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Your move: a tribal wave effect

13 October 2011

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Stuart Gidden
MiP Editor

Are practice managers the underdogs of the health service? Feelings of being left out of decisions made ‘higher up’, concerns of talents going unacknowledged and frustration at being the unrecognised force guiding the smooth running and profitability of GP surgeries are things I hear from practice managers across the UK on a regular basis.

But the thing about underdogs – at least if Hollywood is to be believed – is that they don’t remain underdogs for too long. Rocky may have started out an impoverished street fighter in his inaugural movie, but too many sequels later he was a champion boxer with his own motivational theme tune. Tim Robbins gets an unjust life sentence at the opening of The Shawshank Redemption and less than two hours later his life is smiles, sunshine and sailing. Jamal Malik’s story begins with him as a ‘slumdog’; by the end he’s a millionaire.

Life doesn’t reflect the pictures, of course, although it seems everyone has been thinking of one classic film narrative in this tough financial climate: the one where everyone comes together in the face of adversity and, putting aside petty squabbles and personal differences, manages to pull through.

“We’re all in this together” is the Conservative Party’s famous slogan for tackling the budget deficit. Although with public sector workers, including frontline healthcare staff, discussing the possibility of strike action over government proposals to reduce their pensions, the notion of togetherness seems somewhat dimmed. At the same time, Health Secretary Andrew Lansley’s criticism of the pension reform plans as “inappropriate” – warning that they will hit female health workers particularly hard – does little to suggest unity, at least where cabinet thinking is concerned.

The theme of tackling dire circumstances collectively has occurred across the UK. A recent report by Audit Scotland said public sector budgets in the country were to drop by £4bn over the next four years, and urged public bodies to focus on sustainability. Scotland’s Auditor General said strong leadership was needed to cope with “the most difficult financial conditions since devolution”.

In response, the British Medical Association (BMA) in Scotland warned politicians not to get “bogged down by tribal politics” and instead “look to the dedicated professionals working across the public sector to help them make the changes and achieve the savings without compromising on the care provided to the public.”

“Tribal politics” is an interesting phrase and one that will no doubt strike a chord with practice managers accustomed to balancing the varied interests of GPs, primary care trusts/health boards and, of course, patients. Tribes working in general practice are no less likely to escape the harsh impact of these “difficult” financial times.

Practice managers in the East of England are reacting furiously to proposals by NHS Peterborough to close up to nine GP practices in the city in an effort to make £6m of cost savings. Plans are in place to extend larger surgeries there, but local practice providers have warned of a “dangerous shortfall” in GP provision, despite PCT reassurances.

Across the UK, practices are starting to feel the squeeze. In this issue, Lorraine Hughes describes how she and her peers in Northern Ireland are feeling “undervalued and unsupported” in the face of the radical reshaping of health services caused by the budget deficit. Lorraine suggests that greater consultation and a consideration of practice’s workloads would at least lighten the morale and enable practice managers to feel more involved.

So it sounds as if talk of togetherness is merely lip service. After all, the Northern Ireland Health Minister recently announced a new review panel to consider how health reform should be implemented. “I would encourage anyone who feels they have a contribution to make, or who wish their voice to be heard, to provide comments,” he said. But will these comments make a difference?

Inclusiveness, listening exercises, avoidance of “tribal politics” – practice managers in England might not have much faith in these grand notions, for as we report in this issue, despite reports of inclusive clinical commissioning group (CCG) boards, many practice managers feel sidelined and ignored, as if their skills and potential contribution have been left out in the cold.

Granted, this column has been all doom and gloom so far. So why am I optimistic for the future of practice management? Articles in this issue provide plenty of answers. The evident lack of engagement with the profession displayed by some CCGs is both regrettable and ultimately self-defeating.

However, the flipside of the radical drive towards local commissioning in England is that plenty of practice managers are not just involved, but are positively instrumental, forcing a wider re-evaluation of what the profession can offer.

In Northamptonshire, practice managers work as directors on the Nene Commissioning Board, overseeing corporate management and wider public engagement. In North London, practice manager Jacqui Tonge finds her role as an elected CCG board member allows more influence than that afforded to practice managers previously.

This issue, we profile Liz Brimacombe, a Plymouth-based practice manager and CCG board executive. All practice managers in her locality are shareholders of a community interest company providing commissioning input. Liz finds this a significant step change. As she puts it: “Never has anyone truly provided the opportunity to put both GPs and practice managers around one table on the same level, making decisions collectively.”

These individual cases are by no means anomalies – the Health Service Journal has reported that practice management involvement dominates the boards of England’s emerging CCGs. But other opportunities also present themselves – and again, practice managers are taking on the challenge.

In her article, Alison Rounce speaks of new doors being opened in Nottingham as a result of the Transforming Community Services programme. Alison speaks of her excitement at both the “totally new experience” of bidding to provide integrated local services and how practice management could contribute to the development of those services.

Those outside England may well say this doesn’t apply to them, that this is a rather England-centric view to take, as the reforms do not apply in Scotland, Northern Ireland and Wales. But I would argue that the developing role of practice managers in commissioning groups and integrated alignments will have a significant impact on the profession across the UK, and that those who have hitherto viewed practice management – unwisely – as a ‘Cinderella’ profession will no longer be able to ignore the crucial benefit that more empowered and involved practice managers bring to the table.

This issue also includes a focus on the impact of the now-delayed Care Quality Commission (CQC) registration requirements – another England-only requirement. But as both Fiona Dalziel, a practice management consultant in Aberdeen, and Jack Nagle suggest in their articles, new regulatory standards can be a useful opportunity for all practice managers to re-evaluate the quality of what they are doing, which they can use to future-proof their practice and improve their performance.

Just as awareness of CQC requirements can bolster quality in the practice, a consideration of the part practice managers are playing in commissioning groups can invigorate a renewed focus on the broader role for the profession in the wider healthcare system, and the unique skills and expertise practice managers bring to general practice. With the King’s Fund’s Chris Ham and GP Dr Ian Rutter – both from England – appointed to the Northern Ireland health review panel, devolution is by no means the last word when it comes to health policy development.

At the recent Management in Practice event in London (31 August), Fiona Dalziel expressed a view that seemed to be shared by many of the delegates present, who felt they had been overlooked by their CCGs, when she said practice management has a “credibility issue” in the eyes of government and senior policymakers. The lack of standardised professional accreditation, she said, can be a barrier to recognition by those in power, leaving practice managers having to “fight for their place” in order to be heard.

We’re back to Rocky again. But with practice managers across the UK – not just in England of course – demonstrating their value time and again, it seems more than likely that this is a fight that will get progressively easier. As practice manager Lynn Jones says in our CCG report, those who don’t yet recognise practice managers’ strengths will need to “come round” and to recognise that they need to get the profession onboard – pun intended. Any argument that practice managers cannot play a bigger role in commissioning should become progressively weakened.

So whether or not you’re in England, or on a CCG board, whether you desire a wider role or want to remain focused on the vital responsibility of managing your practice, the ongoing success of practice managers in commissioning teams could well create a ripple effect that will enhance opportunities for the entire profession.

So say goodbye to the underdog image. This could be a very important time for practice management. Even if you feel as if doors have been closed to your profession, elsewhere those doors are being opened. Perhaps it will not take too long before all practice managers, if they want to, can step on through.