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Workforce reckoning

16 January 2012

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Patricia Gray

Management Adviser, Trainer and Facilitator

Patricia is an HR specialist in general practice. She was the managing partner of a large practice for more than 10 years, and now provides HR and management advice and training. She is also a trained facilitator and a coach

If you had a blank sheet of paper, would you have the same workforce helping you run the practice in the manner you have either inherited or somehow acquired? Would you have the same number of staff and would they be doing the same things? Would you re-employ your current staff if you could undertake a completely new selection process?

Many practice managers would answer “No!” Ideally, the practice would be staffed by different people with different skills, working differently in more flexible work patterns. However, most people take a pragmatic view and accept that you cannot just wipe the slate clean overnight and reinvent a new workforce.

Practices are often too influenced by the way things are done now rather than how they could be done in the future. It takes a leap of faith and strong determination to make dynamic changes to a work environment. It also takes a lot of patience, as change cannot be achieved overnight.

Role change
However, general practice itself has evolved over the years; many practice jobs are not the same as they were only 10 years ago – take the role of the practice manager, for instance. The responsibilities and scope of the job have changed dramatically over recent years. Gone are the days when the practice manager was most likely to be promoted from the senior receptionist role and mainly undertook administrative tasks.

Nowadays, the practice manager’s role encompasses strategy and management of all aspects of the organisation, as well as overseeing the administrative functions of the practice. At the highest level, the manager is actively involved in commissioning, preparing bids to provide new services, and planning for the future. These roles require a different set of skills and knowledge from carrying out routine administrative functions.

Equally, the role of the practice nurse has developed over the past 20 years, with an array of different levels of nursing skills available: from traditional treatment-room duties to high-level diagnosis, treatment and prescribing for medical conditions. It took some time to persuade practice nurses that healthcare assistants (HCAs) could undertake many routine nursing duties, but now most practices could not imagine working without them.

The role of the practice receptionist primarily used to be to meet and greet patients, make appointments and take messages. Nowadays, the average receptionist does all this as well as a range of administrative tasks such as managing rotas, setting up clinics, using IT packages, performing searches and audits, scanning documents, sending out recall letters and being responsible for health and safety measures.

The term ‘skills mix’ has become synonymous with a more efficient use of staff and has become a popular aspiration for many practices. However, skills mix takes planning and implementation.

Needs assessment
Every practice should take a proactive view towards planning the workforce it will need for the future. The starting point is to make a strategic assessment of how the practice will look, what services it will provide, what the working environment will look like, how technology can help, etc.

This type of planning takes time and imagination, and is best undertaken at a practice away day – ideally with the GP partners and the manager. For this kind of lateral thinking, it might be helpful to have a facilitator provide the right tools and guide the process. During the discussions, it is helpful to elicit each team member’s aspirations about the future vision of the practice and how it might operate differently. From the vision comes a plan with objectives, key performance indicators, timescales and responsibilities. 

Once the vision becomes clearer, the practice can start to plan how to achieve it. An assessment should be undertaken of the skills and capabilities of the current workforce. The question should be posed: “Do we have the right skills and resources for the future?” If gaps are identified, they may be filled by training and developing the existing staff or they may only be filled by recruiting new staff with different or specialist skills.

Workload considerations
Everyone in the practice should be working to their optimum level of ability. As soon as it becomes clear that staff are working below this level, there is an impact on cost-effectiveness and the threat that staff will be under-challenged and their potential undeveloped.

The obvious time to consider potential changes is when someone retires or resigns. This gives the practice an opportunity to consider whether to employ someone else in the same role or do things in different ways. Retirements usually provide more time for this planning, whereas resignations can make the practice feel under pressure to replace like for like. However, I would always advise you to take stock of this opportunity before rushing into recruitment.

Workforce planning should start at the top, with the clinical workload. Many practices have struggled with the ‘partner versus salaried doctor’ debate and have tried various options; many have settled for a mixture of the two. To make sure this combination works successfully, a clear definition of the roles and responsibilities of the partners and the salaried doctors is required, while engendering a team spirit between all the GPs.

