Most GP practice change failures occur because teams are asked to change behaviour before they understand why, want to be part of it, or have any friction removed from the new way of working. Bottom-up approaches with shared vision, concrete scripted actions and incremental testing produce better results than top-down plan delivery.
Every practice owner has tried to change something about how their practice operates, only to watch the team quietly revert to the old way. You will find no shortage of consultants claiming that 70% of change initiatives fail, but that number is an urban myth, traced by Mark Hughes (2011) in the Journal of Change Management to an unsourced assertion in a Harvard Business Review article and a self-described 'unscientific estimate' about 1990s corporate reengineering. The question worth asking is not how often change fails in the abstract. It is why the same practice that rebuilt its entire service model in a fortnight during COVID can spend years struggling with a new chronic disease workflow. This post is the first of two on change management in general practice. It covers why change stalls, how to build a shared picture of where you are headed, and how to break ambiguous goals into actions your team can take. The second post covers the practical mechanics: meetings, incentive design, breakthrough collaboratives and what to do when things go wrong.
Why do practice teams revert to old ways of working?
Andrea Shapiro, in writing about ISO 9001 implementation, summed up the problem: a manager said his change project was 'going fine, except for the people.' We focus on process and technology details and expect staff to adapt instantly. In GP practices, owners introduce new clinical systems, restructure appointment books, change billing models, or assign new tasks. The plan looks fine on paper. The team either ignores it, does it poorly, or reverts in weeks.
The King's Fund reviewed evidence for NHS England in 2022 and found that traditional approaches to changing general practice are not strongly supported by evidence. Financial incentives and targets can change activities, but do not always improve outcomes. Bottom-up approaches that empower frontline staff work better than top-down directives, yet most changes in general practice are still imposed from above.
The Prosci research programme, which has studied change across thousands of organisations, reports that projects with excellent change management are seven times more likely to meet their objectives than those without it. That ratio is consistent across sectors, including healthcare. With that context, the question becomes what 'excellent change management' looks like in a practice with eight GPs, a practice manager and a handful of nursing and admin staff.
How do you build a shared picture of where the practice is headed?
A practice can accommodate many differences among its doctors. Different consulting styles, different clinical interests, different views on bulk billing. But the people who work together need to share a sense of where they are headed. When team members hold different visions of the practice's future and never discuss them, the group loses its ability to change direction.
Creating a shared vision is not a top-down process; it requires leadership. Someone must start the conversation, frame the questions, and allow honest disagreement. If an owner presents a finished plan and asks for buy-in, the room is lost. Instead, define the change in terms of shared values and describe a concrete near-term future that the team can see themselves in.
Johnson and Stewart (2008), working with the TransforMED practices, found that presenting changes as a means of delivering better patient care made it easier for staff to feel invested in the changes. One practice unveiled its change programme with an impressive data presentation at an all-staff meeting. It demoralised the team. Staff could not see the big picture or what it meant for them personally. Some asked, 'What did we do wrong to bring this on ourselves?' The practice held a second meeting, this time with the physician champions, talking about what the changes meant to them and why they cared. That shift from data to values was the turning point.
As well as the big picture, you need a clear view of the near-term future that shows what's possible. Not a five-year strategic plan, but a concrete description of what the practice looks like six months from now if the change works. What is different for the reception team? What is different for the patients? What is different for the GPs? If people can see the destination, they are more likely to tolerate the discomfort of getting there.
Why does values-based framing outperform logic in practice change?
Changing people's behaviour starts with their values. That makes some practice owners uncomfortable. As clinicians, we rely on evidence, logic and protocols. But research is clear: motivation for change is visceral, not cerebral (Johnson and Stewart, 2008). Stripping emotion from the process and focusing only on the plan is counterproductive.
