Halfway there: Most Significant Change Evaluation in the times of COVID-19 by Sarah Chalmers-Page

As soon as I learned about Most Significant Change (MSC) as a methodology, I was excited about the way it could let the people who matter most – the patients and the staff – lead evaluations in a way the usual surveys and interviews didn’t. I’m self aware enough to know the perspectives I bring shape the questions I think to ask; MSC would take control away from me, and give it to the people who could actually see what was going on.


My team were working on introducing a new role, the GP Assistant or GPA, which was intended to take some of the burden off GPs, who routinely worked long over their hours, and help patients be seen far more quickly. The standard evaluation I would have done would be a baseline survey asking GPs about routine waiting times and their administrative burden, backed up by semi structured interviews for GPAs and GPs working with them. To this, we planned to add the MSC methodology, giving space for the teams themselves to tell us what most changed because of the role, and what most changed for them because they had taken the training.


We had got as far as baseline surveys, the first wave of MSC stories and some interviews when COVID-19 became a serious threat. All face to face meetings were cancelled, but the staff we were working with were not yet familiar with zoom or teams. And it was obvious that re-running the GP survey would not tell us much about the role; GP work had altered so much because of the pandemic the effect of GPAs would barely have registered. Convening a panel whilst GPs worked all hours to reorganise every aspect of their care seemed to be a non-starter. So what could we pull out from a collection of stories?

As soon as I learned about Most Significant Change (MSC) as a methodology, I was excited about the way it could let the people who matter most – the patients and the staff – lead evaluations in a way the usual surveys and interviews didn’t. I’m self aware enough to know the perspectives I bring shape the questions I think to ask; MSC would take control away from me, and give it to the people who could actually see what was going on.


My team were working on introducing a new role, the GP Assistant or GPA, which was intended to take some of the burden off GPs, who routinely worked long over their hours, and help patients be seen far more quickly. The standard evaluation I would have done would be a baseline survey asking GPs about routine waiting times and their administrative burden, backed up by semi structured interviews for GPAs and GPs working with them. To this, we planned to add the MSC methodology, giving space for the teams themselves to tell us what most changed because of the role, and what most changed for them because they had taken the training.


We had got as far as baseline surveys, the first wave of MSC stories and some interviews when COVID-19 became a serious threat. All face to face meetings were cancelled, but the staff we were working with were not yet familiar with zoom or teams. And it was obvious that re-running the GP survey would not tell us much about the role; GP work had altered so much because of the pandemic the effect of GPAs would barely have registered. Convening a panel whilst GPs worked all hours to reorganise every aspect of their care seemed to be a non-starter. So what could we pull out from a collection of stories?


Giving people the space to tell their own stories, with their own emphasis on what was most significant to them, showed first and foremost we had underestimated our administrative teams. The GPAs were largely drawn from the administrators and receptionists. They, it turned out, were a largely untapped pool of shimmering enthusiasm. Without being steered, people used terms like “passionate about care,” “lust for doing more,” and their joy at being able to help their teams out more effectively. They had “loved” the chance to learn. The opportunity was clearly rare – people were “just so grateful” that they could learn on the job, rather than have to give up income to train; we now know that there is a cohort of people who would love further training but cannot give up income to take it. Space emerged immediately as an issue too, as soon became nationally apparent with home schooling – extremely conscientious candidates spoke about the stress of trying to study whilst also sharing a single living space with families, cooking dinner and trying to keep their children’s homework going. This is not news now, but was clearly an issue for adult learners even before the pandemic. This can translate immediately into better support for our adult learners – releasing team members for training is essential, but so is asking if they need a quiet corner of an office during their protected time.



The stories could be extremely powerful on an individual level; we talked to one young man who for the first time he could remember was considering taking a degree, possibly in nursing, because he had enjoyed both helping patients directly and learning so much. On a system level, we learned a lot about what would have helped more; better marking schedules so people knew if they had to do an essay or a few sentences, providing space as well as time for learning, the fact the most significant support some people had had was from practice managers or nurses rather than GPs.


Despite the lack of the full methodology, the results of this evaluation were still richer and more useful than a survey or even traditional interviews would have approached.It is a clear example of aiming for the stars; you might fall short, but you will be a lot further forward than if you had not tried.

Giving people the space to tell their own stories, with their own emphasis on what was most significant to them, showed first and foremost we had underestimated our administrative teams. The GPAs were largely drawn from the administrators and receptionists. They, it turned out, were a largely untapped pool of shimmering enthusiasm. Without being steered, people used terms like “passionate about care,” “lust for doing more,” and their joy at being able to help their teams out more effectively. They had “loved” the chance to learn. The opportunity was clearly rare – people were “just so grateful” that they could learn on the job, rather than have to give up income to train; we now know that there is a cohort of people who would love further training but cannot give up income to take it. Space emerged immediately as an issue too, as soon became nationally apparent with home schooling – extremely conscientious candidates spoke about the stress of trying to study whilst also sharing a single living space with families, cooking dinner and trying to keep their children’s homework going. This is not news now, but was clearly an issue for adult learners even before the pandemic. This can translate immediately into better support for our adult learners – releasing team members for training is essential, but so is asking if they need a quiet corner of an office during their protected time.


The stories could be extremely powerful on an individual level; we talked to one young man who for the first time he could remember was considering taking a degree, possibly in nursing, because he had enjoyed both helping patients directly and learning so much. On a system level, we learned a lot about what would have helped more; better marking schedules so people knew if they had to do an essay or a few sentences, providing space as well as time for learning, the fact the most significant support some people had had was from practice managers or nurses rather than GPs.


Despite the lack of the full methodology, the results of this evaluation were still richer and more useful than a survey or even traditional interviews would have approached.It is a clear example of aiming for the stars; you might fall short, but you will be a lot further forward than if you had not tried.