Managers are rushing to meet the deadlines for establishing primary care groups. But long-term success will depend not on whether they complete them on time, but on how well they have used the tools of change management. A critical aspect of implementing PCGs will be coping with the ending and loss of existing commissioning models.
For the first time doctors and nurses are to be brought together at board level and will share governing responsibilities for the PCG with lay members and social services colleagues. Although the health professionals may have experience of operating as a clinical team providing individual care packages to patients, the experience of joint governance will be new.
PCGs will create new organisations with specific functions. To successfully build on existing commissioning models, managers and GPs will need to acknowledge the importance of the transition process.
William Bridges explains that change is not the same as transition.1 Change is situational: the new site, the new boss, the new team roles, the new policy. Transition is the psychological process of coming to terms with the new situation. Change is external, transition is internal. PCGs are an external change, so to create them managers and healthcare professionals must go through an internal process of transition.
Bridges stresses that 'change focuses on the outcome, whereas the starting point for transition is the ending that must be made to leave the old situation behind.
'Situational change hinges on the new thing, but psychological transition depends on letting go of the the old reality'.
Transition has three phases. It begins with 'letting go' of something, and the second step is understanding what comes after letting go, 'the neutral zone'. This is a time when the old way is gone but the new way does not feel comfortable yet. Managers, GPs and other healthcare professionals will only make the third phase, the 'new beginning' if they have first made an ending and spent some time in the neutral zone.
These first two phases will also give them the opportunity to ask themselves whether they wish to be as involved as before - or more, or less. For example, chairs of multifunds and total purchasing pilot sites may need to reflect on their previous experiences and areas of expertise before deciding whether or not they wish to stay in a leadership role.
Many in the primary healthcare team have created significant developments over the past seven years, such as increasing the range of services. These professionals may feel that their most recent achievements have been lost. Managers and GPs have coped with an extremely large and demanding agenda for a long time. Without a grieving period, it will be even harder to generate the strength of purpose and enthusiasm to implement the next set of policies. They should ask what it is that people are losing. How will the familiar process of working be affected? Who is going to have to 'let go' of something? And what must they let go of? For a lead GP, perhaps a role that gave them influence in the wider health service? For a community nurse, maybe their chances of promotion? Bridges suggests asking: 'What can I give back to balance what's been taken away? Is it status, team membership or recognition? If people feel that change has robbed them of control over their futures, can we find some way to give them back a feeling of control?'
They will also need to recognise that PCGs will require new skills. They will be working in a more inclusive model with other healthcare professionals. The environment and the language have changed. Managers, nurses and GPs will need skills such as visualisation techniques, which allow them to see the big picture. Being able to convey this to to others will be very important.2
PCG boards may find it useful to distinguish between transforming leadership and transactional management. The distinct characteristics of each are set out in the box.
PCGs will require both sets of skills. Initially, it will be important to identify someone with transforming leadership qualities. If groups of GPs, nurses, therapists and associated practitioners are to be enthused and convinced about the purpose of change, PCGs will benefit from board members who inspire others, are able to challenge constructively and who can focus on the long term.
The operational level will require managers highly skilled in transactional management. Some GPs involved in multifunds and total-purchasing pilots have already discovered the need for different skills at different stages of organisational development. In the US, the Independent Practitioner Association has said that there is more concern when a manager resigns than when a doctor does, because the doctor's skills can be easily replicated and are not as critical to the success of the organisation.
The board members and management team of the PCG in the transition phases may not necessarily be the best team for the fully formed organisation. And as a PCG progresses between levels one and four, the type of expertise that is required will change. The transformational competencies will become less important while the qualities of the transactional manager will become more so.
For leadership, the guidance promotes an inclusive participative approach. As the PCGs need to meet tight deadlines, it may be tempting to take Dunphy and Stace's view, which challenges the widely held and oversimplified prescription of participative management in change situations.3 Their studies suggest that incremental and collaborative or consultative modes of change implementation can be highly inappropriate. These strategies are time-consuming and can generate conflicting views and ideas which generate tensions that are not always readily reconciled.
On the other hand, where rapid strategic change is necessary, transformative approaches carried out in directive and coercive modes can be effective. But we believe that if this happens, the shift from an exclusive to an inclusive mode of decision-making will not permeate the new organisations.
We suggest the leadership style described by Nelson Mandela may be more appropriate. In his autobiography, A Long Walk to Freedom, he says, 'a leader is like a shepherd, he stays behind the flock letting the most nimble go ahead whereupon the others follow, not realising that all along they are being directed from behind'.4
As we move to an inclusive model of decision-making, those who are managing the change will have many issues to consider. This will be compounded by the government's tight timetable. However, managers need to recognise the three phases of transition, and support staff through the 'letting go' and 'neutral zone' phases.