Leggislating change – why some innovations catch on, and others are disastrous

What had changed in the 15 years since I was last in India? I would never have guessed: leggings. Women everywhere were wearing them.

And Prime minister Narendra Modi had just announced demonetisation, a bold measure to tackle corruption. From midnight on 8th November 2016 the banknotes which comprised 85% of India’s currency were no longer legal tender. The result was economic chaos.

Top-down imposition

Why do some innovations catch on when others are disastrous? An Indian journalist described demonetisation as “a bad idea, badly executed on the basis of some half-baked notions.” Many have said the same about reorganisations of the NHS. The health service is no stranger to top-down imposition of change.

Governments’ horizons are usually short-term. The possible unintended consequences of their policies are an inconvenient truth which is given scant consideration; implementation is someone else’s problem.Only one person knew in advance about Modi’s demonetisation plan – the governor of the Reserve Bank of India, who had to arrange

Only one person knew in advance about Modi’s demonetisation plan – the governor of the Reserve Bank of India, who had to arrange printing of new bank notes. It’s true that the NHS – usually – goes through a process of consultation, if a brick through the window constitutes listening to the people who actually provide and use the health service.
Following demonetisation, there weren’t nearly enough banknotes to go round, so millions of Indians queued every day, waiting to change their now-useless savings. Businesses went bust, people could not buy or sell. They had no money to buy food and crops rotted in the fields. Reorganisations of the NHS can quickly demonstrate flaws in new policies – think of Andrew Lansley’s disastrous 2012 Health and Social Care Act. But front line staff still have to carry on. Bank staff in India faced with millions of desperate people, NHS clinicians doing their best to mitigate the damage and keep the service going for patients while getting their head round the new demands and new structures.

Reorganisations of the NHS can quickly demonstrate flaws in new policies – think of Andrew Lansley’s disastrous 2012 Health and Social Care Act. But front line staff still have to carry on. Bank staff in India faced with millions of desperate people, NHS clinicians doing their best to mitigate the damage and keep the service going for patients while getting their head round the new demands and new structures. Being the fall-guys

Being the fall-guys

When the Department of Health is criticised in the press and in parliament, GPs are convenient fall-guys. It is not the failure of primary care to embrace seven-day services that is causing the nationwide crisis in A&E, but by the time that point was made, the popular press had ensured that every prejudice against GPs had been reinforced.
Unless they make a big effort to stay in touch, the decision-makers in governments and large organisations are insulated from the day-to-day reality of the people they are supposed to serve. By the time a policy has filtered down through layers of management, what may have seemed like a surgical strike has turned into something resembling carpet bombing.

Bigger organisations

Unfortunately the pressure is on general practices to form bigger organisations. Whatever the potential gains, as the lines of communications are lengthened, the opportunity for big mistakes which are difficult to unpick will increase.

Effective change usually happens from the bottom up. Checking capillary refill time wasn’t mentioned when I trained, and it seems that it only entered the literature 10 years ago. I don’t suppose many high-level managers know what it means. Yet now it is a test every GP uses. It costs nothing, is easy for both the doctor and the patient, and it gives useful information. So it caught on quickly. As did pulse oximeters. These were first widely used by US anaesthetists in the 1980s, then hospital practitioners picked up on them. They are easy and quick to use and the information they provide is cheap at the price and helps decision-making. Now few GPs would want to be without one.

Endomysial antibody and faecal calprotectin tests have both proved their usefulness, as has guidance on sepsis, and the vast majority of GPs will be familiar with them. When a few innovators introduced self-referral to physiotherapists, physio services were not overwhelmed. GPs’ time was saved, patients were happy with direct and quick access and outcomes improved. Now self-referral is the norm and other services are taking it up. The idea wasn’t handed down from above; it caught on because people who tried it found that it was effective. Similarly, one-stop clinics and one-stop assessment centres have worked to everyone’s advantage and the models have been copied and adapted for use in different places and circumstances.

From the ground up

What gets the ball rolling? Rarely governments; they are busy devising carrots and sticks to urge forward their latest must-dos. Good ideas spread like dandelions in a field. Word of mouth propelled Dr Henry Heimlich’s manoeuvre into everyday usage and significantly reduced the death toll from choking. Articles in the press, meetings, websites can be catalysts of change. And locums. Unlike partners, they see a lot of practices in action, and their employers are recognising that a locum’s skills and experience are a useful resource. Practice B has a problem. A locum can tell them how practice A found a neat way of solving the problem. Partners who learned their trade using paper notes can ask a young IT-savvy locum how things could be done more easily. And then practices pass on the advice.

Back to leggings. Nobody in the government demanded that Indian women wear leggings. In fact, politicians probably see them as a threat to tradition. But women found them cheap and practical, and now leggings are available everywhere, in bazaars, on pavement stalls, online. A change that comes from the ground up.

Judith Harvey

Judith Harvey was a research scientist, ran the VSO programme in Papua New Guinea and taught in a Liverpool comprehensive school before going to medical school. She has been a partner, a salaried GP and a locum, an LMC chair and a long-time supporter NASGP. Her charity, Cuba Medical Link, enables medical students to go to Cuba for their electives.

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