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Shouting in a vacuum?

14 October 2011

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Steve Williams
Practice Management Consultant

Steve has worked in or with the NHS since 1984. A former Royal Navy Officer and a qualified accountant, he is member of the Institute of Healthcare Management and AMSPAR. Steve has worked at all levels of the NHS, has lectured on many primary care topics and is a successful author on primary care management. He acts in an advisory role for health organisations and general practice, and as an executive partner

Having been given the opportunity to take part in the government’s ‘listening exercise’, this appeared to be an ideal chance to put forward some relevant points about how I saw the future of primary care working. I was initially elated at the opportunity to do this. I rallied my staff and explained to the GPs the process of the meeting.

Once information had filtered around the primary care trust (PCT), the practice became inundated with requests to attend the event. In the end, despite our best efforts, representatives from other groups and the PCT arrived to put forward their views. It became apparent that those listening already had a preconceived idea of whom they wanted to talk to. It was not me or my staff!

The discussion that took place unfortunately relied predominantly on the input of the clinical and PCT delegates. Much of the discussion concerned their own internal politics and it was difficult to bring in other practice staff. This was not because they lacked an opinion, but simply due to time and the forceful nature of others present.

Prior to the meeting, we were advised that the agenda should cover four areas. These were notified to us in advance and were as follows.

“How can we best ensure competition and patient choice drives NHS improvement?”
The discussion turned towards the use of the private sector and the privatisation of the NHS. Reference was made to waiting lists and the achievement of targets. This identified how the private sector is already used to meeting targets.

I commented that if choice is provided, quality of service determines where patients want to be seen. This then drives competition. I do not think the NHS should be afraid of the word ‘competition’ if quality is the real driving force.

“How can we make the NHS more accountable to the public and ensure that patient involvement is at the heart of its decision making?”
As a practice manager, patient involvement and public accountability are part of the day-to-day role. It is managers who embark on the process of setting up and maintaining patient participation groups, engaging with patients and involving them in local decision-making.

I commented that a practice manager is used to working within confined resources and, as a health commissioner, understands that demand outweighs what is currently available within the health financial envelope. Why are we afraid to address the issue of rationing services based on cost? There simply is not enough money to go around.

“How can we ensure advice and leadership from NHS staff themselves – on improving services and tackling patient needs – are at the heart of the health service?”
An assumption was immediately made that clinical advice and leadership would be combined in one individual. This led those at the discussion to conclude that it should be GPs who will lead the way forward and that the management role would be merely supportive.

I was glad to see the Forum report refers to “multi-professional involvement in the design and commissioning of services” but there is not enough emphasis on the practice manager.(1)

Assumptions are made that the skills lie within PCTs and that these must be retained. The truth is that the skills are already within general practice, but are neither funded nor recognised.

I commented that the assumption that practice managers are automatically included in the process must be clarified – and quickly. Not sufficient representation is being granted at clinical commissioning group (CCG) level, and this needs to be mandatory.

“How can we make sure that NHS staff in the future have the right skills to meet changing patient needs? Are the arrangements we have proposed for education and training the best ones to ensure this?”
Education and training of staff is fundamentally important. I do not think the proposals being put forward have been properly explained, and we have seen training budgets stripped from the GP contract. Since the abolition of the statement of fees and allowances, training monies in general practice have been basically non-existent.

I commented that it is vitally important that general practice receives investment in training for its practice staff. The core competency framework for practice managers is an excellent benchmark of the skills necessary to run a practice. If you do not invest in your staff, you will not retain the calibre of staff capable of taking primary care and the wider NHS forward. I fear the listening exercise overlooked this element, and funding will be scarce or unavailable to those who genuinely deserve it.

Representation concerns
I have heard it said there was sufficient GP representation within the group. This might be a fair comment, but not one practice manager was included. While various primary care organisations were represented, such organisations represent interests broader than those of practice management.

The government and the Department of Health appear to have assumed that practice managers’ voices were fully represented. They could not be further from the truth. I have started to tackle this by making personal representation to various departments and by ensuring that I respond to consultation exercises.

However, despite being passionate about my profession I still feel that I am merely one small fish swimming around in a very big pond. I see myself in a position where I cannot challenge political division and am almost resigned to the fact that I must wait to see what new legislation and requirements are to be imposed on my hardworking staff and myself.

I understand that not all managers will agree to all proposals and that the profession will be divided on many issues. This would not be an unusual scenario. Individual opinion allows debate to occur and as a result an informed view can be taken. However, practice managers’ views do need to be taken into account.

The listening exercise allowed me to focus my own thoughts about what I would like to see happen as a result of the rejuvenated Health and Social Care Bill:

  • Moving services from hospitals to primary care will save the NHS millions. But to do this requires the correct level of engagement with both patients and stakeholders at an early stage. This will generate a degree of competition driven by patient choice.
  • Clarify the assumption that practice managers are automatically included in the process and ensure that there is sufficient representation at CCG board level. Practice managers are natural leaders.
  • Given that the NHS Commissioning Board is likely to become the most powerful and influential health organisation, with its spending powers significantly increased, can we be sure that this organisation also has practice management representation in its early conception?
  • Invest in practice managers and their key support staff.  Each practice should receive a ringfenced annual sum of money to be used on staff training.

While individually it seems we are shouting in a vacuum, perhaps in the near future – and preferably before the revised Health Bill is published – practice managers might be included in the process of making policy in their own right. Let’s hope that someone is listening…