The Prosci ADKAR model breaks individual change into five sequential steps: Awareness of the need for change, Desire to participate, Knowledge of how to change, Ability to implement new skills and behaviours, and Reinforcement to sustain them (Hiatt, 2006). Most practice owners skip straight to Knowledge: they send the team to training, issue a new protocol and update the system. The model says this is backwards. Unless the person understands why the change is happening (Awareness) and wants to be part of it (Desire), the training will not stick.
Anger, frustration, exhaustion and cynicism sit beneath the surface during periods of stability but erupt during periods of change. The TransforMED researchers found that where change stalled, the solution often started with repairing the relationship infrastructure, not reworking the plan. Conflict-resolution tools, viewing problems as process issues rather than people issues, and an occasional outside facilitator to guide the conversation all helped practices move forward.
One practical approach: identify what is already working towards the vision and investigate how to do more of it. Clone the successes. If one GP and their nurse have already adopted a workflow that the rest of the team resists, start there. Show what it looks like in practice, let the team see the results, and use the positive feelings associated with better patient care as the entry point for the rest.
How do you translate ambiguous goals into actions your team can take?
Any successful change requires translating ambiguous goals into concrete behaviour. You need to script the critical moves. 'Improve chronic disease management' is an ambiguous goal. 'Every patient with diabetes gets a GP Chronic Condition Management Plan reviewed at their next appointment, and the practice nurse follows up with a phone call within two weeks' is a scripted move. People can do that. They cannot do 'improve chronic disease management'.
The NSW Agency for Clinical Innovation, drawing on the Safety Net Medical Home Initiative (a five-year US demonstration project across 65 practices), describes change concepts as general ideas that prompt specific, actionable steps that lead to improvement. The eight change concepts tested in that project included engaged leadership, empanelment, continuous team-based relationships, organised evidence-based care, enhanced access and care coordination. Each concept was broken into discrete, testable actions that individual practices could adapt to their own setting.
In practice, this means the person leading the change needs to specify: what exactly are we asking people to do differently, who will do it, when they will do it, and how we will know whether it worked. If any of those questions cannot be answered clearly, the change is not ready to implement.
Why do smaller incremental changes produce better results than big-bang approaches?
Wicked problems are rarely solved with big solutions. They are most often solved by a sequence of small ones. This is the argument for shrinking the change: making each step small enough so it doesn't feel overwhelming and building momentum from early results.
Big-bang change and incremental change represent different strategies with distinct risk profiles. Big bang change may deliver faster results, but it carries a higher risk of failure. Incremental change allows time for testing and adjustment. In a GP practice, where you cannot shut down operations to rebuild from scratch, incremental change is almost always the safer bet. You test a new workflow with one GP and one nurse for a fortnight, measure how it goes, adjust, and then extend it.
The PDSA cycle (Plan-Do-Study-Act) is the formal version of this approach, and it is built into the RACGP's CPD programme for good reason. Each cycle is a small experiment. You plan a change, try it, study the results and decide whether to adopt, adapt or abandon it. Practices that run PDSA cycles consistently build a habit of change that compounds over time. The initial cycle matters less than the discipline of doing the next one.
The other principle here is minimising perverse incentives. Every change creates unintended consequences. If you introduce a target for chronic disease reviews, but the appointment book is already full, GPs may rush consultations or avoid complex patients to hit the number. Think through what behaviour each change will reward and whether that behaviour is what you actually want.
Make it easier to do the right thing
This is the single most underrated principle in practice change. If you want people to do something differently, make the new way easier than the old way. If the new clinical template takes more clicks than the old one, people will not use it. If the new referral pathway requires three extra steps, it will fail. Every barrier you leave in place is an argument against your own change.
In my time at the National eHealth Transition Authority, we learned this the hard way with electronic prescriptions. The technology was sound, but adoption was slow until the new workflow was made genuinely easier. The same lesson applies at the practice level. Before launching any change, walk through the new process yourself, step by step, and count the friction points. Then remove as many as you can before you ask your team to adopt it.