I wanted to leave my job as a CCG Chief Executive for a long time. But it took many months until I finally handed in my notice. I was nostalgic about the past, and clung to memories of a time when I had loved the job. My attachment made leaving difficult. Despite the relentless, day to day pressure there was always this nagging concern; if I left I would no longer be needed in the same way. And I was not 100% clear what my new future would look like. In many ways a bleak certainty was easier to cope with than the uncertainty of the unknown.

I don’t think I am alone. Letting go (of control, of certainty, of routine) is difficult for all of us. Unfortunately, nearly all of the things that can make a difference for general practice seem to involve GPs “letting go” in some guise or other. So, for example:

• Practice mergers. These involve GPs “letting go” of the control of their (smaller) practice for a lower amount of control in a bigger practice.
• Introducing new roles. Bringing in clinical pharmacists, paramedics, physician associates and the like involves GPs “letting go” of some of their workload so others can take this on.
• Workflow redirection. If you have not come across this yet you should (listen to this), but effectively it involves GPs “letting go” of their post, and trusting much of it to be handled by others.
• New models of care. Okay, not yet a common solution but a designated national direction of travel, and it involves GP partners “letting go” of their independence and becoming salaried employees or, at best, board members in an NHS organisation.

This is why making change in general practice is difficult. It is why practices don’t merge, don’t introduce new roles, don’t make changes to how they operate, and don’t jump into bed with the local hospital just because they are under pressure. The changes may be logically sensible to an outsider, but if they are not underpinned by a strong desire to take whatever action is needed they won’t be implemented.

The big mistake made by those trying to lead change in general practice is starting with the solution, with a description of the change that is to be implemented. Taking the desire to actually make the change for granted, on the basis of the parlous state of general practice, is a fast track to failure.

Professor John Kotter, regarded by many as the leading contemporary expert on change, believes[1] assuming people know they are in trouble and need to change, and focussing instead on strategy and solutions, is what kills most change efforts. He differentiates between a “false” sense of urgency whereby people feel anxious, angry and frustrated, and a “true” sense of urgency whereby people have a powerful desire to move, successfully, now. The former does not lead to taking action, but the latter does. GPs feeling under pressure and angry is not the same as GPs wanting to make a change.

Ultimately I made my decision to leave based on a strong desire to create a new future for myself. After many months of anxiety, frustration, and (frankly) inaction, I reached a point of determination to make a change, however hard it would be. It was only then I was able to actually resign. To be successful, those leading change in general practice must first focus on establishing a sense of urgency for change, before ploughing into the details of the uncertain future they want to create for their GP colleagues.

[1] A Sense of Urgency, Kotter J.P. Harvard Business Review Press, 2008