Managing change in general practice: a step by step guide.

B.J 1992;304:231-4 Over the past five years general practitioners have been challenged by proposals from both the government and the Royal College of General Practitioners to fundamentally change the administrative structure and day to day running of general practice.`'Changes range from individual practice based innovations, such as developing structured surveillance for chronic disorders and improving the provision of preventive services, to broader initiatives, such as performance review and an emphasis on medical audit. Though much attention has been paid to the content of such change, less energy has been directed towards establishing how change can be managed most effectively. Experience in industry suggests that even the most rational change can be obstructed if its implementation is either badly planned or inadequately negotiated. Several models have been developed to assist the successful management of change,6' some of which have been applied to various aspects of the NHS.8-'° We discuss how one such model, which was first developed in industry, has been usefully applied in general practice settings. We worked with a management consultant (RC), who has considerable industrial experience, to develop and adapt a model for managing change for general practice; the model emphasises a team approach. We have applied this model to different situations in general practice, including introducing screening services and surveillance of chronic disorders, incorporating new technology into practice administration, and improving liaison and effective working relationships between different professional groups." 12 The model can be used either by a practice that already functions as a cohesive team or by a person within the practice who wishes to move towards a team based decision in introducing change. In practices that already function well as a team, with regular meetings of the whole team in which each member's contribution is recognised and respected, the process of shared decision making about an innovation can be started with few of the preliminary steps described here. However, more often an innovation is sponsored by a single person. In this case the strategies described can be used to introduce an idea to other team members, to negotiate agreement and implementation, if appropriate, in such a way that it strengthens the team and has maximum chance of success.