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‘Practice managers run primary care, really’

13 October 2011

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In an exclusive interview with Dr Laurence Buckman, Stuart Gidden finds the chair of the GPs’ Committee supportive of practice management but less convinced that general practice has reasons to be cheerful…

Dr Laurence Buckman is combative and defensive about general practice – but he is also surprisingly dejected. Not defeated, certainly – it’s hard to imagine the Chair of the British Medical Association’s (BMA) GPs’ Committee (GPC) throwing in the towel at any stage of a fight – but there seems something almost beleaguered about the North-West London GP.

Speaking of the GPC’s demands over revisions to the Health and Social Care Bill, Dr Buckman, who is “on my 12th set of reforms” since qualifying as a GP in 1977, strikes a note of weariness at the lack of variety in modern politics.

“Who are we appealing to?” he rhetorically asks. “Parliament is dominated by the three main parties, all of whom agree this [the thrust of the health reforms] is what they want – with different nuances, perhaps, but they all broadly agree. So who are we going to have backing us? Nobody. A few cross-bench peers in the Lords, perhaps, but you can’t fight governments on that.”

This is rather disconcerting coming from the chair of the sole negotiating body for general practice, representing practice professionals across the UK. After all, Dr Buckman speaks from longstanding experience in facing up to the government.

Elected to the GPC in 1990 and a negotiator since 1997, he has been the committee’s chairman since 2007, during which time issues such as Darzi centres, patient surveys and PE7 and PE8 quality indicators have kept him busy (if not fuming). Now his attention is back on to the government’s Health Bill, which has resumed its way through parliament following the ‘pause’ in which the NHS Forum Forum conducted its listening exercise.

Having spent more than 30 years as a GP, the concept of family doctors being at the heart of the health service, responsible for commissioning £60bn of services as part of new clinical commissioning groups (CCGs), excites him less than you might think. Doesn’t he find it empowering?

“Nothing empowers GPs,” he says. “Any sense of empowerment will be taken away by people elsewhere. For all the claims of ‘bottom-upness’, this is a very top-down set of reforms.”

At the recent Local Medical Committee annual conference in London, held in June, Dr Buckman laid out the GPC’s three key demands as to amending the Health Bill: an explicit duty on CCGs to involve all relevant clinical staff; the regulator Monitor’s primary duty to ensure integrated services rather than to promote competition; and a more realistic timetable for handing over commissioning responsibilities to CCGs.

The Future Forum included all three points in its published recommendations, and the government’s subsequent response indicated that it would accept them. So is he now reassured by these developments?

“I was quite reassured by the Future Forum report,” he says. “But when you look at the amendments to parliament, they are not as clear as the government’s statement after the Future Forum published. So if you take Mr Cameron’s statement and match it against the legislative amendments, they don’t match. So I will wait and see.”

Care Quality Commission
One thing that will certainly affect GP surgeries in England is registration with the Care Quality Commission (CQC), which Dr Buckman described as “on the torture horizon” in June. Following consultation with the Department of Health, this has now been postponed by a year until April 2013.

Dr Buckman welcomes the deferment for two reasons. “First, nobody has to do anything now and secondly it gives the CQC the opportunity to review what it’s trying to do and simplify it,” he says.

The CQC itself has sought to reassure GPs, saying “we want to lighten any potential burden and ensure that we add as little extra work as we can onto GPs.”(1) In response, Dr Buckman says: “The problem wasn’t with CQC it’s with the regulations that tell them what they have to do. The problem with the regulations is they are too vague and cover quite a broad spectrum of matters.”

He is clear where most of the compliance work will end up. “The burden of this will fall on practice managers,” he says. “Registering is just filling a form, there’s nothing terribly hard about that. But the amount of work involved in preparing for compliance could be very, very substantial.”

The GPC believes this will be a costly enterprise that will not benefit patient care. At the LMC conference in June, delegates passed a motion that was, in effect, a vote of no confidence in CQC and called for it to be abolished.

Dr Buckman defends the decision. “We have asked all along: what is the added value of CQC?” he says. “I understand what it does for nursing homes but what does it do for GPs? What is it CQC are offering to general practice? How will the nation’s health be improved by it? I think the answer is not. I think this offers nothing.”

How should practice managers prepare for April 2013? Dr Buckman’s advice is clear. “I suggest they do absolutely nothing,” he says. “In particular I suggest they don’t spend money getting outside consultants to advise them on how to comply. What was very sad was for us to advise GPs not to do this and then find that loads of practice managers have been told to sign up by primary care trusts. So nobody should be spending any money or time doing anything.”

