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Tuesday 11 December 2018
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How has practice management changed over the past 20 years?

Practice management has never been easy to define.

NHS reforms over the past 20 years have put the role in a continual state of change and some might even say there is confusion about what the job entails.

Are practice managers meant to act as administrators, as they were supposed to when the position was first introduced? Or are they increasingly ‘jacks of all trades’?

This year’s First Practice Management (FPM) Salary Survey of 1,030 practice managers pointed out that we are starting to see a new shift for what the role implies, with practice managers acknowledging that the role includes numerous aspects such as HR, finance and IT.

What is more, the role changes according to the size of the practice. In some cases, practice managers fill in as receptionists or, as Kay Keane, a practice manager in Stockport, Manchester, told us, they might find themselves ‘fishing a nappy out of a blocked toilet’.

But despite the seemingly limitless remit and variations, it is possible to chart a clear line of evolution that has created the role we see today.

1997: The Labour Government abolished GP fundholding, which had largely created the need for practice managers

Fundholding was introduced in 1991 under the Thatcher government to allow GPs to own and manage a practice’s budget and decide which new services to deliver. This extra administrative workload had created a need for a new type of expertise — that of the practice manager.

Jennifer Gosling started as a practice manager in 1991 and worked in the role for 16 years. She is now assistant professor in management at the London School of Hygiene and Tropical Medicine, but she recalls ‘Every couple of years or so, I would move to another practice. I was usually the first manager they had appointed. I think that is when it developed as a job.’

Jan Harley-Doyle, a former practice manager now working as a private consultant in east London, agrees that fundholding created a need for specific financial and business management skills in primary care.

‘With fundholding, general practice began to attract managers from a variety of commercial backgrounds, who chose to use their experience in a healthcare setting,’ she said.

Imbalances in pay between male and female practice managers were also recorded at that time, and were much worse than they are today. The latest FPM Salary Survey showed that the gender pay gap is at 7.7% this year, an improvement on 2016’s 10.18%. But Ms Gosling, whose PhD researched the development of practice management, found that in the 1990s there was about a salary gap of £5,000 between men and women. She also discovered that the women practice managers who were coming from outside general practice were earning more than the managers who had been promoted internally from jobs as receptionists.

Again, fundholding had been the turning point. ‘Previously, practice managers were home grown. People would come in a junior position and then move up into management. But with fundholding more people with a commercial management background were attracted.’

The Labour Government abolished fundholding in 1997. According to a Royal College of General Practitioners (RCGP) document published in 2003, this made some practice managers redundant, at first. But, says Ms Harley-Doyle, the role was here to stay.

‘Practices need managing and leading regardless of fundholding,’ she said.

Indeed, she thinks that fundholding produced many benefits. ‘I thought that if done appropriately and ethically, fundholding was fantastic for both patients and individual practices. The problem was that it was exploited by some practices and therefore when the Government changed, the good things were thrown out with the bad things. Rather than looking at what we gained from it, they threw it out wholesale.’

Moving on from fundholding, the complexities of running a practice continued to increase, making the role of practice managers ever more essential. In fact, shortly after fundholding was abolished, new health authorities were introduced, such as primary care trusts (PCTs) in 2001.

2003: GMS contracts

According to RCGP archive papers, practice management as a discipline grew in importance after the introduction of a generic competency framework in the 2003 General Medical Services (GMS) contract.

For the first time, the document set out the skills and responsibilities of a practice manager. These included ‘strategic issues, the development and delivery of services to patients and practice infrastructure’.

Although there were no specific career entry requirements, candidates with experience of management and non-mandatory qualifications such as the diploma in primary care management offered by the Association of Medical Secretaries, Practice Managers, Administrators and Receptionists (AMSPAR) or the managing health and social care certificate offered by the Institute of Healthcare Management (IHM). A few universities also began to offer specific courses for practice managers, such as a two-year part-time diploma in management for general practice, at the University of Westminster.

2009: Three significant changes in just one year

This year was a year of change for the profession. The Practice Management Network (PMN) was established to help practice managers influence the development of policy. The NHS constitution was set up, making patient-led services more important and leading to the formal requirement to create patient participation groups. And the Care Quality Commission (CQC) was created to ensure public health services provided patients with the best care.

The former chief executive of NHS England Sir David Nicholson launched a money savings drive, known as the ‘Nicholson challenge’.

PMN co-chair Steve Williams said: ‘Sir David announced a drive to create efficiency savings of £20bn between 2011 and 2014. During this time practice managers were consulted to suggest ways that primary care could contribute to this savings target. The Nicholson challenge – also known as the Quality, Innovation, Productivity and Prevention (QIPP) initiative — triggered new changes to the Personal Medical Services (PMS) contracts and local services.’ This left practice managers in confusion, so they sought advice from the PMN, which actively reviewed practices’ PMS contracts and advised on the changes, he explained.

2013: And then came CCGs

In 2013, PCTs were replaced by clinical commissioning groups (CCGs), which increased the complication and quantity of the practice manager’s role.

2014: CCGs and onwards

In a 2014 survey by Management in Practice’s parent company Cogora, practice managers reported that they were greatly involved with CCGs’ work. On the other hand, they reported that overworking was having a detrimental effect on their morale.

The practice manager’s workload was spiralling with the introduction of stricter CQC regulation, contractual charges and difficulties with practice payments. Wessex LMC warned that many practice managers were considering leaving.

To help practices cope with workload, the British Medical Association (BMA) published Quality first: Managing Workload To Deliver Safe Patient Care. It suggested practices consider working with neighbouring practices — either merging entirely, or sharing functions such as HR, training or finance management. Also, practices could opt out of CCG meetings that were for activities outside constitutional obligations, although this might lead to a diluted influence over the CCG.

However, Ms Harley-Doyle believes that CCGs aren’t necessarily to blame for the rise in workload. ‘There is a general feeling that each new organisation that comes around is causing more stress than the one before it. But I don’t think CCGs have been any more stressful to primary care than their predecessors. There were other health services — health authorities, then primary care groups (PCGs) and PCTs that were the same players in healthcare management.

They simply moved from one organisation to another. Of course, their role is now becoming increasingly different. At least CCGs are local. You get to know the people who are in the organisation and create working relationships.’

She adds: ‘What is more of a problem is the anonymous departments that send last-minute information requests or a plethora of forms to be completed with unrealistic deadlines. An example is NHS England, where we rarely have a named contact, so it is difficult to build a relationship or get answers to queries.’

2016: Thinking forward: the GP Forward View

With practice management now firmly established at the forefront of an ever-evolving profession, a fund of £6m has been allocated by the GP Forward View to encourage local and national networking between managers and provide peer-to-peer support.

As they work more behind the scenes, though, they see a worrying shift away from the front line.

‘In recent years, I have had considerably less opportunity for patient contact,’ said Ms Harley-Doyle. ‘There is now so much going on behind the scenes that if you are not careful, the only time there is direct patient contact is when there are patient problems.’

She fears this might endanger the connection with patients, which would be detrimental. ‘I think it is important to find the time to maintain a close relationship with your patient population, or there is a danger that general practice becomes just another business and loses its patient focus.’

Practice managers are aware that their role will continue to evolve.

Leadership skills will become more specialised, says Mr Williams. Previously, leadership was seen as something natural, but now we have ‘the concept of transformational leadership, as practice managers engage more fully with the practice population.’

And change is always around the corner. Systems are bound to change again, says Sarah Longland, business manager at Sutton Coldfield Group Practice in the West Midlands. She believes this might see further specialisation, and possibly fewer generalised managers. ‘I believe we will see managers in specialised disciplines rather than jacks of all trades,’ she said.