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Practice managers in a reformed NHS

1 December 2010

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Stuart Gidden

MiP Editor

One message that was clear from the final Management in Practice Event in Birmingham is that there is a feeling among some practice managers that they are being wrongly excluded from involvement in the formation of commissioning consortia.

Indeed, anyone reading press reports about the healthcare reforms that will lead to the establishment of GP-led consortia could be forgiven for believing this is something that GPs will be doing singlehandedly. The term “GP commissioning consortia” does seem to conjure an image of a board meeting attended by doctors in stethoscopes – and nobody else.

Yet both Department of Health officials and health commentators have said the proposals, which will involve consortia handling £80 billion of public spending, will not be successful unless consortia comprise a broader assortment of talent, which of course includes managers.

But while primary care trust (PCT) managers with experience of contract handling and commissioning will be almost assured of a place in new consortia, the message from MiP Birmingham was clear: don’t forget practice managers. Delegates seemed to welcome the plans to give greater responsibility to the frontline – but, where appropriate, they want a fair share of that responsibility.

The MiP event in October kicked off with a keynote speech from Jill Matthews, Director of Primary Care Improvement at the Department of Health. During a question and answer session that followed, a practice manager criticised the “GP-led” white paper.

“I think you’ve forgotten practice managers,” she said. “The GPs think they’ve got to lead all of this [the commissioning consortia], including the management, and I feel there’s no room for me at all.” The practice manager said that the effect of this was “quite negative” for the profession. “The GPs think they’ve got to do it all, and the managers can just sit in the back room and not have a part to play,” she said.

Responding to this, Ms Matthews affirmed that the NHS reforms outlined in July’s white paper “cannot and will not be successful predicated on two or three clinicians talking about pathways. I think as GPs come to realise the magnitude of the task, many of them will look to build teams to do this.”

Speaking of the radical plan to abolish PCTs and strategic health authorities, she reminded delegates of the scale of the new responsibilities. “This is big business in the future. This isn’t practice-based commissioning. It’s essentially doing everything that the current NHS system does,” she said.

Speaking of Andrew Lansley’s desire to see GPs take control of the purse strings, she said: “The Secretary of State has a passion for general practice and GPs, and he wants them to feel responsibility for this, but he is very clear that they won’t do it all, and nor should they. GPs will be leading the consortia, but we don’t believe they will be doing all the work to establish them. Over the next few months, as we start to develop shadow consortia, more opportunities about the role of others will emerge.”

However, not all practice managers feel neglected. In response to a story concerning the above exchange posted on the Management in Practice website, one manager was dismissive of the idea that the profession would have a diminished role, and made a strong distinction between the white paper and how things are being rolled out locally.

“Yes, practice managers are overlooked in the white paper, but I have certainly not been overlooked within my practice, or indeed my local consortia,” she said. “I am a practice manager representative on the board and also my partners are looking more to me to inform them of what is happening then ever before. It is up to us to accept the challenge and make it work – at the end of the day, the majority of GPs will admit they are not managers and want to get on with doing what they do best – treating patients.”

However, another practice manager, from North London, believed the sense of being overlooked to be “quite typical”. He suggested that, unlike PCT managers, whose reputation in some cases may be tarnished by overspending, practice managers remain unblemished by recent events and are much-needed operators in general practice.

“Most local GPs are confusing practice management worth with that of PCT management staff, some of whom have been responsible for not properly monitoring and controlling contracts and activity with the acute sector,” he said. “Hence, in many cases, a large financial deficit. So why do I keep reading that new consortia should be employing ex-PCT staff in commissioning roles? These are the very layers of expensive and less effective bureaucratic management the white paper is trying to eliminate.”

Another online reader from Staffordshire considered that the hierarchy of management itself may change. “Perhaps consortia will want ‘commissioning managers’ to oversee six or so practices each to ensure those practices with less expertise are not left behind?” he said.

Ultimately, a culture of support would appear to be necessary as primary care reorganises itself. In a separate speech at MiP Birmingham, Dr Beth McCarron-Nash, a negotiator for the BMA’s GPs’ Committee (GPC), told delegates that practice managers had a key role to play in advising their GPs who the best PCT managers are, so that they could be retained in the new structure.

“I’d urge you to speak to your partners, work with your practice teams and identify good PCT managers and local leaders who you think you want to keep within these new [commissioning] organisations,” said Dr McCarron-Nash. “In my area we’ve already seen a leeching of skills, and we don’t want that to be lost.”