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Go at bringing a really bright idea to your new practice

You may be the newcomer but partners will recognise you are more up to date than them, says Dr Stefan Cembrowicz

Bursting with bright ideas, you become a partner in your first (and maybe lifelong) practice.

But as a newcomer it may not be so easy to introduce change into an established practice and you may encounter unexpected obstacles to progress.

How do you tactfully start to bring your new practice up to date?

Practice dynamics

First, sit back and observe. Figure out how the partnership works. Who makes the decisions? Do you have a vertical or horizontal hierarchy?

In some practices the senior partner still makes all the tactical and strategic decisions, although this traditional model may not suit today's climate of mega-change where everybody's skills need to be deployed to respond to the demands of the new contract and beyond.

A more horizontal (and democratic) model of decision-making used by some practices involves each partner being responsible for managing specific areas of clinical expertise, for example asthma, diabetes, child health.

Changes in policy may be agreed in two ways. First by vote. Here it can be difficult to reach a true consensus, rather than just comfortably avoiding disagreement, among doctors who need to rely on each other for clinical back-up. Second, by general acclaim. Here a partner who presents a good idea and has the enthusiasm to make it work will be given space to get on and develop it, unless anyone else strongly disagrees.

Other key staff such as the practice manager, practice nurse and even

partners' spouses may have an influence on practice policies and you will need to take them into consideration as well. This influence may sometimes be covert.

The practice manager may be a good person to talk to about your ideas to spot any unpredicted implications and pitfalls.

The manager may also give you a good idea of which partners are the most active intellectually. Perhaps you did Belbin scores in your VTS to define your own role in group work; remember that your new partnership is also a small group. You may recognise behaviour that you remember from your VTS days. Who is the motivator, the ideas person, the reliable back-up ­ and the silent partner?

Proactive ­ or reactive?

You may also find you are in a practice where strategic decisions do not get made at all as everyone is too busy working reactively rather than proactively with their clinical caseloads ­ dysfunctional communication is not confined to patients' problem families.

In such a case you may only be able

to help the practice introduce change

by starting regular meetings as a forum

for communication, for example for

clinical presentations or, more spicy,

to present critical event analyses. Another way of engaging at least some of your partners in working together would be to begin with a project with obvious benefit to the practice.

Financial ones may be most eye-catching, for example an audit of income from travel immunisations, or costing out a proposal for doing insurance reports by means of a computer printout.

Make sure the benefits of your proposal are measurable and that an audit to demonstrate this is in place.

Find an ally

Having studied the dynamics of your practice you may find it tactful to

choose an ally to talk your bright idea through with.

As incoming partner you may feel very much like the new boy or girl but do not overlook the fact that your partners chose you for your skills and will respect the fact that you are more up to date than they can be ­ and that though they have more worldly experience than you, your vocational training will have been more rigorous than theirs and will make you a useful practice resource.

And what about using those VTS group-work skills to set up a practice awayday as a forum for change? (PCT funding may well be available for this.)

Look out for the hidden agenda

It may be unwise to announce proposals for major change in your practice out of the blue, so consider first the implications for any changes you have in mind from

the point of view of each individual partner.

Many GPs have commitments outside the practice, such as occupational health, clinical assistant posts, medicolegal work, Section 12 or police surgeon work and other sources of income. Proposals that would unwittingly disrupt these activities would be blighted from the start.

Once you have prepared your ground, defined the practice's hierarchy and communication style, identified the key players, enlisted the support of an ally, and considered the obvious pitfalls ­ you are all set. Good luck!

Stefan Cembrowicz is a GP in Bristol

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