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Talkin’ ’bout an evolution: an overview of practice management

1 March 2007

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Debbie Bodhanya
Executive Director
The Limes Medical Centre, Epping

In the late 1980s, Debbie became a neonatal intensive care nurse, before moving to the USA to further her nursing career. There, she moved onto the management side of a large private healthcare company, worked her way up to become vice president of operations, and later completed an MBA. When she returned to the UK, she was managing director of the healthcare division of a plc. Debbie moved into primary care seven years ago

“What is it you do again? Oh, a practice manager – that must be a nice little job in a GP surgery!”

I can’t say how many times I have been asked that question. What I do know is that the perception of the practice manager’s role couldn’t be further from the truth!

I have always sympathised with medical receptionists, who have forever been labelled the “dragons” or “gatekeepers” of practices when, in reality, they have a complex role that is integral to the facilitation of patients’ needs. Along the same lines, the role of the practice manager has developed – from someone akin to a senior receptionist or perhaps the lead partner’s wife, helping out with a bit of personnel – to one of experienced, adept business manager.

One of the great difficulties in the profession is that each general practice is an independent business and, as such, will have its own ethos, philosophy and modus operandi. Over the past seven years, besides being based in a large teaching practice in Epping, Essex, I have had the privilege of working in many practices across the country and have seen examples of singlehanded, multipractice groups, innercity and rural practices and, although the level at which the practice manager may work varies, each practice needs the manager to have a complex toolkit of skills.

In an average week (if there is such a thing in general practice), a manager may be dealing with balancing the cash flow in order to make the payroll or tax payments, negotiating with the primary care trust (PCT) for a new enhanced service, recruiting staff, resolving patient problems, overseeing the practice’s Quality and Outcomes Framework (QOF) position, monitoring data, dealing with child protection issues and being the general sounding board for clinicians who need to offload after a difficult or challenging consultation. That’s not to mention practice-based commissioning (PbC), Choose and Book, flu campaigns – the list goes on!

Now, I wouldn’t want anyone to read this as a whinge about the diversity of the role – for me, it’s the challenge that puts a spark into each working day, as I’m never quite sure what I’m going to be dealing with. This may be the smallest business that I have managed in terms of the level of turnover, but in its content and variety it is right up there!

A question of experience
So, what are the entry criteria for joining the practice management profession? I guess this is where we have our first challenge and why it is sometimes difficult for the wider healthcare community to accept the role as a profession. Is there a minimum skill set that a manager needs before joining a practice? Is there a minimum qualification?

During my short time working in general practice, I have met the most fantastic managers who have worked their way up through the ranks and who have firsthand experience of all aspects of general practice. I have also met managers who have come into the role from general management fields such as the army, banking and law. Which is the right route? Is there a right route?

To me, one of the key elements of success appears to be the breadth of knowledge of the core facets of the role: ie, business development, finance, operations and personnel. Each of these areas requires a certain amount of general management experience, but also specialist knowledge in the field of primary care.

When I came into general practice, I had a healthcare and management background, having trained as a nurse and worked as a manager in a large healthcare company in the USA. Nevertheless, I was surprised at the amount of specialist knowledge I soon realised I would need. One of the first tasks I was given was to decide whether we should be opting for the new Personal Medical Services (PMS) contract. I had no idea what the existing General Medical Services (GMS) contract was, let alone PMS. A very steep learning curve!

Skills and development
I am often asked what training is out there for practice managers and how new managers can ascend that steep learning curve to be effective as quickly as possible. The new General Medical Services contract (nGMS) laid down expectations of the organisational, educational and management factors a practice should achieve in the QOF and, in essence, created a minimum skill set for any manager.

In order to support the development of managers, money was set aside to implement the new contract and meet the training needs that had been created. This funding was channelled through the Working in Partnership Programme (WiPP – see Resources), and it became one of their aims to improve training for practice managers.

WiPP identified 13 projects around supporting the nGMS contract. Two of these looked at training and development for practice managers. The first of these programmes mirrors the GP registrar format of training, whereby a “trainee” works alongside, either physically or virtually, an experienced manager “trainer” for a 12-month period.

The first cohort of this pilot has completed the programme in both England and Scotland and the results appear to be very positive. I was fortunate to have the opportunity to be one of 10 England-based trainers, with a local trainee who was new to general practice, having been recruited from the legal profession.

We held weekly tutorial sessions covering topics that met needs identified by the trainee, allowing her to achieve the level of competency expected for entry into membership of the Institute of Healthcare Managers (IHM – see Resources).

The second programme is a distance-learning modular course that also equips a newly appointed manager, or one with limited experience, with the skills needed to tackle the everyday demands made upon the practice manager.

Both programmes have attracted much interest from primary care organisations (PCOs), strategic health authorities (SHAs) and practices, but the issue for all of these is funding in order to mainstream the projects. There is a great commitment from the project groups who have managed both programmes to ensure that the good work and lessons learned are not now lost.  However, without financial support these great opportunities may go by the wayside.

Support for practice managers
The IHM supports managers across the NHS and has active practice management representation. For the past few years, the IHM has been working towards chartered status and hopes to achieve this in 2007. This would certainly help managers who are members of the IHM to be accountable at a level that would be nationally recognised. The IHM supports the training and career development of practice managers with a range of services, from face-to-face networks across regional areas, to support documents on issues such as becoming partners within the practice.

Challenges for managers in the current environment are as diverse as ever: from the introduction of the Choose and Book system, just one of many IT initiatives, to implementing PbC; from becoming extended service providers to working alongside the private sector. The dynamic and rapid pace of change in general practice seems to keep us constantly on our toes!

Every day, whenever I hear the early morning news I wonder what reference the government is going to make to primary care and general practice. Last week, for example, issues that directly relate to our work were discussed by government on four out of five weekdays, including during Prime Minister’s Question Time and while the prime minister was visiting constituencies. These topics included GPs commiss­ioning secondary care services, surgery opening hours, GP contracts and out-of-hours care.

So, when I’m asked what my job entails, I often smile and think: “Well, which day would it be that you are referring to?” What I know for sure, and what is the most important thing for me about my role, is that the entire practice team directly affects patients’ care. This means that we can, and do, make a difference by managing effectively and efficiently in a professional manner. I stumbled into practice management, a bit like many managers out there, but I am passionate about what we do, the way we do it, and the importance of the practice manager to primary care.

Working in Partnership Programme

Institute of Healthcare Management