Wendy Garcarz
MA DipEd DipTM
Managing Director, 4 Health Ltd
Wendy is managing director of 4 Health Ltd, a training and development consultancy firm based in the West Midlands. She is an organisational development specialist and architect of learning organisations, and has authored several books and publications on healthcare development
Healthcare services in the UK are traditionally funded through taxes, meaning that historically the political influence on their structure and performance has been significant. Previous governments have been judged by the infrastructure and services they have provided for the population, as their policies and spending plans defined the services we got. Their success or failure had a direct relationship to the government’s performance in elections.
In July this year, the white paper Equity and Excellence: Liberating the NHS changed that. The white paper describes an NHS system rather than a national service, where “any willing provider” can contract to deliver services with commissioning consortia led by GPs. This strategy has received mixed reviews from ideological, tactical and operational perspectives, but it is clear that the coalition government is determined to pass their accountability for effective healthcare on to commissioners and regulators. The responsibility for value for money and tailored healthcare will be shared between commissioners, providers and patients, reflecting their “Big Society” ideology.
All healthcare providers will become independent, standalone businesses (foundation trusts, social enterprises and community interest organisations), a status that GP practices have always had. This change impacts on the business climate by placing all organisations linked into the NHS system under the commercial pressures that any independent business is subject to, namely to: operate efficiently; offer value for money; control/reduce costs; make a profit/surplus; manage risks; and comply with the law and relevant regulations.
These organisations may feel the pressures of efficiency drives more keenly than the initial investment, as efficiencies will almost certainly need them to review their current practices. Change in this area is challenging, as the culture of the organisation will naturally try to retain the status quo. This will prove a real challenge for public sector managers, but many practice managers will breeze through the changes as they are used to managing their organisations in this way anyway. They may not speak the management speak of primary care trusts (PCTs) but their skills and competencies have been honed in a business environment.
Practice managers already work with the four pillars of business effectiveness:
- Business viability: processes that demonstrate that the business is financially sound.
- Business capability: approaches that demonstrate that the business is operationally sound.
- Business contestability: the business model that demonstrates the business can equal/exceed the demands of the market/their client base.
- Business sustainability: mechanisms that demonstrate the business has a long-term future and can weather change without disruption.
For practice managers, these four pillars are the things that take up their managerial time. The ability to survive, pay wages, meet overheads and ensure a stable income for their GPs all make up the “lion’s share” of their role.
Business viability
Viability means “the ability to survive”, and for many businesses that is ultimately linked to profit/surplus. Even if the business is not currently profitable or creating a surplus, there is an expectation that it will do so at some future date. The expectation of future profit/surplus justifies the business planning and cost control that general practices have to do on a daily basis.
Managers have systems that identify their budgets, cost centres, capital and running costs, financial controls and effective resource management. They operate financial accountabilities and responsibilities and have to keep auditable records and accounts. They have development plans that contain initiatives to generate additional funds and financial analysis that identifies the profitable areas of their business. These skills that practice managers have can offer support to the GP commissioning consortia as they take on their new roles.
Business capability
Business capability implies confident service delivery, reliability and safety, and it delivers on a business and an individual level. There is an expectation of capability in businesses that deliver services to the public in the way they meet the needs of their clients. They need to understand the requirements of their clients, predict and adapt to change and develop new capabilities with greater speed simply to remain effective and cost competitive.
Knowing about and successfully deploying the right new capabilities has always been challenging to businesses, but general practices have worked in this environment for many years. Indeed, some would say that the role of the modern practice manager came from these business pressures.
Some areas are particularly challenging: software and technology capabilities are sometimes as elusive and difficult to pin down as they are valuable and essential to the core operations and processes. Again, modern general practices have operated sophisticated clinical systems that support diagnosis and treatment but also shape the income and expenditure of the business. In the vast majority of cases the practice managers and their teams have helped to develop, implement and update these systems, making them what they are today.
Most business capabilities today are a combination of people, process and technology. Forging such combinations successfully requires an effective facilitation of the interplay between business and technology. When an organisation makes use of its capabilities, there is suddenly a pressing demand for a blend of vision, planning and know-how in order to take advantage of these capabilities.
Practice managers have headed up this drive for general practice, allowing time for GPs to concentrate on their clinical work. Risk management policies, procedures, service standards, clinical and corporate governance, patient satisfaction data/user involvement mechanisms and management information for statistical and business analysis are all tools and skills that are utilised daily in general practice but are eminently transferable to the work of GP commissioning consortia.
Business contestability
To understand how a business measures up to its competition it needs to understand its markets (the arena it operates in), its client base (existing and potential clients), its unique selling points (the elements of service separating it from other providers) and its reputation (how it is perceived by others).
Practice managers have real expertise in engaging their patients and involving them in the developments of the practice. Marketing information (eg, the practice leaflet) can be the difference between patients that use services appropriately and those that put services under unnecessary pressure. This “intelligence” they have gathered over the years would provide their consortia with clear information on needs, aspirations and demands of their populations, all of which will be critical to the local commissioning required of GP consortia.
Business sustainability
By making it a requirement of GP commissioning consortia to assess and address the commissioned services contribution and impacts on the health and wellbeing of the local population, the white paper is making a clear statement of its expectations of value for money and sustainable healthcare.
Practice managers have helped to develop general practice services as they are today, and those transferable skills can do the same thing for GP commissioning consortia. There should be a place for those that want it and can bring their transferable skills, intellectual capital and capability to the next phase of primary care.
