With practice managers taking on ever greater roles and responsibilities, are the existing qualifications and traditional entry routes sufficient for the demands of the job?
Practice managers are ‘jacks of all trades’, often being asked to demonstrate skills and knowledge across a wide spectrum. Few other managers have to deal with regulatory visits, complaints, man management and data collection – often all on the same day.
In addition they are coping with the ever-changing landscape of the NHS, dealing with new organisations and taking on new responsibilities. Dr Robert Varnam, head of general practice development at NHS England, says: “Over the last 15 or 20 years the job of the practice manager has changed hugely, possibly beyond recognition. It is becoming much more professionalised – which I think is a good thing.”
He highlights changes both inside and outside the practice which are affecting the lives of practice managers. First of all, the pace of work has increased with additional requirements from external bodies such as the Care Quality Commission (CQC). There is also a much greater focus on improvement and innovation for practices.
But there are also strong external pressures: the arrival of clinical commissioning groups has made practices more part of a ‘corporate machinery.’ But one change he thinks could have enormous ramifications for the practice manager role is the trend towards collaboration, whether that is practices merging or working together in some form of network or federation.
But should those taking on these pivotal positions within practices have – or be required to get – a relevant qualification? There are many practice managers who would support some sort of requirement.
Russell Vine, practice manager at the Hassengate Medical Centre in Essex, and a member of the Practice Management Network, says: “There is no logic for GPs to go through a five yearly revalidation process but key players in the practice should not. Why should we not need qualifications? There are occasions when a bit of papers is needed to prove you can do the job.
“I’m all in favour of an agreed definition of what a practice manager is and then a qualification that goes with it – so that for CQC purposes we can show that we are a qualified manager.”
Steve Williams, who is also involved with the network and works across a number of practices in London, echoes that. “Most practices managers would not be adverse to there being some sort of statutory requirement,” he says.
NHS England has no proposals to push for mandatory qualifications. However, Dr Varnam says it is keen to understand how it could most usefully support practice managers.
“We recognise the current situation is very heterogenous,” he says. “There are practice managers from a professional background with a growing number having MBAs and so on.”
“People often raise the question about some qualification but they usually very quickly follow it up by saying what matters more is the kind of peer support and development opportunities that will help people do the job really well.”
NHS England – which has just published a document highlighting what it thinks general practice will look like in the future – is talking to practices and practice managers about this, but Dr Varnam says it needs a clear picture of what experience and skills are needed for the role as it changes before it can decide what sort of support is needed.
“We are hearing that it would be good to have development opportunities but we need to be clear ablout development for what. We do have a responsibility to support practices… we are trying to understand more on how we can play a supportive role.”
In the past, many practice managers were promoted from within – perhaps a head receptionist taking on the role in a small practice. The advent of fundholding changed this with people from a professional background often moving into the job – including a number of ex military officers. More recently there has been an influx of people with experience in banking and also former primary care trust managers.
Most of these will have managerial experience – though not necessarily in health. And as Dr Varnam says one of the challenges is that there is no clear definition of what a practice manager does – or does not – do. The demands on a practice manager in a single-handed practice may be different from someone running a large practice with a multi-million pound turnover more akin to a small business. Any definition or prescribed qualification would need to take account of that.
The role can also change over time. Mr Vine joined his practice when there were three GPs; now there are six and an increase in other practice staff. “I wanted a quiet, part-time local job,” he says. “It’s still local! Many practice managers are basically running a good size organisation without the support mechanisms or funding streams you would get from a commercial organisation.”
David Lee, who leads on training for the Institute of Healthcare Management, says practice management is “more than managing people, it’s managing change, the business.” Shirley Cramer, Institute of Healthcare Management (IHM) chief executive, points out the agenda of the health service is moving towards prevention and managing change in conditions: primary care, and practice managers, will be important in this and are well placed to work with local authorities and other bodies.
Recent changes have included NHS England seeing practice managers as a conduit into their practices, CQC registration, GP revalidation and the arrival of CCGs. The last three all involve a considerable administrative burden which practice managers are likely to oversee. The rate of change may make it harder to pin down a universal definition of what a practice manager should or does do. Mr Vine warns that one issue has been that there has been little clarity or sustainability in qualifications in the past. A vocational training scheme for practice managers, for example, ran for a few years in England but has pretty much disappeared – although it still exists in Scotland.
But if statutory regulation looks unlikely are there pressures in the system which could mean more managers look to become qualified – and more practices expect it of them?
One driver towards universal qualification could be the CQC. The Department of Health (DH) has recently proposed a fit and proper person tests for directors of healthcare providers: this includes having the qualifications, skills and experience necessary for the role. The CQC will have responsibility for applying this test when organisations register or change directors.
It says that practice managers would only be scrutinised under the fit and proper person test if they were put forward to the CQC as the registered manager for the practice. This happens in some cases but many practices put forward the senior GP as the registered manager.
But, more generally, the CQC looks to see if practices have appropriate recruitment policies and that anyone employed has the correct qualifications to fulfil their role and that they are regularly assessed and appraised.
Another driver could be the trend towards mergers or federations of practices. Practice managers moving from a small practice to a larger one will find the job transformed: Mr Williams says this could lead to them specialising in one aspect of the job, such as human resources or finance.
In London there have already been steps towards creating larger practices instead of a number of single-handed ones. “There are too many practices which still rely on the Dr Finlay’s Casebook scenario… these are the practices which will be subsumed over the next four to five years,” he says.
Another factor could be the pivotal role practices are likely to play in closer co-ordination of health and social care – and the need for those at the centre of the practice to be able to assist this.
But there would then be the question of who pays for any training or for continuing professional development for managers whose roles are changing. In the past, primary care trusts (PCTs) were quite supportive of practice managers, but CCG interests lie elsewhere and there is no obvious pot of money for practices to access to fund training. At a time when practice income is often falling, GPs may be reluctant to take on additional costs unless they have no choice.
Probably the best known practice management qualification is run by The Association of Medical Secretaries, Practice Managers, Administrators and Receptionists (AMSPAR) and provides a level five certificate/diploma (the level of a foundation degree) which is recognised by The Office of Qualifications and Examinations Regulation (Ofqual). AMSPAR chief executive Tom Brownlie says about 100 practice managers a year go through this, but a planned distance learning option has attracted a lot of interest with around 100 enquiries in a month. “That is the qualification people look for,” he says.
The course offers core elements and also the opportunity to take modules most appropriate to the practice environment.
Some years ago the IHM ran a vocational training scheme for practice managers and potential practice managers in England. In Scotland it was enthusiastically embraced by National Education Scotland, which provided part-funding for those who wanted to take it, and is accredited by the University of the West of Scotland. It involves 800 hours of study over 13 months.
The IHM is reviewing what it offers to practice managers in England but the lack of central funding for it in England could be a barrier. Health Education England (HEE) says it has no responsibility for practice managers as they are employed by “independent practitioners and will therefore make local arrangements.”