Conundrum 2
Holding someone to account
You are the practice manager in a general practice owned by three GP partners.
The practice is a friendly one. Many of the staff have worked there for many years, everyone is on first name terms, and there is a real sense of camarderie.
Along with Primary Care generally, the practice feels under steadily increasing pressure. The local Primary Care Trust is encouraging more and more involvement in corporate decision
making, and in activities such as clinical governance; pages and pages of guidance arrive every week from the Department of Health; and more patients are demanding to be seen more and more often.
At a recent practice meeting you raised the issue of the pressure on appointments. The lead time for routine appointments was currently three weeks, which was leading to great
unhappiness on the part of both patients and receptionists. One of the factors contributing to this, but also exacerbated by it, was the large number of patients asking for emergency appointments on the same day.
When they were seen the GPs reported that many of them were not emergencies and were simply jumping the queue.
Everyone felt this was unfair and that the lead time of three weeks was unacceptable, and it was agreed that a new system would be introduced. A ‘fast track’ of two
minute appointments would be established, and any patients asking for emergency appointments would be seen for rapid assessment in that time. If they raised any routine conditions they would be asked to make a
separate appointment. The reception diaries had been changed for the new system and it started three weeks ago.
Since then you have monitored its impact by keeping a close eye on the reception desk, overhearing some of the conversations, and asking the receptionists for their views.
You found almost immediately that two of the GPs were implementing the system fairly well. They would refer patients back to the reception desk for routine requests, explaining the
system to the patients as they did so. The third, Dr X, however, preferred to deal with all the patient’s concerns while they were there. She explained ‘It will take longer if I have to get them to come
back in, its quicker and easier if I do it all now.’ Within a short while patients were coming in asking for emergency appointments, but insisting on seeing Dr X. When told they could not choose the doctor for
emergency appointments several of them have become very annoyed.
This morning Mrs S is at the desk, insisting that she see Dr X. When the situation is explained to her she refuses to see anyone else, and angrily and loudly tells the receptionist
that she has been coming to the practice for years, that she has always been able to see ‘her’ doctor, and that no-one in the practice cares about patients any more.
At this point Dr X comes out into the waiting room, overhears Mrs S and tells the receptionist to give her an appointment for later in the morning. You take her on one side and
explain that she is undermining the position of the receptionist, but Dr X insists, saying she wants to avoid the unpleasant atmosphere, that she understands how Mrs S is feeling, and this is all the fault of the
government because too much medical time is being spent on interpreting pieces of paper.
What do you do now?
What will you do later?
What preparation will you need to do?
Commentary 2
You are likely to be angry.
Dr X was present at the meeting when the new system was agreed and so has a corporate responsibility for implementing it. Any concerns she had about the new system should have been
raised then and addressed. Similarly any concerns she has now should be taken back to the team for discussion, rather than dealt with in a unilateral way. This is what being part of a team involves.
You also know that behaviour that is rewarded tends to be repeated, so you are fairly sure that Mrs S, and everyone else in the waiting room will now bypass the agreed system by
seeking emergency appointments with Dr X.
But perhaps you should remember that organisational systems have to work with human nature and not against it, and work with the humans who are there and not only with humans
we would like them to be. If Dr X finds it very difficult to say to patients that they will have to go back to reception and make an appointment then you cannot implement a system that requires her to do
so.
Did she express reservations at the meeting at which it was agreed? Perhaps the rest of you didn’t give them the weight they deserved. Or perhaps she didn’t. Perhaps she
is someone who dislikes conflict and is not forthcoming in meetings of that kind. If you know that, and do not find ways of establishing her views, then you must share the blame if the system does not work because
you have not uncovered them and allowed them to be addressed.
Or perhaps Dr X is someone who has never been introduced to the idea that the care offered by health care professionals is not some mushy sentimental feeling, nor does it rest
entirely on clinical skills, but that it involves both work and courage1. Here she would care for her patients more effectively by demonstrating some courage in explaining the new system to them and
requiring them to make another appointment.
The interaction between Mrs S, the receptionist and Dr X would be of interest to a group of psychologists interested in ‘transactional analysis’2. They might
analyse this transaction as displaying elements of Persecutor, Victim and Rescuer. These are all negative egostates that complement each other, and hence can continue for some time, indeed until something happens to
‘cross’ the transaction. You might be able to decrease the risk of this happening by encouraging your patients into positive egostates, for example by explaining the new system on notices, in language
that expects them to understand and want to make it work.
Right now, with Dr X in front of you, and Mrs S at the reception desk you yourself must try and stay in a positive egostate. You must deal with the situation using all your skills
and not dwell on emotional responses. You can ask to discuss the incident later, and ascertain (genuinely rather than retributively) whether Dr X wishes an appointment to be given just to Mrs S or to others as well.
When you do see Dr X to discuss it you can use the XYZ formula3.
But perhaps more important than anything else you need to be certain of your role and responsibilities. Make sure you are clear about the three rules for managing people4,
as they relate to you. Use them now, in your discussion with Dr X. Remind her of what she is expecting you to achieve, and of the skills and resources you have available.
To do so effectively you will need to prepare for the meeting by visioning in the same way as described in commentary one.
1.See the definition of care used in commentary 1. this is derived from work by the philosopher David Seedhouse, and the psychiatrist M Scott Peck .
2.For more information try TA Today , Ian Stewart and Vann Joines, Lifespace publishing
3. See commentary 1 for the XYZ formula
4. The three rules for managing people:
- Agree with them what it is you expect them to achieve
- Ensure that both you and they are confident they have the resources to be able to achieve it
- Give them ongoing feedback on whether they are achieving it.
For more information on this and the other concepts introduced here see Really Managing Health Care, chapter 1.
Please send any comments and suggestions to
conundrum@reallylearning.com
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