It must be clear to all parties that being a partner brings additional responsibilities that contribute towards the management of the organisation. This might include networking outside the practice, eg, meetings with commissioning groups or other GP forums.

Assess the clinical workload by analysing the demand for appointments, how appointments are being used and the consultation styles of different doctors. Consider too if patients are being unnecessarily called back, if telephone advice or triage would be more appropriate, if nurses or administrative staff could have dealt with the patient instead of a doctor, how well the patient can access advice from the practice website and so on.

Using this analysis, it sometimes becomes clear that, in fact, not enough appointments are available to meet the needs of the practice – perhaps because of partners’ outside commitments or because of their own work patterns or inflexibility to work on different days. The practice then has to decide whether to agree fundamental changes to the partners’ work patterns, employ extra salaried doctors or rely on expensive locum cover.

Sometimes an honest analysis of clinical workload indicates that doctors are not working as efficiently as they could or that some of their work could be delegated to nurses, which may lead to an increase in nursing resources.

Likewise, a candid assessment of the nursing team may indicate that their skills are not being used as effectively as they could be, and may also indicate that the nurses’ availability is not in line with the needs of the practice. An efficient nursing team will provide a range of skills and specialisation, while also ensuring that nurses are not de-skilled and are available for cross cover.

The role of HCA should be developed as much as possible. There may be some merit in allocating administrative support to the nursing team so nurses can delegate tasks, such as setting up clinics, recalling patients, managing the nursing appointments and stock ordering and control, to improve efficiency.

Then there is the management function of the practice, including the role of the practice manager, the support of a deputy or assistant practice manager and other supervisors and possible sub-managers (such as a finance manager, IT manager, office manager and reception manager).

Looking to the future, the practice manager needs to assess how their role will develop and what skills and time they will need to keep up with the demands of the job. Having the right people with the right skills available to delegate to and help with the day-to-day running of the practice is becoming increasingly vital to ensure that the manager is able to focus on management and strategy.

Finally, there is the administrative and reception team and the different roles within it. Most non-clinical practice staff are part-time and cover particular shifts, with the understanding that they will be flexible about their hours when necessary. Employing a team of part-time staff who work at different times of the day and days of the week can be a challenge for the manager, particularly with regard to communication and ensuring a team focus when some team members might work with one another rarely or even work at different sites.

Performance management
Although everyone is likely to be busy, the manager needs to ask: “Are all staff working efficiently and to their level of ability, and do they have the skills we will need in the future?” The likelihood is that practices will need administrative staff in the future who are IT proficient, can work on their own initiative, are customer-focused and able to problem-solve.

This will require an honest assessment of each employee’s performance and ability to develop. Ask the question: “Is this person performing to the optimum level and does this person have the ability to develop?”

If there are concerns about performance, is it a ‘can’t do’ or ‘won’t do’ situation? Active performance-management measures should be undertaken with regular performance reviews (including annual appraisals) and monitoring of performance against targets, with reasonable sanctions if performance remains unsatisfactory.

Now that the statutory retirement age has been abolished, practices will need to take a long hard look at the work performance and motivation of staff who would otherwise have been coasting towards retirement. Each employee will be entitled to carry on working until they decide to stop, so under-performance will need to be managed in the usual way rather than ignored or made excuses for.

Of course, the carrot is much more effective than the stick – so coaching, mentoring and development of individuals, while engaging them in decision-making and empowering them to develop their roles, will produce a well-motivated and efficient team that is more likely to see change as a challenge rather than a threat.

Sometimes, workforce planning involves the need to change an employee’s contract significantly – for example, working hours. This should be done initially through a period of consultation (a minimum of one month), during which the proposed changes are discussed, as well as the reasons why. The objective will be to arrive at a mutual agreement to the change, which might involve some concessions on either side.

If the employee refuses – and providing there is a strong business case and the practice has carried out a reasonable consultation – the changes can be imposed by giving contractual notice to the employee, terminating the existing contract and offering a new contract with immediate effect on new terms. Should the employee refuse to accept the new contract, they could claim unfair dismissal but providing the practice has good grounds and followed a fair process this is unlikely to be upheld.