“Central” role
Dr Buckman has no doubt about the value of practice managers in general. “Introduced over the last 30 years, practice managers have gradually become very much part of the business,” he says. “I think they’re central to most of what goes on, certainly in my practice.”

The GPC often complains that the government does not listen to its advice and views. What, then, of practice managers? An oft-heard complaint from MiP readers is that the profession is overlooked by ministers and senior healthcare figures. In 2008, a MiP survey of more than 600 practice managers revealed that 68% felt they were under-represented and their voice was not heard.(2)

On this point, Dr Buckman is surprisingly affirmative about ministers’ work here and suggests the reason the profession may be overlooked lies closer to home. “The government constantly tries to set up forums for practice managers,” he says. “But actually that is seen by many GPs as deliberately intended to undermine them.”

Could practice managers do more to represent themselves? “Oh, I think practice managers always need to mobilise themselves. They’re the people that run primary care really. I like to pretend it’s me but it’s not true. It’s really my manager who runs my practice.”

Primary trust
The BMA recently highlighted concerns that GP-led commissioning could have a negative effect on the high level of trust that patients hold in their family doctor. BMA Chair Dr Hamish Meldrum said: “If patients even suspected that their GP might be rewarded for how well they do financially in terms of commissioning – the suggestion that ‘you might not be referring for me,’ or ‘you might not be prescribing for me because actually that will mean money in your pocket’ – that would seriously damage the trust.”

Dr Buckman supports this concern, but rejects the nightmare worst-case vision expressed last year by RCGP Chair Dr Clare Gerada of patients lobbying outside the front door of GP surgeries (“I don’t think that’s going to happen. Patients have got better things to do than picket surgeries,” he says).(3) However, he does believe that practice managers “most definitely” have a key role in maintaining the trust of their patients.

“Practice managers are the head of the front of house, so it’s very important they know what’s going on in their practice is absolutely whiter than white. They are the people with whom the patient converses first, quite often, on any subject,” he says.

What advice would he give managers to strengthen patient links? “I think that you need to know your practice inside out, you need to be able to describe the ethical positions that your doctors and nurses take and you should be able to intervene if it looks like somebody’s making decisions that appear to be not necessarily for the best of reasons,” he says.

Shifting boundaries
As last issue’s MiP report suggested, scrutiny of the Health Bill has in some sense overshadowed a looming issue for practices – the abolition of boundaries in April 2012. But given the CQC delay and the ‘pause’ in the bill, not to mention huge professional objection to this proposal (a GPC survey found that 85% of GPs did not believe boundaries should be abolished) is it really likely to happen next year?

“I’m sure it will go ahead,” he says. “I think politicians of all three parties will press ahead with it, despite the fact that there’s almost not a soul in Britain other than a group of MPs, some opinion formers and a few commuters who want it. I don’t think people realise what chaos this is going to bring.”

He describes the proposals as “a stupid idea that is going to damage patient care” and his anger is clear. “To have people registering anywhere they like, changing as often as they like, so that people who are criminals or abusing children will be able to change practices every five minutes and nobody will be able to follow them – that won’t improve patient care.

“How can you commission when you don’t know who you’re commissioning for? How can you provide care when you don’t know the hospital that you’re going to be referring to because they live 40 miles away? How are you going to do all of these things? This is so counter-intuitive. It is so foolish and such a waste of taxpayers’ money and practices’ time. I can’t see the benefit.”

Given the huge backing of practice professionals, could the GPC do more to campaign on this issue? “We’re stretching every sinew to get this stopped,” says Dr Buckman. “They know we hate it.”

The only people who would benefit, he says, are commuters who want to find a GP close to work. “There are many other solutions and we’ve published a document saying how you could do that. We’ve given it to the previous government and we’ve re-discussed it with this one.”

Is there anything practice managers can do to prepare? Again, the gloominess descends. “Hope that government officials manage to persuade ministers to stop it,” he says.

Happy note
Years of debating unpopular government health policies with the government seem to have informed this sense of resignation. When asked if he feels positive for the future, Dr Buckman replies, tellingly: “I’ve learned never to be optimistic. Then you’re never disappointed.”

However, this is all said with a certain gallows humour and, despite all of the new demands and structures placed on general practice in England, he still shows a certain positivity when considering the future of the profession he so clearly loves and defends.

“Whatever happens to the health service, GPs and their practices will survive,” he says. “There’ll be different contractual arrangements, different employers, the health service may look very different… but even if it was completely private there’ll still be GPs. The idea that all our practices will ‘go phut’ tomorrow is not going to happen.”