Letters

The government has promised golden hellos and handcuffs and practice-based incentives to help a GP workforce demoralised by new initiatives and rules, increasing demand and constant change.

Most general practices are cottage-industry organisations with infrastructures struggling to come to terms with 21st century demands such as professional development plans, personal learning plans, undergoing appraisal, undertaking staff appraisal, clinical governance, revalidation and re-accreditation.

Therefore most can't manage the change - at a time when patient expectation and demand is rising - even if they wanted to.

Many struggle to deal with even simple internal day-to-day matters, making routine decisions, or getting everyone to use the computer system. Many have 1950s response systems, and allocate an individual GP's time to great swathes of demand which could be dealt with (and are, in some practices) in an entirely different way.

If they were part of the hierarchical NHS management system, you would expect the weary troops to be at least pointing in the same direction as the leaders. But general practice is different. Even if GPs believe in some of the changes, making them happen in the practice is difficult and for some simply impossible.

Outsiders - NHS managers - cannot enforce this change, and the idea that general practice can be 'performance-managed' is laughable. In a practice of four doctors where I recently worked, one GP would not use the computer. No-one could make him change his mind, so the system worked round him.

Perhaps primary care trusts will be able to institute better management or change systems in their practices. But in extensive contact, I have found few GPs talk positively about primary care groups, even when GPs are board members. And which part of PCTs will support, which part performance-manage?

How will you know who is doing what at any one time?

'General practice' may sound like a homogenous group, but it is 30,000 individuals with an intense dislike of bureaucracy, organisation or government gathered in loose organisational forms where individual will is stronger than corporate view.

If we are to retain independent contractors in small organisations as the main form of service delivery for the foreseeable future, we have to recognise that they find it hard to deal with change. It is pointless running ahead with new ideas and initiatives - however laudable - while 'Dr Smith' will not even use a computer.

We have to provide more change-management support in general practice, and help GPs deal with current management issues before heaping future change on them. If we do not, they will become increasingly frustrated with their own inability to cope with the government's and patients' demands.

General practice is known for best accepting change through peer example. GPs need the time to see how more successful practices manage change, they need help in managing increasing demand and above all they need stronger internal management systems. Without these, any amount of government sweeteners will be wasted.

Ray Wilcox Wilcox Penfold Partnership Norwich