Sam Riddell
DipPrimaryCare MIHM
Practice Director
Westgate Medical Practice
Dundee
I have always enjoyed the challenges and opportunities practice management has afforded me. In May 2006, the two practices that I had managerial responsibility for merged, having worked as separate units in the same building for some 27 years.
It soon became clear that this merger would test my managerial acumen to the full. When I started on this merger, my hair was a nice dark colour – now I am almost snow-white, never mind grey!
My route into practice management came during the fundholding era, when, in early 1996, I was appointed as a business manager in a forward-thinking practice in West Fife.
This appointment was my first on my return to civilian life following a successful career in the medical branch of the Royal Air Force. In 1998, I moved to the larger of the two practices housed at Westgate in Dundee, situated adjacent to Ninewells, one of Scotland’s largest teaching hospitals.
The practice now comprises some 11,000 patients with eight GP principals, two GP registrars and associated nursing and administrative support teams. We also have a number of very important attached community team members. In total, there are 47 members of the practice team.
The practice serves a mixed urban/rural area, covering all social classes, with a high percentage being middleclass. Due to our proximity to a large teaching hospital, we have a high percentage of health professionals registered with us.
In addition to my “day job” and being an active member of the Institute of Healthcare Management (IHM), I am a trainer on the Scottish Vocational Training Scheme for practice managers, and an assessor for the Royal College of General Practitioners (RCGP) Quality Practice Award. My hobbies are public speaking (I am currently vice president of Dundee Speakers Club) and “bagging Munros” – for the uninitiated, this means climbing mountains of more than 3,000 feet; there are 284 Munro mountains in Scotland.
Westgate has enjoyed a long and proud association with teaching, research, quality and innovation. In 2005, we became the first practice in the UK to utilise mobile phone technology to book appointments, request repeat prescriptions and obtain clinical advice. Recently, we introduced a clinical results service via mobile phones.
I am very fortunate that I am in a post where I am afforded the opportunity actually to manage. Sadly, too many practice managers are “shackled” by partners who brought them in to manage. As I drive into work to Dundee each day (listening to Radio 4 – yes, we do get it in Scotland) from the beauty of the Angus Glens, I always set myself at least one objective for the day. This normally takes the form of: “What I am going to do today to make Westgate Practice a better place for patients and team members alike?” I find this sets me up for the day ahead.
Always looking for new challenges, in 2006 we established a twinning link with Zingwangwa Health Centre near Blantyre in Malawi, and successfully obtained funding from the Scottish Executive to take this project to new heights.
However, in this article I would like to focus on the challenges we faced during the merger process. The Oxford English Dictionary defines merger as: “The combination of two or more companies, either by the creation of a new organisation or by absorption by one of the other.” To those considering the merger route, I would emphasise from the outset that it is crucial the type of merger is agreed and known by all concerned, as the latter method (absorption) is, in my opinion, to be avoided if at all possible.
On reflection, some nine months into the merger, the key themes I would highlight to those looking at a possible merger are as follows.
Drivers for merger
It is important that these have been clearly worked out and there is universal agreement. In our case, we saw the benefits of merging our nursing teams, working towards the Quality and Outcomes Framework (QOF), premises efficiency, the potential to contain staff costs, and our plans to move into new, purpose-built surroundings in the next 18 months as our key drivers.
The fundamental question you may wish to address is: do you see the merger as a cost-cutting exercise, a means of improving the service you offer, or a combination of both? On a practical note, your accountants need to be involved from the outset to review all the financial implications.
Communication
At all stages of the process, dialogue with all the various members of the primary healthcare team is crucial. Initially, team members need to be informed of what is being planned. This is important to stop the rumourmongers putting their “spin on the story”, and to allow staff time to consider the implications any merger may have on them.
Regular updates to keep staff informed would go a long way to ease any insecurity they may be feeling. No matter how well you communicate, staff will quite naturally have their own fears or worries about life in the new organisation. In our case, a number of staff on both sides had been with their practice for 15 years or longer, so unsurprisingly had some reservations.
The process
As in all management processes, planning is probably the key component:(1)
- Analyse the current set-up of the organisations merging, in particular their financial position. What works well that can be adopted in the new practice? We formed a working group to take this aspect forward, and it is important that their remit continues postmerger.
- Discuss what model you wish the new organisation to be based on – is it going to be better for patients and/or staff?
- Set out a plan of implementation and promulgate this to all team members. It is important that the patients are kept abreast of what is happening. In our case, we used our Patient Advisory Group to best effect.
- Review the staff profile, and look to ensure that you keep your best staff.
- Review your original objectives on a regular basis to see how far you have come.
Culture
One of the aspects that makes general practice management so interesting and challenging is that no two practices in the country are the same. It is inevitable that each side will have established cultures and different styles of work.
It is important that cultural differences are respected. If managed well this can be a real asset, as new ideas are always welcome. Managed poorly and you run the risk of creating the situation where the two systems continue in the new organisation. This could have a destructive effect on your plans.
In our case, both practices had similar but quite separate traditions that they were proud of. It is worth noting that the creation of a new culture within a newly merged team does not happen overnight. At the time of writing, I am pleased to say that things are looking up and team members are working well together.
I can say without any hesitation that this merger has been the biggest piece of change management I have led. No-one underestimated the size of the task we were taking on but, on a personal note, there were times along the journey when I questioned the original decision to merge. My way of coping with such pressure is walking my two black labradors and English springer spaniel dogs. Believe me, it clears your head and the dogs love it!
The unexpected successes have been that the patients generally favour the new practice, and we now have a better gender mix in partners, nursing team development, a cohesive reception team and an improved culture of sharing.
We are now working as a team on two new projects, namely converting to Vision clinical software and designing a new state-of-the-art general practice. Our newly merged team is going to be tested to the full, but I am quietly confident that we will meet the challenge head-on.
I would like to conclude with a quotation from Whitney King Jr, from an address given in a meeting on Wall Street, that I think sums up the whole process we have been through:
“Change has a considerable psychological impact on the human mind. To the fearful it is threatening, because it means that things may get worse. To the hopeful it is encouraging, because things may get better. To the confident it is inspiring, because the challenge exists to make things better.”
Each practice will have its share of all three types of person referred to above. The secret is making them work together to achieve the overall aim.
Reference
- Dash P. Tips on merging two organisations. BMJ Career Focus 2002;325:S210.
