Even by the standards of practice managers, Caroline Kerby has a lot on. In addition to her fulltime role as Managing Partner at a North West London practice serving socially deprived patients, she is one of two national leads for the NHS Alliance Practice Managers' Network, a group set up six years ago with the aim of influencing government policy, now working to "support practice managers navigating through the expectations of what they are going to have to deliver".
Driven by a commitment to high-quality and equitable healthcare provision, Caroline is also a clinical lead for her local shadow GP commissioning consortium, itself a member of the Brent GP Federation, which comprises five locality consortia. Notwithstanding her busy schedule, she has recently joined the Management in Practice editorial advisory board.
Her 'day job', though, is evidently her greatest passion. "I love practice management," she says. "I love working in health, I love the medicine. I find it a huge privilege to work with doctors and nurses. I do a lot of work outside the practice but I would never give up having this role."
This longstanding commitment to health management is perhaps a triumph of serendipity, as Caroline became a practice manager almost by accident. She worked for Nissan until the mid-1980s, but following the birth of her son an opportunity arose at her local GP surgery in Barnet, which wanted someone to oversee the computerisation of the practice.
"At the time I thought, 'I could do that part-time, and when my son's a bit older I'll get a proper job'," she laughs. "But my son tells me I still don't have a proper job, that I'm still practising to be a manager."
She has now been a practice manager for 25 years, spending the last 11 running the 10,000-patient PMS practice in Brent, "one of the most diverse boroughs in the country". The practice has a transient multi-ethnic population – more than 130 different languages are spoken in the area.
"All our patients live in highly deprived postcodes," says Caroline. The practice has a demanding clinical workload, seeing a high turnover of patients suffering from mental health problems and varied social problems.
Far from buckling under the pressure, however, the tough demands of her patient population appear to have had a key influence on Caroline's work and her attitude to practice management. It is precisely the clinical involvement that she relishes the most.
"Working with frontline clinicians, you learn that your core business is medicine and you've got to be able to manage that – not in terms of delivery, but in terms of developing services, developing the workforce and the skill mix.
"For me, that's the biggest privilege of the job. I can't think of another management role where you could be as involved. Not every practice manager wants that and may see it very much as a business role. But to me, the true practice managers are the ones that will pick up some of the clinical side of the Quality and Outcomes Framework and implement it, as well as ensuring the coding is there."
In the context of the dramatic changes to the NHS in England, and the ever-developing role of the practice manager cross the UK, does she see changes ahead for practice management?
"I think over the next couple of years there will be more change, you can feel it speeding up," Caroline says. "When you actually look at factors like the contractual link to commissioning, Care Quality Commission registration and the financial environment, then I think there will be a lot of changes in primary care management."
However, she is also concerned about the wider changes to primary healthcare as it moves into an increasingly competitive marketplace. "If you look at the King's Fund Quality of General Practice Inquiry report, it says general practice needs to move from a cottage industry to an industrial level," she says. "Does that mean that there will be a practice manager in every practice? Or are there things that will be done at a network or higher level?"
The effect of this 'industrialisation' of the sector, and the potential move away from smaller residential practices that the King's Fund envisages, will have a huge impact on the profession, she believes. "I think practice managers are just starting to realise how much their role is going to change. I get a number of calls from practice managers saying, 'For the first time ever I'm worried about my job'."
While Caroline doesn't believe that this would mean a widespread exodus of practice managers, she does foresee significant restructuring of management responsibilities.
Networking and support
Since she became Joint Lead of the NHS Alliance* Practice Managers' Network at the beginning of 2010 – together with Michael Orozco, a practice business manager in Nottingham – Caroline is now in a greater position to help give a voice to practice managers who may have such concerns or want to have their say on healthcare policy decisions.
She believes that practice managers have traditionally lacked a national voice and are under-represented in the healthcare arena. "That's why I've been so passionate about working with the Alliance because they now have practice managers on their national executive, so we have a key role informing NHS Alliance policy."
The Alliance Network has 10 national leads – one in each strategic health authority. Each has their own network of roughly 50 other practice managers in the area (who may not necessarily be members of the NHS Alliance). The 10 leads meet around five times a year to agree on the Network's strategic direction. Lobbying those in decision-making positions is one of the key strengths of the Network, Caroline says, but she indicates that involves a practical, as well as a critical, agenda.
What of her own views on NHS reform and the impact of GP-led commissioning? At the time of writing, Andrew Lansley had just announced the government's intention to "pause, listen and reflect" on the Health and Social Care Bill proposals. Will that make a difference to the proposals?
"I don't think the direction of travel will particularly change, I think what will change will be the speed at which it happens." She would like to see a "closer dialogue between consultants and GPs" because of a misunderstanding among clinicians that GPs will "be the boss and have all the money… and actually the GPs don't see it like that. The GPs see it as a danger to the NHS if it's not managed properly. But they also see it as an opportunity to be able to reshape the health service."
As a clinical lead for her local shadow consortium, Caroline certainly advocates a greater role for practice managers in the commissioning process and believes GPs are making a mistake if they sideline their management colleagues. "Where [GP consortia are] not using practice managers, what worries me is that they will buy in an expensive management consultancy as opposed to developing [existing] local management," she says.
However, the real impact on the health service will not be dominated by political reform, she believes, but by the financial climate and the need to save £15-20bn over the next few years – and this will inevitably affect how practice managers work.
"With the efficiencies the NHS is going to achieve it doesn't matter that much which party is in power," she says. "So you're going to have to understand how you use public money and how you commit NHS resources. You're going to have to work with neighbouring practices. There are going to be some very difficult conversations involving the entire community about what can be funded and what can't. It's a completely new conversation that we haven't really had before."
Issues of financial and collective responsibility are clearly central principles for Caroline. In 2007, she became Managing Partner of the practice after buying the property shares of an outgoing partner. So, just like the GPs, Caroline is a profit-sharing, self-employed partner.
"To me, being a managing partner was about taking professional responsibility, to say that I'm equally liable for how this practice functions. So we succeed together and, if we were to go through difficult times and the profit dropped, then we go through that together."
This pragmatic approach seems particularly apt at this curious time when the health service in England faces both economic uncertainty and question marks over its proposed future direction. While she may face concerns about the changing nature of her profession, Caroline shows a determination to engage and seek solutions.
*The NHS Alliance is an independent, non-political organisation comprising GP consortia, clinicians and managers in primary care.