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Shaping the future

25 November 2013

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The role of practice managers needs to evolve to adapt to the increasing challenges facing general practice 

Those of us of a certain vintage can age a practice manager by how many new contracts they have implemented. From the 1990 contract that turned practices into businesses, I have never been sure what people thought they were before, to the personal medical services (PMS) contract, the revolutionary localised contract based around the needs of your patient population. Unfortunately in my view, PMS has not been developed as it should to support the transformation of primary care, and if the great and the good are reading this, please consider how this could be developed. 

We are too good in the NHS at not getting a return on investment by learning from various initiatives about what has worked – and more importantly, what didn’t – and then reinventing the wheel a few years later, but with square corners. Through the 2004 contract with its practice management competency framework and practice managers having multiple mentions, and the expectation that – like Flash Gordon – we would take 24 hours to save primary care. Then there was the introduction of alternative provider medical services (APMS) contracts with exacting key performance indicators associated to income, and the recent Health and Social Care Bill which failed to mention practice management once. 

Our profession has always rolled up its sleeves, networked and found the solutions to make our practices work, ensure our patients are cared for, and our practice teams are well-trained and motivated. As the Chinese saying goes, we live in interesting times, and it is my firm belief that the next revision of the contract will fundamentally change practice management from the job we have known and loved. 

As practice managers we pride ourselves on our general management abilities; keeping all the balls in the air, knowing which one will drop and safely catching it with style and elegance. Most practice managers I speak to across the country are saying that the number of balls they are now juggling and the speed at which they are beginning to fall is becoming a real challenge. A number have said to me that they feel they do not want to be this style of practice manager and want to go back to just running their practice. Others who want to lead the strategic transformation of primary care are bogged down by operational issues and blocked by a lack of recognition of their abilities and value. Both sentiments are justified and demonstrate to me the splitting between the strategic and operational aspects of our role, not unlike how nurse practitioners and practice nursing have developed.  We know the drivers for change that we are all grappling with which include:

 – Increased regulation.

 – Patient dissatisfaction with access.

 – Unfunded transfer of work into primary care.

 – Expectations and demand on our services. 

 – Increasing workload pressures.

 – Threats to income and viability. 

 – Concerns over contractual security.

 – Technology advancement. 

 – Demographic pressures.

– Challenging clinical workforce recruitment and retention issues.

 – A need to do more with less.

I defy any colleague to say that their practice will not be affected by change. If they do I would advise them to reread Charles Handy’s Age of Unreason, and the ability of a frog sitting in a pan of water which is slowly being heated to appreciate their external environment is changing and take action. I would suggest that they might want to wake up and realise that the water in primary care is beginning to boil and it is time to change. The transformation of primary care is seen as essential in managing both the financial constraints in the NHS but also in coping with the threat to the GP workforce and the increasing demand for services.   

In his speech for the 65th anniversary of the NHS, Secretary of State for Health Jeremy Hunt talked of the vastly higher expectations of the public to 24/7 personalised care and the need for integrated care planning around vulnerable older people. Dr Clare Gerada, the outgoing chair of the Royal College of General Practitioners (RCGP) has questioned if the independent contractor status is passed its sell-by date, and backed the idea of creating single provider units combining with other services. 

Labour policy seems to favour downgrading clinical commissioning groups (CCGs) to clinical advisory roles and for local authorities to have much greater commissioning powers. I don’t think you have to be psychic to predict the impact these changes will have on the current shape of general practice. Single-handed and small practices were incentivised during the 1970s and 80s to form group practices, and it is not too much of a stretch of the imagination to think that incentives for practices to work at scale will be used to drive change.

For me the debate is no longer ‘what if change happens?’ but how as a profession will practice management take its place in leading the transformation of primary care and not be managed out of the new world? The recent report from the Nuffield Trust and the Kings Fund, Securing the Future of General Practice, talks of “more sophisticated management support to undertake strategic planning and service development, create new professional, management and leadership roles that offer a new range of career opportunities” the benefit of which is “to assume a more significant role in the local health system”. 

My personal view is that if we lose the specialist knowledge and abilities of front-line practice managers, both at operational level and at strategic level, primary care will not transform at the speed or efficiency that is required. We should never underestimate the privilege we have had in working shoulder-to-shoulder with front line clinicians and the understanding we have developed about the complexity of primary care service delivery and public health needs. Nor should we underestimate  our ability to take complex policy and translate it into practical implementation. 

The challenge as I see it for practice management is to envisage what primary care will look like in the future and what the management structures will look like. If we are working in single provider units caring for populations of 30,000 to 100,000 patients, what will the competencies and skill sets be at various levels? Like our clinical colleagues we will be challenged to develop more specialist management and leadership skills. Who will be the directors and chief executives of these new organisations?    

I think it is down to the individual practice manager if they see the world as a threatening Armageddon or if they are excited by the challenge of transforming primary care so general practice remains alive and well over the next 65 years. To the practice managers who have said to me over the past couple of years that they are worried they will be out of a job, please be assured you have already smelt the coffee and will be leading change. To those who are just beginning to feel the water warming up, it is not too late; think the unthinkable, be creative and make sure that the primary care baby in your area is not thrown out with the bathwater by a management workforce who do not understand the true value of what general practice delivers.