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by Steve Williams
29 December 2017

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Practice management — a changing game

Primary care and the role of the practice manager have changed radically in the past decade.

Reforms in healthcare and wider spheres of life, together with operational considerations mean that the job calls for an increasing set of professional skills — and even personal qualities.

In 2007, smoking had just been banned in public places, but the NHS had already seen 10 years of continuous reform. Andrew Lansley, the Conservative shadow health secretary, outlined his vision for the future of the NHS while Tony Blair resigned as Prime Minister.

Walk-in centres were introduced by health minister Lord Darzi. They aimed to provide services 12 hours a day, 365 days a year, and held their own patient lists. Practice managers saw patients transferred from their own lists, with direct reductions to the contract sum. Ten years on, it has become normal for aspects of the contract that attract funding to be amended every year – changes that the practice manager has to be alert for.

In 2009, the NHS was becoming more patient centred. The NHS constitution was published, setting out patient rights. About 40% of practices had a patient participation group; now this is a contractual requirement.

The Practice Management Network was established to give practice managers a voice.

The financial pressures continued with the crash of 2008/09. The Quality and Outcomes Framework bubble burst, upsetting a system that had significantly boosted practice profits since 2004. PMS contracts were scrutinised and PCTs sought to claw back contract sums.

In 2009 the Care Quality Commission (CQC) was created and NHS England chief Sir David Nicholson announced a drive to create efficiency savings of £20bn by 2014.

In 2010 the nation was shocked by the Francis report on the Mid-Staffordshire NHS Trust scandal. Low staffing levels saw such poor care that hospital patients were left without drinking water. Pilots were launched of the national out-of-hours number, 111, while general practice started to see the effects of recruitment and retention issues. The PMS contract also came under attack, with widespread cost reductions enforced by PCTs.

That same year, Labour leader Gordon Brown lost the general election. A coalition government was formed between the Conservatives led by David Cameron, and the Liberal Democrats led by Nick Clegg. In 2011, the health and social care bill, which created clinical commissioning groups (CCGs), was proposed, with reforms that gave rise to many objections. They were put on hold for consultation and ‘listening exercises’. Many participants remarked that they were heard, but not actually listened to.

In 2012 the health and social care bill was passed and Any Qualified Provider (AQP) contracts came in. Restrictions on practice boundaries were lifted and a scheme was piloted that allowed a choice of providers. Personal health budgets were rolled out to people with disabilities and long-term needs.

Austerity measures became more obvious in primary care. In 2013 PCTs were replaced by the new CCGs. The friends and family test was introduced. Simon Stevens was appointed chief executive of NHS England. He published the Five-Year Forward View plan.

In 2015, devolved powers for health and local government were given to Greater Manchester. A general election gave the Conservatives a majority government. Junior doctors went on strike over a new contract. The year after NHS Improvement was launched.

This year, after yet another election and the Brexit vote, we have a minority Conservative government, with Jeremy Hunt remaining health secretary.

So what has all this upheaval meant for practice management? Aside from the stricter financial environment, there is more emphasis on leadership. Ten years ago, leadership styles aimed to match the environment. Task-oriented leaders performed best in situations that were extreme — very easy or very difficult. People-oriented leaders did best in the middle. But the move towards a patient-centred service has seen the development of transformational leadership, which depends on the ability to engage, energise and develop followers; engaging with patients and other key stakeholders.

Practice managers now put a greater focus on empowering followers and involving patients and practice teams in decision-making. The GP Forward View recognised that practice manager development had been largely ignored and allocated £6m investment. While this only touches the surface, it recognises the contribution we have made to the NHS — and will continue to make.