Medical Organisations can be confusing places – for patients and the media, and visiting dignitaries. NHSreality tries to tease out some of the cultural indicators. A report in Nurse Economics by Sovie MD in 1993 pointed out in “Hospital culture–why create one?”:
“Hospitals, to survive, must be transformed into responsive, participative organizations capable of new practices that produce improved results in both quality of care and service at reduced costs. Creating, managing, and changing the culture are critical leadership functions that will enable the hospital to succeed. Strategic planning and effective implementation of planned change will produce the desired culture. Work restructuring, a focus on quality management along with changes in clinical practices, as well as the care and support processes, are all a part of the necessary hospital cultural revolution.” This equally applies to GPs and their practices.
It is important for Immigrants to understand something which is possibly alien in their own experience. Public Health England tries to help with an immigrant guide… but this fails to differentiate between different practice cultures.
It is also important for new doctors looking to join a practice, either as a salaried doctor, or as a partner. Newly qualified GPs fresh off their training schemes dont normally join a practice immediately, and will have jobs as locums or out-of-hours doctors, and perhaps a couple of sessions as a salaried doctor are offered over time. The culture of an organisation is explained succinctly and diagrammatically in “Understanding Organisations”, a paperback by Charles Handy (1993) now in it’s 4th edition, which has become a basic managerial text. I have always recommended reading it to GPs looking for partnerships. Smaller organisations (General Practice) are more easily Horizontal, but history often dictates that they are effectively Vertical. Larger organisations (Hospitals) need some form of power hierarchy and are necessarily Vertical, but managing units with them horizontally is possible. (In Horizontal organisations the emphasis is that equals are treated equally, and in Vertical ones, that unequals are treated unequally)
There is a different cultural expectation in different areas of the UK. In South Wales, the origins of the old NHS, and now a region governed by the Welsh Assembly, there is an expectation that everything should be free. Prescriptions are no exception… In London and Birmingham, cities with large immigrant populations, many GPs have historically been single handed, and purpose built premises are rarer.
CC Butler – 1998 published: Understanding the culture of prescribing: qualitative study of general … www.bmj.com/content/317/7159/637
In 2010 The Kings Fund published “Quality Improvement in General Practice”.
In addition there is a health “Teaching culture” (Marjan Kljakovic in Asia Pacific Family Medicine 2009) in some practices, and an equally health “Safety culture” (Dorien Zwart in BMC Family Practice 2011) – these two often being present in the same practices. This was developed and enhanced by: Seven steps to patient safety in general practice – published by the National Patient Safety Agency.The Royal New Zealand College of General Practice has espoused the term “Cultural Competence” (Report) to encompass all these aspects.
Some people hark back to the “personal, old fashioned family doctor” as in Dr Finlay’s Casebook (BBC TV 1962-1971), but the reality is that it is in small and single handed practices, without sufficient peer review, where things go most wrong. Dr Shipman (Crime Library) was single handed… Recent TV Comedy such as Doc Martin (2004 – ?) are great fun, but give the impression that a Surgeon (task orientated) can easily become a GP (process orientated) in a very short time, and without training… and in Single Handed practice as well. (GP Magazine’s Neil Roberts, reports 14 October 2013: Single-handed GPs targeted in ‘radical’ NHS reform plan) .
I am aware of some very large practices, around the regions, who are trying to move to an organisational size and culture more associated with a hospital than General Practice. What these organisations need is competition in the form of a small 2-4 doctor practice set up in competition. This would rapidly encourage a change in culture – or the business would fail.
If a friend moved to a new location I would ask him what sort of General Practice he felt most comfortable with. Smaller practices usually give more continuity of care, and larger practices more access/availability for suddenly ill children. Access to a women GP (80% in future) is hardly an issue as they are generally universally available except in really remote locations. I would recommend a practice with a wide age range of partners, a sex mix, and a teaching practice assuming distance/transport/parking options from home were not issues. For special cases a partner with an interest in Sexual Health or Mental Health might give an advantage. I would personally like a GP who might take me through to the grave, so he needs to be younger than me! Other things to consider are a reputation with neighbours (the usual way) and QOF scores. Does the practice have a patient participation group (PPG) and how much holiday/time away does each partner take. Practices with all part-time doctors rarely give good continuity of care, especially for suddenly sick children, and need competition to make them change.Understanding all these issues and concepts is also important for the prospective partner/applicant.