Adaptive reserve: A path to sustainable general practice in a pandemic

Grant Russell   
doi: 10.31128/AJGP-COVID-31   |    Download article
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The COVID-19 pandemic will shape society for decades to come. Governments have been challenged, citizens mobilised and, across the world, healthcare workers overwhelmed, applauded and mourned. For the first time in memory, many general practitioners (GPs) have been anxious about simply going to work.

Since March 2020, Australia’s 6000 general practices have been asked to embrace new models of care, long-promised telehealth reforms and new guidelines for screening, management and safety. While The Royal Australian College of General Practitioners and other organisations have provided comprehensive information on what is needed to negotiate the pandemic,1–3 these resources fall short of giving insights into how practices can make the changes required. Even national primary care pandemic plans have concentrated on systems change rather than providing practical advice to practices.4,5

Where does a practice start when there are pandemic-induced spot fires breaking out everywhere? How do practices balance quality care, safety and simply staying in business?

Ingredients for successful practices

The concept of adaptive reserve may be worth considering. Adaptive reserve (a practice’s ability to make and sustain change)6 has emerged as being a key variable in how general practices can best negotiate the sometimes overwhelming effects of recent international moves towards primary care reform. In North America and parts of Europe, thousands of family practices have been asked to embrace, often within little over a year, capitation, patient enrolment, enhanced health information technology and team-based care.6

While none of these reforms have been as rapid and dynamic as COVID-19, they have placed major demands on practices, most of which are very similar in structure and function to our own general practices.7,8 Evaluations of these natural experiments have uncovered why some practices struggle through major transformations while others flourish. Compelling data come from the US National Demonstration Project (NDP),9 an exhaustive two-year investigation of reform-inspired change in 36 diverse family practices across the USA.

The NDP found that practices that were successful in responding to the challenge of systems-wide change had significant adaptive reserve combined with a stable practice core, and strong links with the local health environment.

The key features of a stable practice core are effective governance, high-quality staff and secure finances. Practices with a strong core were well run, delivered reliable clinical care and were able to cope easily with disruptions such as the installation of new software or the departure of a trusted, long-term staff member. Successful practices were also well linked with the external environment. Staff often lived locally, and practices used the capabilities of local health networks and often had good relationships with major local employers.

However, ‘even the most robust trees are blown over by extraordinary winds ... unless they are able to bend under force’.10 And so it was found that significant change threatens even the best and most well-integrated practices. The NDP evaluators identified the concept of adaptive reserve as being critical in helping practices reinforce themselves against these ‘extraordinary winds’.

Adaptive reserve – The reinforcing factor

Adaptive reserve combines creative leadership with four distinct approaches: clarity of practice direction, using data to learn from experience, building on creative tensions, and fostering learning conversations.10 While the practice core and links with the environment often take years to build, adaptive reserve is dynamic and can be reinforced at times of strain.

It is a very unusual practice whose members lack a direction or motivation for their work. Sometimes that motivation relates to profit; other times it relates to prioritising patients with special needs or delivering quality care. In 2020, leaders can start by exploring what members of the practice are most concerned about in the midst of the pandemic: Is it personal safety? Financial security? Ensuring that the vulnerable are not missing out?

At a time when local risk, patient demand, supplies of personal protective equipment and even item numbers are fluid, there is huge value in learning from practice experience. This can be as simple as collecting data on service use: How many telehealth consults are we doing? Which patients with major needs are we not seeing? Who is overloaded? Who has capacity?

Importantly, practices that prospered were able to build on creative tensions. This needs courageous leaders who can identify conflict by seeking it out – and, critically, being able to talk about it. Bringing those tensions to the surface needs personal interaction, something the NDP found was best achieved by fostering ‘learning conversations’. These conversations – whether in formal practice meetings or the many informal interactions that make up the tapestry of a practice – can be directed at helping the practice find common ground in negotiating 2020’s unique challenges.

Leadership has emerged as being fundamental to society’s ability to deal with the pandemic.11 The recipe for boosting adaptive reserve mapped out by the NDP requires courage and insight from practice leaders. However, as Churchill said, ‘Never let a good crisis go to waste’ – the payoff may be that leaders who can help their practices negotiate these once-in-a-century challenges may be able to build a template for the future of a truly resilient primary care system.

First published online 12 August 2020.

Competing interests: None.
Provenance and peer review: Not commissioned, peer reviewed.
Citation: Russell G. Adaptive reserve: A path to sustainable general practice in a pandemic. Aust J Gen Pract 2020;49 Suppl 31. doi: 10.31128/AJGP-COVID-31.
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