General Practitioners; the
Boundary Specialists
Martin Marshall
Professor of Healthcare Improvement, University College London
Lead, Improvement Science London
NHG Annual Conference 2014
Amsterdam
About 60 per cent of the
problems that patients present in
general practice cannot be
understood in terms of
recognised disease processes
Plan
1. Introduction to the boundary role in
general practice
2. The origins and evolution of the role
3. Examples of boundary activities
4. Implications for quality improvement
Can I get
it when I
need it?
Will it
make me
better?
Is it safe?
Framework
for quality
Is it good
value for
money?
Will I like
it?
Is it fair?
Elizabeth’s boundary problem
Illness
Unhappy
relationship
Disease
Depression
Elizabeth’s view
of the world
A doctor’s view
of the world
Self-care
Treat the
problem
Professional
care
Prescribe
Prozac
The boundary
specialist’s view
of the world
Mohamed’s boundary problem
Illness
None
Mohamed’s
view of the
world
Individual
need
Affordable
food
Place to
socialise
Disease
Poor diabetes
control
A doctor’s view
of the world
Collective
need
Close chicken
shop
The boundary
specialist’s view
of the world
The Boundaries
Health
Illness and
Disease
Individual
need
Self care
Collective
need
Professional
care
Plan
1. Introduction to the boundary role in
general practice
2. The origins and evolution
of the role
3. Examples of boundary activities
4. Implications for quality improvement
'Surgeon and Apothecary.
Prescriptions and family medicines
accurately compounded. Teeth
extracted at one shilling each.
Women attended in labour, two
shillings and sixpence each. Patent
medicines and perfumery. Best
London pickles. Fish sauces. Bear's
grease. Soda water. Ginger beer.
Lemonade. Congreve's matches and
Warren's blackening.‘
Apothecary shop window, Manchester, UK,
1842
Defining General Practice/Primary Care
•
•
•
•
first point of access
provision of comprehensive care
whole-person orientation
commitment to families and
communities
• provide continuity of care
• act as advocates on behalf of patients
‘The general practitioner’s job is to
witness people’s suffering’
Heath, 1995
‘General practice is the specialty of
diseases without names’
Marinker, 1995
“In the varied topography of professional practice, there
is a high, hard ground overlooking a swamp. On the high
ground, manageable problems lend themselves to
solution through the use of research based theory and
technique. In the swampy lowlands, problems are messy
and confusing and incapable of technical solution.
Donald Schon
The Reflective
Practitioner,
1987
The irony of this situation is that the problems of the
high ground tend to be relatively unimportant to
individuals or society at large, however great their
technical interest may be, while in the swamp lie the
problems of greatest human concern.
The practitioner is confronted with a choice. Shall he
remain on the high ground where he can solve relatively
unimportant problems according to his standards of
rigor, or shall he descend to the swamp of important
problems where he cannot be rigorous in any way he
knows how to describe.”
Plan
1. Introduction to the boundary role in
general practice
2. The origin and evolution of the role
3. Examples of boundary
activities
4. Implications for quality improvement
Health
Illness and
Disease
Health:
A state of complete physical, mental and
social well-being and not merely the
absence of disease or infirmity (WHO, 1948)
Illness:
The patient’s perception that something is
wrong
Disease:
The objective label that is given to a problem
Health
Illness and
Disease
‘The doctor put me on Prozac a few months back, for
living here, because it’s depressing. You get up, you
look around, and all you see is junkies (drug
addicts)…..I’ve started drinking a hell of a lot more
since I’ve been here… I drink every night just to get to
sleep. I smoke more as well. There’s lots of things (I do
that I didn’t used to do before I moved here)’
Popay et al., 2003
Health
Illness and
Disease
‘Medical science has made such tremendous progress that
there is hardly a healthy human being left’
(Huxley)
‘A healthy man is one who has been inadequately
investigated by a physician’
(Burgess)
Health
Illness and
Disease
Change in definition of pre-diabetes
increased prevalence by 2-3 fold
Change in treatment threshold for
raised cholesterol could result in 25%
of adult population in UK receiving
lipid-lowering medication
Self care
Professional
care
Self care
Professional
care
Primary Care
What people do for themselves
Secondary Care
What families and communities do
Tertiary Care
What general practice teams do
Quaternary Care
What general hospitals do
Quinary Care
What specialist hospitals do
Individual
need
Collective
need
‘The GP must strive always, vehemently, to be on the side
of the individual patient’
(Heath, 1995)
‘General practice has untapped potential to engage in a
more proactive approach to improving the health and
wellbeing of the local population’
(Nuffield Trust, 2013)
Plan
1. Introduction to the boundary role in
general practice
2. The origin and evolution of the role
3. Examples of boundary activities
4. Implications for quality
improvement
The McNamara fallacy
‘The first step is to measure whatever can be
easily measured. This is OK as far as it goes. The
second step is to disregard what which can’t be
easily measured, or to give it an arbitrary
quantitative value. This is artificial and
misleading. The third step is to presume that
what can’t be measured easily really isn’t
important. This is blindness.’
‘The fourth step is to say that what can’t be
easily measured really doesn’t exist. This is
suicide’
Robert McNamara
US Secretary of State
for Defence, 1961-68
Solution 1. Acknowledge the wider
role of the general practitioner
‘Most of the decisions that we make are not
between right and wrong but between right
and right’
(Handy)
‘We will never understand anything until we
have found some contradiction’
(Bohr)
‘The boundary is the best place for acquiring
knowledge’
(Tillich)
Einstein’s thought experiment
All that can ever be known
What we do know
What is currently unknown
Solution 2. Adopt more sophisticated
approaches to change
Stacey, 2012
Solution 2. Adopt more sophisticated
approaches to change
Approaches to managing change
Focus
Activities
Diagnostic change
Behaviours
Managing
processes
Dialogic change
Mindset
Promoting
conversations
Bushe, 2011
Bevan, 2014
Achieving change
Power through hierarchy
Influence through connection
Mission and vision
Shared purpose
Making sense using rational
argument
Making sense using emotional
connection
Leadership driven innovation
Viral creativity
Tried and tested change
Experiential co-creation
Transactions
Relationship
Solution 3. Build the capacities and
capabilities of people to deal with
boundary challenges
Phronesis
Practical wisdom
Solution 4. Carry out more research
into the boundary role
• What are the most important
dimensions of the boundary role?
• What are the facilitators and barriers
experienced by practitioners in
exercising this role?
• What do effective boundary
practitioners do differently?
• What are the most effective ways of
learning about the role?
• What do patients think about the
boundary role?
In Summary
• General practice needs to be able to demonstrate
measurable improvements in the care that it provides but
it also needs to do more than this
• One of the most important roles of the general practitioner
is to manage the tensions inherent in competing demands
– the boundary role
• This boundary role needs to be better understood,
practiced and valued if general practice is to thrive
“A new truth does not
triumph by convincing its
opponents and making them
see light, but rather because
its opponents eventually die,
and a new generation grows
up that is familiar with it”
Max Planck
martin.marshall@ucl.ac.uk
@MarshallProf