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Changing roles in practice management

4 October 2010

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Practice Manager
Keelinge House Surgery, Dudley, West Midlands

You would assume that after 10 years away from general practice, things would have changed dramatically. However, while I have had to grapple with new primary care structures, targets and the IT revolution, the core skills of providing care to patients and managing a practice team are almost the same.

I re-established myself into general practice in November 2009, after a break for independent working and spending time with my daughter. I applied for the new role at a practice in Dudley, with very little knowledge of how things had changed in 10 years but I was up for the challenge – and, oh, what a challenge it was!

Learning a new clinical system was hard enough, but on top of that I had to come to grips with the Virtual Ward, Open Access, Executive Appointments, the Quality and Outcomes Framework, ImmForm,, NHS Choices, Chart and Primis, just to name a few. What on earth were all these, I thought – and this was all in the first week.

My saving grace was that I had an excellent administrator beside me, who explained that, once set up, most of this would be easy to follow. With my memory, I thought I would never remember all these passwords, let alone what to input on each new website and computer system. Still, I had made this choice and I was not going to let it beat me.

Within a few weeks I had my first practice-based commissioning meeting, involving all the practice managers in my locality. After a brief introduction, the meeting began. On the agenda were electronic discharges, open episodes and patient data systems – all of which meant nothing to me and issues passed swiftly by, like a swallow swooping over one’s head. I thought: will I ever catch on?

Practise like it’s 1999
Whenever I think back to my final months in general practice in 1999, I always remember it as cold, dark and very snowy. My last days were just before Christmas, a time when the world always seems to come to an end, with patients requesting more than their usual allocation of medication just in case they get sick over the festive holiday. Ironically, we were only closing for two days over the Christmas break, yet the GPs were grumbling about the amount of extra work they had to do and the amount of prescriptions they had to sign.

Some things then were just as they are now. At that time I had recently seen a patient who had made a complaint about a home visit that no one will own up to being responsible for not putting in correctly. Fortunately, I was able to address the patient’s fears and assured him that this was a one-off malfunction, and would not happen again.

As it was heading towards the end of the month, the GMS statement had just arrived and I could cross check against my audit books to see what payments had been made against what I knew we had submitted. No surprise – the Family Health Service Authority (FHSA) had missed out a complete block of maternity payments, so I needed to contact them and find out why. I also checked off the Postgraduate Education Authority payments and made sure that all our GPs had their quota in for training days. And great news, our practice had hit 99% on our smears and immunisation targets. The GPs will be happy with that, I thought.

Our then-modern clinical system was playing up, constantly switching on and off. Perhaps it was overexcited at the prospect of Christmas, meaning it will have a rest from inputting data.

Our appointment system also seemed to have a mind of its own, so both I and my IT lead were trying to sort out why one patient was booked in at 9.30pm at night rather than in the morning. Little did we know back then that the new GP working contracts in 2010 would mean we actually would be providing appointments late in the evening.

New rates of pay had also just been approved by the FHSA, with an increase of 3.5% in the cost of living along with incremental rises for everyone. I had installed all these new rates on my new payroll software – it’s so quick and easy I can’t think why I didn’t use this before, I thought. The senior partner still had reservations and decided to take the software offsite and install it on his home computer as back-up, but even he was happy with the transition – especially as it was completed within an hour, meaning no more Tipp-Ex on those P11 forms every time you were interrupted and made a mistake.

I had also just completed the practice staff appraisals, which, as always, were long and tedious. We needed to complete these in order to make a practice training plan, as we had a few longstanding leavers, which gave me the opportunity of rethinking the way we do things. Amspar and performance-related-pay were the latest buzz words, so I made it my mission to make sure everyone had either got one or the other, depending on their chosen role.

At this time, I was enrolled at Birmingham University on a postgraduate course in learning and development in healthcare. Juggling study, a two-year-old daughter, fulltime working, a house and a husband was getting complicated. For a while things were very stressed, but I managed it well and completed three modules on the course. All this so that we could spend money via the FHSA on training – until, as always, they closed the door on the funding.

As we stepped into the millennium I decided to make a career change. I came to the conclusion that I needed a more challenging role, and as I had managed to implement all the changes the GPs requested, along with a few of my own, I left the practice with the biggest challenge of all: a new build.
Having found a site within spitting distance of the practice’s two-storey Victorian house and a plan in place for its development, I left to take on new challenges. My new role was to assist GPs throughout the country in advising on how to provide new buildings to deliver better primary healthcare by introducing developers to them for new builds.

Back to the frontline
When I returned to frontline general practice in November 2009 I was looking for a new challenge and, in a sense, a job role that I had missed. Every day offered new challenges and opportunities, particularly the challenge of getting to grips with all that had changed.

One week is never the same; the days they seem to get shorter in time when you have urgent things to attend to, and when you are due to leave early the days seem to become longer. A good day is when all the actions on my list are completed and I go home satisfied.

Not long after restarting as manager, the practice had a Quality and Outcomes Framework visit. Some say it’s like the tax visit. I’m not sure that’s the case, but it certainly was an eye-opener. Whereas 10 years ago I could sign off projects as complete, everything now needs to be justified and evidenced. This results in a constant paper trail to justify funding to wanted outcomes.

That is probably the biggest change I have had to confront: the justification of everything to all the practice stakeholders. This, alongside the constant need to feed information for statistical purposes to the primary care trust. While I understand the need to maintain standards, it adds to the amount of time patients have with their GP before any treatment can 
be agreed.

Technology, while making many of my tasks so much easier, seems always to create roles that never used to exist. Rather than sending a bundle of documents to a single administrator, I now have multiple email addresses for all the stakeholders that require various bits of information about the practice. I often wonder which email address to use.

Systems that seemed like new science experiments 10 years ago, like payroll and an integrated clinical system, are now just taken as the norm. These days I find it hard to imagine what I would have done without them.

The biggest challenge, however, over the next few years will not be a personal one but a new change to the organisation of the NHS. The new government’s white paper, which proposes putting GPs at the heart of the NHS, with GP consortia having the funds to buy the services for their communities, will effectively return us to a system of GP fundholding, but with a new name. My experience of a system 10 years ago will surely come in useful – it is almost as if we have come full circle.

As with all new challenges, if we work hard we will rise to them, as I have done back in practice management. There may be times that I wonder why I rejoined but, in the end, along with my band of merry men and women we try and serve our community well.

Happy days!