Published: 28/07/2005, Volume II5, No. 5966 Page 17

I left this year's NHS Confederation conference with a sense of unease.

Each time I go to it, my intentions are the same: to keep up to date with other people's successes, to share problems - always hoping that someone has come up with the magic answer - and to meet colleagues.

However, in the bar early one night I found myself venting my frustration about one of the sessions I had attended earlier that day. I was amazed by the lack of confidence in the room in tackling the problem under discussion. The issue was choice in primary care and the ability or inability to stimulate a market.

We all recognise that developments in primary care, or out of hospital care, are now very much at the forefront of policy. This higher profile stems from the number of complaints, made all over the country and not just during the general election campaign, about difficulties in making appointments with a GP. But, more importantly, it has also been inspired by the increasing awareness that investment in primary care is more cost-effective than continued investment in hospitals.

The new general medical services contract allows primary care trusts, as the commissioners of primary care, to offer a much broader range of primary care-based services, not just through the national contract but also through alternative provider medical services arrangements.

Commissioners need to identify both demand and the capacity available in primary care to meet it and then invest to make the new services accessible. We, as commissioners, have the ability to deliver a local service matched to local need.

What amazed me about the conference session was the nature of the conversation about choice. I had expected a debate about the practicalities of using the contract to extend primary care. I wanted to know: how do you measure demand in primary care? What is the new relationship with the local medical committees? How can you invite tenders? Did you, for example, tender for one practice or should we be looking at a preferred partner model for a number of years? In other words I wanted answers to all the new problems we now face delivering choice.

Instead, I was perturbed that the discussion centred on the idea that something had to change fundamentally for us to offer choice, and that people were not sure if this was a good or a bad thing.

My first reaction was irritation that people did not seem to understand the opportunities already present in the contract. But quickly I came to see the conversation in a different light - the audience was made up of many intelligent people who understood the new contract and the opportunities it presented very well, but were hesitant about taking the first step.

The discussion seemed to be about gaining permission from others - colleagues and academics - to step in this direction. Was this nervousness in the room, a real reluctance to go ahead because of the consequences of failure, or just tiredness?

As I chatted to colleagues during the conference I kept hearing about the level of stress that people were many new faces there were at organisations. Many people mentioned colleagues who were off sick, had been off sick or staff who were struggling to cope. They were finding the range and complexity of problems more difficult to manage than ever.

Stalwarts of the profession were admitting they could not remember a more challenging time and were not always as confident or as sure as they would like.

But I should not have been surprised. The national staff survey showed worrying levels of stress in all staff groups, but notably in senior managers. Policy changes seem to be constant and are coupled in several instances with uncertainty about whether they can be supported. Technical details that are needed to make the system work are often late or not provided at all.

In my PCT, as in many others, we are reorganising the management structure not just to make the organisation fit for purpose for the next three years (who can predict longer than that? ), but also in an effort to reduce costs. The end of the high levels of growth in investment in the NHS is in sight.

The first response to our new structure from staff was a legitimate concern over how we were going to manage as an organisation with fewer staff but a constant - at best - workload.

After all, people were already working hard. The danger is that the loss of a post simply transfers the work to someone else. The textbook answer is, of course, to work smarter.

But this answer can leave you in grave danger of physical abuse. Yes, we all know that groups and meetings can be self-generating and we are taking the opportunity to examine not only what we are doing but how.

Organisations must be clear and brave, but not macho about what matters and where the focus lies.

This approach must be coupled with support for those leading these changes.

The leadership framework set out for the NHS was the first time we were clear about what we require or expect from our leaders. The ability to handle ambiguity is one that is often seen in person specifications;

perhaps this skill should be renamed resilience.

Colleagues who I admire in the service have the ability to keep going though whatever changes are imposed, taking staff with them and delivering real change. They regularly stand up and are counted.

If these people falter, then we will have problems. We cannot take them for granted. To offer support is not a sign of weakness.

So next year I hope to be at the confederation conference again to see more of the old faces and perhaps even meet some new ones. I also hope I come away with a greater sense of renewed energy.

Lise Llewellyn is chief executive of Brent PCT.