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by Marie Hoyle
23 October 2015

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Taking the lead

The practice manager’s voice is not always heard in primary care. However, some clinical commissioning groups have recognised their value and they now play an essential role on the board

When I became a practice manager back in 1989 the primary care landscape was very different with practices operating in much the same way they had done since the NHS began.
At that time my role was to organise the practice in preparation for the 1990 general practice contract, successful implementation of which required computerisation – initiating the process of creating the electronic patient records we have today. Recognition of the evolution of the e-record and its ability to provide real-time knowledge of our patients’ needs, together with six years’ experience as a GP Fundholding (similar to the clinical commissioning groups (CCGs)) manager – where I saw the impact the “power of the purse” had on positively influencing service provision – left me with both an appetite for modernisation through technology and belief in commissioning to improve services.
Hence when CCGs were forming, I was keen to be involved, and when Barnsley CCG decided it wanted to have a practice manager role on its governing body, I was impressed by this decision and delighted when I was appointed. I agreed with Barnsley CCG’s ethos of “putting people first” and wanted to have some part in enabling the CCG goals.

My relationship with the CCG
I am now a member of three distinct but inter-relating teams: the practice team; the governing body; and the practice managers’ group (36 practice managers locally). Being part of a governing body was the new experience; a team of people who for various reasons stepped forward to undertake responsibility for the commissioning function, within a new organisation and from an array of backgrounds.
Adjusting to the dynamics of the new configuration was a personal challenge initially. To be heard in the boardroom and represent my sector effectively, I decided I needed to upskill in leadership. So, following my personal development review (PDR) with the CCG chair I was supported to undertake the NHS Leadership Academy’s Nye Bevan programme. It was an intense period of learning while working in two roles, but the concurrency had reciprocal benefits. I was more able to enact a better fit for my role within each team, increase my understanding of local health and social care landscape; equally I became more proficient at prioritising my practice work through improved understanding of the local direction.

Benefits to the practice
The practice has also benefited, despite losing me for one day a week to my CCG secondment. Through my exposure to CCG functions, I now have a more in-depth understanding of finance and performance monitoring, patient engagement, equality and diversity, audit, quality and safety – all which has influenced how I manage within the practice. In the case of patient engagement, we undertake more routes of engagement now, consequently I feel more connected with our registered list. Involvement with Healthwatch leads and my participation at the CCG patient council gives me insight into the patient view. Additionally, through being a CCG link to the local college, I was encouraged to pursue apprentice placements with peer practice managers. This resulted in a highly-successful placement within our practice where we took a healthcare assistant apprentice. It produced employment, realised service provision benefits for patients and was rewarding for the practice team, providing a more cohesive approach to our workforce.

It is fair to say that as badly as I wanted the position, I had underestimated the required workload and time commitment. I compounded the problem through undertaking a leadership programme alongside, but I am now glad I did.
There is an enormous amount of documentation to read that coincides with increased administration workload at the practice. However, life is about balance and I have learned how to manage this, and though I still have some very long days, I feel I am now focused enough with prioritising that I manage.
However, what I am ever more mindful of and fly the flag about is that there is too much to do at practice level and we have not yet built an adequate infrastructure to cope with it. There is appetite to deliver the three growing service demands: acute appointments; more in-depth long-term condition management and increasing illness prevention work. However, we are not resourced to departmentalise this work and undertake it at the level of sophistication it deserves.
For the manager, all these streams bring additional administration needs but do not realise enough resource to enable sustainable, consistent delivery.

Value of a practice manager on the governing body
It is the non-clinical, administration workload that accompanies service changes that is often the unheard story. I feel able to vocalise the practice manager perspective and raise practice manager considerations when service changes are explored/developed in CCG meetings. Fortunately, within our CCG there is a culture of awareness and consideration of this.
I make sure I attend the managers’ group, have a standing agenda item, produce my blog, and work closely with the chair. I appreciate how the CCG has supported the groups’ continuity and increasingly involved managers, the default position now being to “ask the managers” when developments are proposed. This has made a much more cohesive arrangement than we have had before, particularly significant as the CCG has taken on delegated responsibility within co-commission primary care from April 2015.

Practice manager profession
Having met with many leaders through my role(s) and participation in the leadership programme, I am sometimes left feeling that the practice manager role is under-appreciated. We often value organisations often according to their share of the budget rather than their importance to the public service. Practice managers are general managers and though the role profile varies from organisation to organisation, the range and depth of responsibility still exists. By raising their prominence within corporate governance structures, we are recognising this value and the contribution of their experience. They operate very close to the front-line and know their registered patient needs and behaviours.

CCGs in the future
The future we know will inevitably bring more reformation and change but the commissioning function will remain in some guise. There is the continuing and justifiable trend for more work to be delivered through primary care, this is something practice managers will have to continually pre-empt and seek resource opportunities to deliver. Practice organisation structures are flat, yet our remit is broadening and becomingly more complex.
We know our existing structures are stretched to the limit; that the horizon view shows significant increase in disease management and resources are not likely to grow aligned to this trajectory of need. CCGs will be challenged to address this alongside overcoming the potential conflicts that will emerge.

Practice member engagement
Engaging primary care members into the CCG has been challenging, primarily because of the lack of capacity – an overburdening workload does not leave much room for GP practice staff to participate. In Barnsley the approach to improve practice engagement has been productive through tapping into successful engagement events such as GP education programmes and providing locum cover for practices to get to CCG development sessions.

Clinical leadership in primary care
Undoubtedly Barnsley CCG has addressed strengthening clinical leadership in primary care. The governing body’s GPs recognise the demands of delivering service change and the consequence of failure to work inclusively with local clinicians. Establishing a clinical senate and clinical transformation board demonstrates the breadth of clinical representation. Investment has been made to enable more services across all local practices, and the CCG is supportive of the emerging local GP practice federation.

Marie Hoyle, practice manager on governing body, NHS Barnsley CCG.