It has been said that ‘practice managers are the key to the sustainability of primary care’. But what if GP practices could operate efficiently without them?

Virginia Patania held the title ‘practice manager’ of Jubilee Street practice until she traded her title in for ‘transformation partner’ three years ago.

Empowering the staff

She established a leadership based on the holacracy model, which enables decentralised management. It gives more autonomy to the staff and empowers them in a unique decision-making process.

Ms Patania and her partners signed off their authority and wrote a constitution, with the vision drawn up with the staff, which states what terms the practice operates under.

But the process was very slow to settle. This model is difficult to implement, as there has to be an important cultural shift. To be successful, the practice manager must trust their staff and the team has to be confident in taking their own decisions.

‘I don’t know what my staff does, but I know my practice works well. It has achieved outstanding with the Care Quality Commission.

‘The staff is incredibly happy and joyful. They love their ownership, aren’t afraid of change and even ask for more work,’ she said

But giving full authority to the staff also means that she has not a say in decisions.

‘Empowerment means empowerment. If I disagree with a decision, I’ll send an email explaining my thoughts but won’t intervene.

‘As long as the outcomes are positive, how the staff got there is really immaterial,’ she said.

Managing with circles

The practice has between 34 and 43 employees. They all sit on circles, which are self empowering areas determining where they make decisions.  

‘Some circles are very generic, such as human resource or finance, so they only have four or five employees.

‘Others circles are delivery functions and are usually managed by the people that actually deliver them. We have big circles, including clinical delivery, practice management, communication and engagement and clinical governance, and sub circles, which are the things that actually define such circle and allow it to happen,’ she said.

Employees use a physical board to write their names on. They can either cancel their names or swap circles, as long as they have been within a circle for at least six months.

Under such model, employees can be in charge of their own payrolls, rota and holiday, among other things.

‘For example, if I was an administrator that did diabetes, all people carrying diabetes functions, including my lead GP, my lead nurse and the healthcare assistant would sit with me.

‘It means that, as a practice manager, I wouldn’t be doing claims or chasing up the money and I wouldn’t be looking at the premature ovarian failure points that I need around diabetes. These would all be held by the people actually dispersing the function,’ she said.

Role of the manager

But if all the practice manager’s traditional tasks are relegated to the staff, what functions are they left with?

Ms Patania’s role in the practice is now limited to two things.

‘The first thing I do is setting culture. It is fundamental because, if you don’t have people that inspire and set culture, this model is unobtainable.

‘The second thing is managing quality improvement and development for the practice. I always think about where we need to be in five years time and what ideas I need to toss to ensure that everybody in the practice can get us there,’ she said.

Communication and feedback are the core principles of this leadership model. The practice runs meetings called effective skills, where ideas are taken forward, and monthly meetings to assess the level of the staff’s happiness.

‘I think different things will work in different practices. I have a vision of collective and distributed leadership where you are not playing one specific person to carry out a collection of functions that could be delivered just as easily by other highly skilled people.

‘I don’t feel enthusiastic about organisations that feel the need to manage, which implies removing control from others and telling them what to do and, for that reason, we shouldn’t have practice managers,’ she said.