There is nothing permanent except change (Heraclitus, 535–475BC)
Ambitious, wide-ranging and trailed as the biggest overhaul of the National Health Service since its inception, the NHS plan ("a plan for investment, a plan for reform") is about to bring far reaching changes for the NHS and health care professionals in England.
Putting patients firmly at its centre, the plan promises greater opportunities for the development of professional roles, and better ways of delivering more effective, appropriate and responsive care in better co-ordinated organisations.
There are a number of drivers to ensure that the care provided is of high quality and based on evidence. The National Institute for Clinical Excellence (NICE) will produce guidance on best treatment and interventions and national service frameworks (NSFs) will set national standards for key conditions and diseases. Working under protocols for common conditions will eventually become the norm; these protocols will identify best clinical practice and define the professional most suitable to provide each element of care.
It makes a welcome and long overdue change for the pharmacy profession to have been acknowledged a number of times in such a document, and to be viewed, as Lord Hunt recently wrote, "as contributors to the modernisation of the NHS". This is a positive time for pharmacy, especially in primary care, and the most must be made of these new opportunities as they present themselves.
There is recognition that the NHS needs to use the most appropriate skills of the most appropriate professional at the most appropriate time. As a consequence, many professional roles are going to extend and blend. For pharmacists, working in both primary and secondary care, a major challenge will be to evolve from traditional practice and use unique skills to support and deliver the pharmaceutical care and medicines management components of NSFs, standard protocols and NICE recommendations. This is going to require a great deal of change, not just in the working practices and attitudes of pharmacists but also in those of fellow professionals and colleagues. Many are going to require a lot of help to change their existing behaviour.
Influencing changes in behaviour is not simple - ask any prescribing adviser! But this is something many pharmacists are already engaged in, both with doctors (eg, changing prescribing practices) and with patients (eg, promoting concordance). A little understanding of how best to influence and manage change can go a long way towards helping to achieve success.
People do not resist change - they resist being changed. People are much more willing to accept change if it does not impact on them personally. If change means altering familiar habits or behaviour, people will resist it. If change conflicts with the things that are most valued, then attempts at resistance are usually even stronger. This is where the problem often lies with prescribing initiatives. Prescribers deeply value their clinical and professional freedom and may also perceive some initiatives purely as cost-cutting exercises. Being advised on what they ought or ought not to do may be seen as threatening. These perceptions and values present a significant challenge to pharmacists offering prescribing advice in any setting.
Those leading change need to be committed and clear about what they are trying to achieve (the vision) and why it is important (the values). They also need to offer some practical ways of achieving the change, accompanied by practical resources, knowledge and skills.
Several features make a proposed change more likely to be adopted.1 A change needs to offer perceived advantages over what is currently being done and be perceived as being compatible with existing needs and values. It needs to be uncomplicated and something that can be tried out before committing fully. The benefits must be observable. Change needs to involve little risk to the user, and be proposed by someone credible.
For example, introducing delayed prescriptions for patients with sore throats in a practice may offer GPs time savings from reduced future episodes of patient reattendance. This change is compatible in that it fits in with the policy of ensuring prescribing is evidence-based and efficient. With the right support it is relatively simple to introduce. It can also be tried with a few patients and the proposed benefits and effects monitored. It poses little risk to the GP in that patients are unlikely to leave the practice list because of the initiative.
Knowing whom to target first is also paramount for success. If one initially attempts to make changes with those known to be most resistant to change, one's initiative is doomed from the start. The people most likely to respond quickly to change are those who have been successful innovators in the past. These innovators are the idea generators and rarely need help to change, as they have usually already done it. Other groups of people will take progressively longer to change. Concentrate initial efforts on the "early adopters". Once an idea is mentioned to them they will be off and running. These are well-respected people, often seen as leaders, and are willing to promote change. They also bring the added bonus of credibility and inspiring confidence in others. The next group, the "early majority", tend to adopt new ideas more slowly as they are more conservative, but still open minded, in their approach to change. They like to see a working example before they come on board. Those likely to follow them are the termed the "late majority". Being much more sceptical, they need to be motivated by peer pressure and want to see the change bring proven benefits before they embrace it. The last to adopt a change are quaintly called "laggards". Often isolated, basing decisions on past experience, they may only change if it is essential for their survival and legislation makes it necessary.
When trying to facilitate changes in practice it is essential that everyone involved, including the patient, is motivated to change. This only occurs when they are clear about what is expected, know how to achieve what they are aiming for, receive feedback about how they are doing, and understand what they are doing well and where improvements are needed.
One of the biggest opportunities ahead for the pharmacy profession is proving it can deliver high quality pharmaceutical care and medicines management in the new environment. This will require a lot of change, both in terms of the professional role and in the way we support and work with fellow professionals, colleagues and patients.
As a starting point, a new National Prescribing Centre resource, entitled "Managing antibiotic resistance", offers a practical guide on how to introduce change effectively, using the national priority issue of reducing inappropriate antibiotic prescribing as a working example. Targeted at primary care groups and trusts, the resource provides a tailored approach to help board members, GPs and the wider primary health care team successfully introduce local initiatives to improve antibiotic prescribing. It is being aimed primarily at prescribing advisers and leads and clinical governance leads, and will be launched to primary care groups, trusts and health authorities during September and October this year.
It is important that pharmacists establish themselves in a central role in medicines management and the provision of high quality, patient-centred care in the future. Understanding the concepts and processes of change management will go some way towards helping the profession to move forward its practices and to support others in their changing roles.
Annie Coppell is assistant director of the National Prescribing Centre
| 1. Rogers E. Diffusion of innovations (4th ed). New York: Free Press; 1995. |