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Retirement can wait: managing a trailblazing rural surgery

5 September 2008

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Grant Scott

Practice Manager
Church Street Surgery
Spalding, Lincolnshire

I have been a practice manager for about 18 months. Previously, I worked for the Department for Environment, Food and Rural Affairs in London before taking early retirement and moving to Lincolnshire to contemplate my navel.

I got bored with retirement very quickly. There was only so much daytime television I could take, so I decided to look for a job. After a couple of false starts I was very fortunate that the skills I had developed in my career – primarily working blind in a government-induced bureaucratic bog – were recognised by the partners and I was appointed practice manager.

Our surgery is one of three in Spalding, a small market town in Lincolnshire famous only for its annual flower parade and bulb fields. The team consists of six doctors and 30 support staff, most of whom are part-time. We are a part-dispensing practice with 12,500 patients. We occupy a central town location with outdated and inadequate accommodation, and no patient parking.

It doesn’t sound as if we have much going for us – but like many other practices in rural Lincolnshire, we have ambitions to develop our services to improve patient care, and I hope it will be useful to share some of my experiences.

PCT support
The first lesson I learnt was the importance of developing a good working relationship with the primary care trust (PCT) – we would achieve very little without their help and support.

Over the last few months, while having to keep on top of the daily activities that are associated with the job, much of my time has been spent on three or four major topics. These are: practice-based commissioning (PBC); establishing a sexual health clinic at primary care level; pursuing new premises; and everyone’s favourite, Choose and Book. Any success that the practice has achieved is partly down to the great support we have received from the PCT.

Cluster chemistry
Attending my first PBC meeting was quite a shock. The practices were very suspicious of one another. There was little openness in any of the discussions, a general mistrust of the PCT and seemingly little prospect of any real progress. However, over the months progress has been made – the 2008–09 plan has been prepared and approved, and the PBC cluster is working well.

Initially, the review and development of commissioning opportunities was hampered by the lack of information coming out of the PCT, so the practice enlisted the help of a third party to produce pseudonymised hospital activity data for the cluster and individual practices. This provided the evidence needed to kickstart the process, and significant progress is now being made.

I am pleased to say the informatics team at the PCT is now looking to provide the data itself, rather than relying on a third party.

For my part, I have been working with Dr Caroline Manners at the practice to set up a sexual health clinic through the cluster. All evidence indicated that the local population was affected by high levels of teenage pregnancy and sexually transmitted infections (STIs).

Yet there was little provision of services, particularly for the under-25s. As Dr Manners had a particular interest in sexual health, she suggested we approach the PBC cluster with a proposal for establishing a clinic at primary care level.

The proposal was well received by the cluster, and agreement was given to submit a full business case with a view to seek funding from the PCT for this service. The PCT recognised the need but had not developed a countywide strategy, and there was some reluctance to proceed.

However, we battled on and eventually received an agreement to proceed with a pilot, which would be reviewed after a year. We embarked on an extensive round of training for clinicians, and all our frontline administrative staff received training through the Lincolnshire Teenage Pregnancy Unit. The practice achieved “Young Person Friendly” status and became part of the Condom Card Scheme.

The clinic was launched to very positive local radio and press coverage. It is the first of its kind, and the practice intends to make it a success. Hopefully it will provide a model for setting up other clinics throughout the county when PCT funding is available.

Laying new foundations
Premises has also become a real issue in Spalding, and the practice has been in discussion with the PCT for several years about new premises. Before I finally retire, it is my goal to see the practice established in new premises – being closer to 60 than I care to admit doesn’t leave much time.

I am working hard in conjunction with the PCT Estates Department, a local developer who may be able to release suitable land, an agent we have appointed and the local planners. However, progress is slow and I intend to apply another lesson I have learnt since I became a practice manager: never take “no” for an answer – even if it comes from the PCT – and keep pursuing your objectives. At the end of the day the main beneficiaries of improved services are the patients!

Appointment target complications
The other issue causing a rise in my blood pressure is Choose and Book. I am the first to admit it is a great service if it works and there is sufficient appointment capacity at local hospitals.

However, in practice this is not the case in deepest Lincolnshire. The local hospitals are only releasing appointments four weeks in advance. If I was a cynic I might suggest that this is to enable them to meet the 18-week treatment target.

As many of our patients are elderly, they do not wish or are unable to travel great distances for treatment. Getting appointments for them locally is extremely difficult and frustrating for them and our staff.

However, we continue to work very closely with the PCT, and, while we may engage in robust exchanges from time to time, we do recognise the need to maintain and develop a good relationship.

In addition to all these challenges, I am also very much “hands on” with recruitment and contractual matters, arrangements for extended opening hours, dispensary considerations following the recent white paper, and so on …

However, I am very fortunate that I joined a superb team. They have made my job one of the most interesting, varied and, dare I say, enjoyable that I have ever had.