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by Costanza Pearce
19 April 2019

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‘Practice management is unrecognisable from the job I started 11 years ago’

Linda de Silva, practice manager at Freshford Practice in Braintree, Essex, talks to Costanza Pearce about her reasons for leaving the job after more than a decade

It’s clear that Linda de Silva, who has been a practice manager for many years, is dedicated to the NHS but she does not hesitate to speak out about its problems. She talks of the ‘constant pressure’ of the job and describes her workload as ‘impossible’.

After training in catering and residential management, Ms de Silva began working in primary care and has been in the sector for 22 years, spending 18 at Freshford Practice and seven teaching and supporting NHS practice staff at Essex-based organisation Equip. She has been practice manager at Freshford Practice for 11 years, but will leave the post at the end of May.

When she gave her three months’ notice, Ms de Silva didn’t have a job to go to. ‘The pressure of the work was so great that all I could think about was getting out,’ she says. The practice has now offered her a less strenuous role; for two days a week. ‘I am happy to accept this and the loss of income for the sake of my mental health,’ explains Ms de Silva.

The day before we spoke, she had spent her morning on 75 emails. ‘Out of an eight-hour day, I spent four hours clearing emails and by the end I had more in my inbox than I’d had at the beginning,’ she says.

Many of these emails come from the CCG, NHS England, the LMC and other organisations, and Ms de Silva says she has found that communicating digitally has made them much less succinct because multiple long documents can be attached at no extra cost. Practice managers then have to comb through it all to ensure they don’t miss anything important.

Collecting ‘meaningless’ data

Ms de Silva says NHS England is a key source of time-wasting, with much of the data it collects from practices effectively being ‘meaningless’. One example is the friends and family test, which reports monthly. Patients score practices from one to five: one being ‘very good’ and five ‘very bad’. However, Ms de Silva has seen reviews ‘giving five out of five because you’re a five-star practice’ and others deliberately scoring badly to prevent the practice becoming popular, which might increase waiting times.

She also finds the new appointment utilisation tool – which monitors the uptake of appointments and how long patients wait for them – frustrating and inadequate. She explains that if a patient wants to book an appointment a month in advance, her team will help them do that. However, this is then listed by the tool as an entire month’s wait, affecting the data average. ‘If practices let people book in advance their data won’t look good, even though they probably have better access,’ Ms de Silva says.

She also thinks taxpayers’ money is being wasted on initiatives that do not improve patient care, with patient wi-fi being one example. The NHS rolled it out to every practice to ‘improve access’ but Ms de Silva says she hasn’t seen any patient benefits from it. ‘Once the patient is in the building, they don’t need to be on the internet to access our services,’ she says, adding that it might have been better ‘to give that money to the practices to do the day job’.

Ms de Silva is similarly critical of schemes that aim to improve the workload for GPs but ‘add further pressure to practice managers’. The money for each scheme is claimed in a different way, and she thinks this should be streamlined to avoid ‘different funding streams for small pots of money’. It would be much better for practice managers, she says, if the money was given as a core baseline for practices to spend ‘as appropriate for their patients’.

‘It’s just overwhelming’

Freshford Practice is rated ‘outstanding’ by the CQC, but Ms de Silva says inspections fill her with anxiety. The fear of missing something is, she says, ‘a constant worry; you feel that if you got a bad rating you would be letting your partners, staff and patients down’.

The ‘sheer diversity’ of the role doesn’t help. Ms de Silva reels off an intimidating list of daily tasks, from dealing with patient complaints and emergencies to responsibilities for staffing, finances, access, health and safety, fire regulations, the building and car park, IT, insurance and indemnity. Practice managers have ‘enormous responsibility, with so many balls to juggle to make sure everything is up to date’, she says.

The ‘crux of the matter’, Ms de Silva explains, is that she wants to spend her time running her business ‘so the doctors can get on with being doctors’, but she finds she can’t because of ‘the overflow of information’ coming from NHS England. ‘It is just overwhelming,’ she says. For her, bureaucracy and decisions made ‘for political reasons rather than real patient benefit’ have been the worst parts of the job.

Over the years, being a practice manager has become increasingly difficult, Ms de Silva says. ‘It’s unrecognisable from the job I started 11 years ago: the levels of work and bureaucracy have increased enormously’.

She worries about the ‘unpleasant trend’ of practice closures, explaining that she has seen ‘more practices fold in the last five years than in the last 25 put together’. Recruitment is one factor, but Ms de Silva suggests practices also close because ‘they just couldn’t do it all with what was provided’.

‘More bureaucracy’

At the moment, there is a big drive towards working at scale, with primary care networks being a focus of the NHS long-term plan and the new GP contract. Ms de Silva is concerned this ‘will just add another layer of bureaucracy’. As it stands, each network will have to nominate a practice to receive funding on its behalf and Ms de Silva believes it will be up to practice managers ‘to split that money up’.

The consistency of extra funding is even more of a worry for Ms de Silva. She explains that when something new is introduced by the GP contract, it might at first have a payment attached but after a year or two it becomes part of normal expectations. ‘To get that extra money, you then have to do something else,’ she says. ‘Things don’t ever get taken away. You’re just expected to do more and more.’

Unfair deadlines are something else that piles the pressure on, she says. While practices are given tight timeframes to deliver services, she says there have been ‘incidents’ over the last few years when NHS England was slow to make payments, such as with the dispensing services quality scheme last year, and flu jab payments a few years ago. She points out that this can cause hardship.

‘If a practice misses a deadline, that’s tough. However, if NHS England can’t meet a deadline it says it’s because there aren’t the staff and it will be done as soon as possible,’ she says. ‘NHS England is a big organisation and we’re small, we can’t stand up to it.’

In response to this, NHS England said there are times when payment delays unfortunately can’t be prevented. ‘NHS England aims to make payments to all GP practices in a timely manner. However, there are occasional, unforeseeable delays,’ says Rachel Webb, director of primary care and public health commissioning at NHS England and NHS Improvement – East of England. ‘When this happens, we contact the practices affected and resolve the matter as soon as possible.’

‘It’s time for change’

Dedication to the Freshford practice and the great team she works with there has, Ms de Silva says, been the best thing about being a practice manager. This and a commitment to the NHS is what’s kept her in the job so long and is the reason she’s willing to stay in general practice.

Nevertheless, she has no regrets about resigning as practice manager. It reached a point where Sunday evenings were filled with dread about facing another week. ‘Having a better work-life balance is far more important than money,’ she says.

In February, Ms de Silva posted in a practice manager Facebook group to say she was quitting because of the unsustainable pressures of the job. An outpouring of support and frustration from other practice managers followed. She says that in more than 100 comments, no one criticised her decision. Indeed, many said: ‘if I didn’t have children and a mortgage, I would do the same’ or ‘I totally understand, it is impossible’.

She believes the problem is that practice managers are unlikely to speak out until after they have handed in their notice, but hopes that sharing her story will help others who are struggling.

Despite the difficulties she describes, Ms de Silva is strikingly positive about what lies ahead. As she speaks. the weight lifting from her shoulders is almost audible. ‘It’s exciting,’ she says. ‘It’s time for change.’