It is one of the perennial challenges of NHS management – how do we engage the GPs? I remember when I was an NHS management trainee, in the days when GP fundholding was imminent but had not yet arrived. There was a look of fear in the hospital contract manager’s eyes, as he grappled with the prospect of engaging GPs, with no real clue of how to do it. Some STP meetings feel similar. We want GPs to be central to the whole process, but (ahem) as we look around the table, there are none to be seen.

It works the other way. GPs have previously been duped into participating in a whole raft of system initiatives, largely against their better judgement. Generally, if it works for them (e.g. fundholding) it gets taken away, or if it gives them any real power (e.g. CCGs) the power gets taken away, or if it has the promise of power (e.g. practice based commissioning) it turns out to be an illusion and built on sand.

Which leaves GPs facing the prospect of accountable care systems with an understandable lack of relish. Promises and reality have been so different over the years that scepticism seems like a reasonable starting point.

So how do you get GPs engaged? Professor Kotter, Harvard professor and one of the leading current thinkers on change, is clear the first (and most important) step is to create a sense of urgency. What he talks about is creating a clear reason, a rationale, for getting involved in the change, and why action is needed now. If you haven’t read his “penguin” book, Our Iceberg is Melting, I would highly recommend it.

There are potentially three ways to create a sense of urgency for GPs related to accountable care. The first is the current crisis engulfing GPs. Accountable care, and partnerships with other organisations, represent a potential way out for GP partners who no longer want to continue with the daily struggle of trying to keep up with ever increasing demand without the staff or resources to realistically cope. Certainly this has been one of the drivers in some of the vanguard areas.

In my closeted management world, a distinction is drawn between “towards goals” and “away-from goals”. Towards goals are ones like winning a medal at the Olympics, where individuals have a very clear picture of what they are trying to achieve and they use this picture to motivate everything they do in pursuit of that goal. Away-from goals are ones like wanting to change job because you hate your boss, where individuals don’t necessarily want the job they are going to, they just don’t want to remain in the situation they are currently in. You know where I am going with this. Towards goals work well, away-from goals do not (you end up in a different job that you hate equally), and using the crisis in general practice to motivate GPs to engage in accountable care is an away-from goal.

The second way is to draw out how the NHS world is changing, and how involvement in accountable care is the only real way for GPs to shape the environment they will operate in in the future. The voice of GPs through CCGs is getting lost as commissioners merge and align with STP areas. Despite assurances about where the core GP contract sits, the reality is accountable care includes all of what general practice does (not just the extra services the local federation provides), and the changes will include to a greater or lesser extent some aspects of how GPs are reimbursed.

This is a tough sell, largely because the default GP strategy of head down and wait for the wind to blow over has by-and-large worked for the last 70 years. Why will it be any different this time? Worse, there is no legislation to fall back on. At least with CCGs you could point to the Health and Social Care Act and the 1^st April 2013 for CCGs taking on real responsibility. No such luck this time. But on the plus side, the threat of acute hospitals controlling primary care expenditure will corral many GPs into action.

The third way is to attempt what I describe as the Martin Luther King approach (“I have a dream…” etc.). In the true spirit of “towards goals”, we could start with an inspiring vision of what accountable care can do for our communities. What if we asked our local community what they really wanted from their health system, and what if we could work with our local partners to make their vision a reality. What if consultants, GPs, social workers and the voluntary sector could really work together to change the experience of diabetes or asthma or frailty (or all of them) in our area. Starting with the difference individuals wanted to make when they chose to become a GP and tapping into that may ultimately be both the hardest and most productive route to follow.

In the end, the contracts manager did what these days we often fail to do: he went out to all the practices, listened to what they had to say, built a relationship with them, and the hospital survived fundholding. There are no shortcuts for this. If we want to engage GPs in accountable care, whatever arguments or approach we want to take, we have to get out to the practices and talk to GPs about it.