AFA FIAB MIHM
Independent Healthcare Consultant
Director of Primary Care
National Services for Health Improvement
Steve is a former Royal Navy Officer, and joined the health service as a chief management accountant in 1984. He has worked at all levels of the NHS. He was an associate tutor at the Institute for Health Policy Studies at the University of Southampton and has worked for the professional development committee of the Institute of Healthcare Management
The nature of the new General Medical Services (GMS) contract meant that the former payment mechanism and process of reimbursements to practices was replaced by an annual budget.
Personal Medical Services (PMS) and PMS plus contracts, together with Alternative Provider Medical Services (APMS) contracts are a variation of this contract, and may or may not include or exclude specific contract requirements.
These sums are cash limited, whereas there was greater flexibility under the old scheme. Additional services can be provided as national or local enhanced services and will attract a payment that has been agreed by the primary care
Can you detail the type of contract that your practice holds, together with any enhanced services?
Whether you like it or not, you will need to deal with your PCT at some time. They contract with your practice, but it would be fair to say that management styles vary around the country. Very often meetings are convened or arranged by the PCT, and this can impact on the very busy daily schedule of the practice manager.
You should develop a key relationship with a named individual at the PCT, such as your locality manager. If in doubt, contact this person for clarification. PCTs have numerous departments and, sometimes, communication breaks down. How many times have you done something, submitted the information and not had any feedback?
If you think that a meeting is relevant to the practice, attend. If you believe that your time would be more beneficial elsewhere, then do not be afraid to send your apologies.
List the names of your current PCT contacts with whom you have regular contact. List the current PCT meetings you attend, their purpose, attendees and frequency.
From time to time – though normally infrequently – a specific development may arise in the practice. This could be the introduction of a new service, a change in staffing skillmix or a practice relocation. These developments need to be managed differently, but need to be managed all the same.
It is important there is a mechanism to ensure such projects are not overlooked or underprioritised. It is also important to ensure that any proposals the practice may have will be in synergy with the plans of the PCT. The current climate affecting general practice means that it is more important than ever to look at all practice development opportunities.
List any current projects that you may have in your practice and detail the timescales involved.
It would seem inconceivable that your practice staff will not know the services available within your practice. However, not all consultation patterns will be the same week after week. Some variances are planned; others are caused by temporary changes, such as annual leave or long-term sickness.
Services are not just those in the practice, but extend to the services that you commission on behalf of your patients. Included in these services are care pathways, and it is important to understand how these services will affect your patients.
Understanding how patients are treated throughout the patient journey will help shape how you provide services within your practice and tackle any potential deficiencies.
No two practices are exactly alike, and understanding why your practice is different illustrates a good understanding of local health needs.
Produce a clear schedule, which illustrates the number of clinical appointments per week (these should include all clinical staff). Also detail the number of additional clinics and their frequency.
There is no doubt that the practice manager will engage with numerous other care providers throughout the course of the week. Some may be clinical; others may be suppliers.
As an independent contractor, the practice is effectively a small independent business that will interact with other members of the NHS from time to time. A good example of this is community nursing staff, who will work with the practice and its patients but are not actually employed by them.
As we move into a new era of patient participation and involvement, there is a greater demand for the practice manager to be aware of other organisations that will be useful. Examples of this can be found in local voluntary groups or national charities.
Produce a list of other organisations with whom the practice has contact with more than once a year. Produce a secondary list of organisations where the frequency of contact is only on an ad hoc basis.
This is an area that should not be overcomplicated. However, failing to put a robust strategy in place could mean that future problems will arise.
First, the practice should be able to define where it currently sees itself now and where it expects to be in the next 3–5 years. Whatever plan is adopted, it is essential that there is agreement at the outset between partners or associated parties.
Without this, any strategy formulation will be destined to fail.
To ensure that objectives are achieved, the plan should remain fluid and should adapt to changing local needs. The current political climate is a good indication of how we may see services being forced to change in the future. As manager, you are able to control the day-to-day factors that affect your practice, but will have little control over legislative and policy matters decided by the government.
Produce a concise statement of where the practice currently sees itself and what changes are planned, if any, for the following 3–5 year period.
This can be defined into two main categories: clinical and organisational. When conducting a clinical audit, a clear definition to the purpose of the audit should be identified – otherwise unnecessary time may be spent on something that does not have any tangible benefits for the practice. If the PCT requests information, find out what it is being used for and expect feedback.
Organisational audit revolves around understanding the processes that drive the practice on a daily basis. Most practices will have a majority of procedures in place, but very often work is undertaken by staff who simply do what they have always done. Where this is the case, you should ask the member of staff to document what they do – this document will then become the foundation of the new procedure.
Procedures are considered to be less important when things are working smoothly – but when something goes wrong, they assist in identifying what the problem is. Concise, sound procedures are invaluable.
Liaise with your clinical governance lead and agree a clinical audit, explaining the benefit to the practice. Choose a practice procedure and review it. Make suggestions on the adequacy of the procedure and amend if required.
The new contract has meant that the way in which general practice is now funded has become simpler to understand. However, it has also allowed the development of locally devised funding mechanisms, which mean there are different financial interpretations across the country.
In theory, the replacement of the "red book" (the statement of fees and allowances) should have made life easier, but now there are so many items that may or may not be included in the contract. Many of these items are now covered by locally agreed enhanced services. Some items have been taken out of the main contract and been redefined as national enhanced services.
