-being and not merely the absence of disease or infirmity (WHO, 1948) Illness: The patient’s perception that something is wrong Disease: The objective label that is given to a problem

Health Illness and Disease ‘The doctor put me on Prozac a few months back, for living here, because it’s depressing. You get up, you look around, and all you see is junkies (drug addicts)…. . I’ve started drinking a hell of a lot more since I’ve been here… I drink every night just to get to sleep. I smoke more as well. There’s lots of things (I do that I didn’t used to do before I moved here)’ Popay et al. , 2003

Health Illness and Disease ‘Medical science has made such tremendous progress that there is hardly a healthy human being left’ (Huxley) ‘A healthy man is one who has been inadequately investigated by a physician’ (Burgess)

Health Illness and Disease Change in definition of pre-diabetes increased prevalence by 2 -3 fold Change in treatment threshold for raised cholesterol could result in 25% of adult population in UK receiving lipid-lowering medication

Self care Professional care

Self care Professional care Primary Care What people do for themselves Secondary Care What families and communities do Tertiary Care What general practice teams do Quaternary Care What general hospitals do Quinary Care What specialist hospitals do

Individual need Collective need ‘The GP must strive always, vehemently, to be on the side of the individual patient’ (Heath, 1995) ‘General practice has untapped potential to engage in a more proactive approach to improving the health and wellbeing of the local population’ (Nuffield Trust, 2013)

Plan 1. Introduction to the boundary role in general practice 2. The origin and evolution of the role 3. Examples of boundary activities 4. Implications for quality improvement

The Mc. Namara fallacy ‘The first step is to measure whatever can be easily measured. This is OK as far as it goes. The second step is to disregard what which can’t be easily measured, or to give it an arbitrary quantitative value. This is artificial and misleading. The third step is to presume that what can’t be measured easily really isn’t important. This is blindness. ’ ‘The fourth step is to say that what can’t be easily measured really doesn’t exist. This is suicide’ Robert Mc. Namara US Secretary of State for Defence, 1961 -68

Solution 1. Acknowledge the wider role of the general practitioner ‘Most of the decisions that we make are not between right and wrong but between right and right’ (Handy) ‘We will never understand anything until we have found some contradiction’ (Bohr) ‘The boundary is the best place for acquiring knowledge’ (Tillich)

Einstein’s thought experiment All that can ever be known What we do know What is currently unknown

Solution 2. Adopt more sophisticated approaches to change Stacey, 2012

Solution 2. Adopt more sophisticated approaches to change Approaches to managing change Focus Activities Diagnostic change Behaviours Managing processes Dialogic change Mindset Promoting conversations Bushe, 2011

Bevan, 2014 Achieving change Power through hierarchy Influence through connection Mission and vision Shared purpose Making sense using rational argument Making sense using emotional connection Leadership driven innovation Viral creativity Tried and tested change Experiential co-creation Transactions Relationship

Solution 3. Build the capacities and capabilities of people to deal with boundary challenges Phronesis Practical wisdom

Solution 4. Carry out more research into the boundary role • What are the most important dimensions of the boundary role? • What are the facilitators and barriers experienced by practitioners in exercising this role? • What do effective boundary practitioners do differently? • What are the most effective ways of learning about the role? • What do patients think about the boundary role?

In Summary • General practice needs to be able to demonstrate measurable improvements in the care that it provides but it also needs to do more than this • One of the most important roles of the general practitioner is to manage the tensions inherent in competing demands – the boundary role • This boundary role needs to be better understood, practiced and valued if general practice is to thrive

“A new truth does not triumph by convincing its opponents and making them see light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it” Max Planck martin. marshall@ucl. ac. uk @Marshall. Prof