Engaging primary care physicians in system change – an interpretive qualitative study in a remote and rural health region in Northern British Columbia, Canada

Abstract

ObjectivesTo describe how physicians were engaged in primary healthcare system change in a remote and rural Canadian health authority.DesignA qualitative interpretive study based on a hermeneutic approach.Methods34 transcribed in-depth interviews with physicians and administrators relevant to physician engagement were purposively sampled from a larger data set of 239 interviews gathered over a 3-year period from seven communities engaged in primary healthcare transformation. Interviews were coded and analysed interpretively to develop common themes.SettingThis research is part of a larger study, Partnering for Change I, which investigated the efforts of Northern Health, a rural regional health authority in British Columbia, to transform its healthcare system to one grounded in primary care with a focus on interdisciplinary teams. It reports how physician engagement was accomplished during the first 3 years of the study.ParticipantsInterviews with 34 individuals with direct involvement and experience in the processes of physician engagement. These included 10 physicians, three Regional Executives, 18 Primary Healthcare coordinators and three Division of Family Practice leads.ResultsThree major interconnected themes that depicted the process of engagement were identified: working through tensions constructively, drawing on structures for engagement and facilitating relationships.ConclusionsPhysician engagement was recognised as a priority by Northern Health in its efforts to create system change. This was facilitated by the creation of Divisions of Family Practice that provided a structure for dialogue and facilitated a common voice for physicians. Divisions helped to build trust between various groups through allowing constructive conversations to surface and deal with tensions. Local context mattered. Flexibility in working from local priorities was a critical part of developing relationships that facilitated the design and implementation of system reform.

Geographic accessibility to primary care providers: Comparing rural and urban areas in Southwestern Ontario

“…Historically, due to a variety of barriers, primary care has not been involved in system-level change (Skillman et al 2017). However this is shifting, and PCPs are recognized as key partners for and drivers in system change (Snadden et al 2019).…”

How can rural community-engaged health services planning affect sustainable health care system changes? - A process description and qualitative analysis of data from the Rural Coordination Centre of British Columbia’s Rural Site Visits Project

“…Autonomy impacted both the sense of wellbeing of the partners, but could also produce very practical, rapidly implemented changes with positive results, for example in the community of Hope . The exercise of autonomy however can be problematic if not carried out within an agreed framework that requires the limits of decision making to be set and agreed with health service administration and which recognizes historical power differences in health care (15, 24). Finally, change over time is recognized as being an important contextual factor in the provision of services to small rural communities and the resilience of these communities seems related to their ability to adapt to often unexpectedly changing circumstances.…”

Partnering for change

“…Engaging in such a large, multifaceted change process comes with multiple challenges. Such processes are imbued with tensions, including tensions between professionals, tensions in goals, tensions related to power, tensions about timing and pacing of change, and tensions inherent in making local changes within a large, complex, publicly accountable regional health system that needs to accomplish provincial mandates (Hanlon et al , 2019a, b; Snadden et al , 2019) Instead of seeking to manage or to create a synthesis of tensions when they are managed (Van de Ven, 1992), NH leaders have understood tension as described by McCormack et al (2013) as:[…] a strain that generates differences amongst partners; presenting an opportunity for partners to engage in reciprocal learning […] [where] partners are challenged to think differently and to move […] to a new space where creative and effective solutions are found.(p. 18)…”

“…The first step was to review data from the participants in each community and regionally in each year, followed by reviewing data from similar types of participants across communities and years. For example, all interviews with physicians were explored for processes of engagement (Snadden et al , 2019). Patterns in the data that expressed how change occurred through partnering were identified.…”