Understanding what your budget is actually comprised of is vital. Just because the review body does not approve a pay increase for GPs does not mean that your budget may not be adjusted for other factors. It is important to understand what these variations are.
Rent reviews are a common area in which funding implications can be overlooked. A practice should know in advance what its key available resources are. This allows the practice to produce a reasonably robust budget for the forthcoming year. This budget can be adjusted when more concrete information becomes available.
Produce a financial summary detailing your current year budget. Compare this with your last year's budget and understand the reasons for any significant variances.
Just because something is done one way, it does not mean that there is not a better way to do it. Practice managers should encourage their staff to put forward proposals or ideas. It may not mean that all ideas are adopted, but it creates a healthy culture of support and learning within the practice.
If someone suggests numerous ideas that are never adopted, this person is likely to stop contributing in the future. So if an idea is not put into practice, explain to the person concerned why. This will help them understand that their contribution to the practice, however trivial it may seem, is invaluable to the process of developing the practice.
Linked to innovation is also research – but research by its nature can be quite time consuming. If you or a member of staff are to research an item, ensure that it is relevant. To research a topic adequately you will need sufficient protected time. This can be costly to the practice if the research does not lead to a future project coming to fruition.
Summarise one area of the practice that you would like to change, and explain why. Offer an alternative and explain the benefits to the practice.
Whether you believe in formal qualifications, experiential learning or a combination of both, CPD is now a fundamental requirement of today's modern practice manager. It is for the individual to decide the level of commitment that must be engaged to make sure that you are fit to manage effectively.
This responsibility also extends to your practice staff and ensuring that all available opportunities are made to those who willingly wish to contribute to the future development of the practice.
General practice may be a contracted part of the NHS, but the skills exhibited by the majority of practice managers throughout the UK represents a significant value in respect of healthcare management knowledge.
These skills mean there is potential for managers to work for different NHS organisations, such as PCTs or hospital trusts. If the NHS is truly primary care-led, then practice managers, by ensuring compliance to CPD needs, are ideally placed to be at the forefront of future developments within general practice and the NHS as a whole.
"Professionally you will develop through periods of change and your catalogue of experiential learning will grow day by day. Learning does not end."
"No matter what I may learn today, I will learn something new tomorrow."
Applying those skills in practice …
Adele D'Cunha is the practice manager at the Wellbrook Surgery in London. Here, she shares her approach to the "practice operation and development" competencies outlined on the preceding pages
What type of contract does your practice have?
We are a PMS practice. Before this, we were in a partnership, but we have found the current contract model easier to recruit and retain GPs.
Do you attend PCT meetings?
To be honest, I prefer only to attend meetings I feel will have a direct impact on the day-to-day running of the practice. I am supported by a strategic manager, who will often deal with the policy matters. I do have a contact person at the PCT, and I find that this is useful if I want clarification on any matter.
Do you have any current practice developments ?
The biggest change that we are going to face is the relocation of our main surgery. Although our current surgery is still relatively new, the local council has placed a compulsory purchase order on the surgery, and we are currently involved in discussions about where and how the new surgery will be created. However, there are other issues to deal with, such as our list size being capped as patients are moved out. At the moment, it is anticipated that the new development will mean twice as many patients as now, so we will need to adapt our practice over 2–3 years to manage these changes.
Are the clinical services you provide the same every week?
I wish it were that simple. We actually operate out of two sites. We do not look upon them as being the main and branch surgery. They both have different patient needs and therefore are run to address those needs. I have another manager at the other site who ensures that services run effectively there. We do have different clinics at each site and we regularly review services to see whether they need to be amended, reduced or increased.
Who do you deal with regularly?
Obviously, it goes without saying that there is regular contact with the PCT. I probably deal with four or five different departments throughout the course of the month. I have to deal with attached staff, such as community nurses and midwives. I also have to organise visits from pharmaceutical representatives, and plan and organise training events. We share a building with another practice, so I have to liaise with their staff on certain occasions.
Do you really know what the future holds for your practice?
I am fortunate that I have the assistance of a strategic manager who advises me on the majority of policy issues. This allows me to concentrate on running the practice. To be honest, I don't worry too much about the future. I feel it is important to deal with what is happening now, but I do understand the need to be always aware of the changes that affect primary care and in particular general practice.
How many audits do you carry out?
I have been taught that you should be constantly reviewing your practice information. Obviously the Quality and Outcomes Framework has meant that I carry out regular reviews and clinical audits. Recently our PCT has introduced a performance management framework, which means that I will have to ensure both clinical and organisational audits are done on a regular basis. Failure to do so could lead to the practice losing money from its contract sum.
Do you have a good understanding of the practice finances?
I would like to think I do, but I must admit there are times when some of the financial issues seem to be overbearing. I rely on the practice accountant and also specialised staff, but I do take an interest in the overall finance issues of the practice.
I need to control the day-to-day spending of the practice and am responsible for staff salaries and authorising overtime. As you know, staffing is a large part of the practice overheads, so it needs to be controlled appropriately.
How do you fulfil your CPD requirements?
I would like to say very easily. In truth, I have to rely on the generosity of my doctor to allow me to attend training events and seminars. I will only attend something if I feel it will benefit the practice. I do, however, understand the need to remain in touch with wider developments within the NHS. An example of this could be the white paper regarding the pharmacy contract. Although this does not directly affect my practice now, at some time in the future it could do. I am now embarking on creating my own CPD register, which covers many of the topics mentioned in this article. This will also keep me informed when it comes to my annual appraisal.