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Friday 28 October 2016
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Key players in an unfolding drama

Insight: commissioning

Rebecca Thornley

Associate Director

Primary Care Commissioning 

Rebecca is an associate director with Primary Care Commissioning (PCC), a provider of primary care development services to the NHS

Practice managers are often the unsung heroes of change. Whether it be as early supervisers of fundholding, negotiating on behalf of partners for nGMS, designing and delivering local enhanced services with the primary care trust (PCT) and local medical committees or ensuring patient satisfaction and quality outcomes, their work has always been challenging but fundamental to the success of primary care.

Without the contribution of practice management, the success of clinical commissioning will be compromised and there is a real risk of failure.

Managers can be used strategically in developing effective local needs assessments, reviewing/shaping clinical and management capacity, contributing to a dynamic estates strategy, identifying patient need from local disease registers and raising patient awareness while retaining effective income generation from core general medical practice business.

Operationally, practice managers are best placed to know the strengths of their individual and collective clinical teams, know what services work well in their locality, understand the needs of their practice population and know what new services they can host and deliver.

Not all practice managers are able to dedicate protected time to strategic planning and policy development locally, but if they work as a network they can support one another, taking different lead areas. Through their existing local and national networks they can empower one another, using individual strengths and skills to produce an effective leadership resource.

How to prepare for change
Managers must fully understand the difference between service "provision" and "commissioning". Currently practice managers are mandated by their practice employers to deliver the priorities of providing good general medical services and maximising and protecting existing income. Management of the practice comes first, but in this new world of commissioning an effectively run practice will enable clinicians to be released to support the wider commissioning agenda. Where capacity is created and skills are available, services can be effectively moved from secondary care to primary care to support patient access and deliver value for money.

Good information held by the practice in its clinical system will be an essential element of the data that will form commissioning information. Practices will be able to use audit, clinical registers, public health information and patient feedback to inform service prioritisation and system redesign.

To prepare for change, managers must first assess their current practice strengths and weaknesses. It will help if they were fundholding managers, have already shaped and delivered innovative enhanced services, or been active participants in practice-based commissioning (PBC).

Practice managers can begin the process by engaging and working more closely with PCT secondary care commissioners. This has already started where PBC has worked well, but may be a new concept for many who have, until now, only had direct communication with primary care contracting managers or public health leads.

By understanding what PCTs are doing now, clinical commissioners can work with practice managers to identify areas where their management teams can become involved and identify where there may be duplication.

Practice managers should familiarise themselves with the quality and productivity challenge. The QIPP (Quality, Innovation, Productivity and Prevention) programme demands a sophisticated approach that uses service redesign to deliver savings while concentrating on raising quality. The tension between these aims creates significant challenges for clinical commissioners and for practice managers who have a critical role to play in implementing change and monitoring progress.

Many PCTs have already produced QIPP plans using tools such as Primary Care Commissioning's Quality and Productivity calculator, which highlight key areas for potential savings and service improvement. This knowledge is the legacy that clinical commissioners will need to deliver high impact change.

Practice managers can identify sources of information and analytical tools to aid the commissioning process, particularly by levering relationships through networks with other practice managers and with PCT managers.

Future roles
Practice managers clearly have a role in supporting and influencing GP behaviours, which will be key to the success of GP commissioning. They will develop skills in negotiation and facilitation to bring together practices that may have been rivals for many years.

Encouraging collaboration and even, in some cases, the merging of existing businesses will be necessary to give providers the scale and depth of expertise to deliver the range of high-quality services that patients need, to support moving services to primary care settings where they may be more appropriate and cost effective, and to make the best use of estates capacity.

Where there are historic breakdowns in relationships between some practices (ie, where practice partnerships have split) it will again be the practice managers who can act as marriage counsellors.

In recent years, practice management has encompassed a widening range of skills. Many practices now have business directors, financial experts and ex-PCT commissioners who can strengthen the new leadership teams of consortia as representative board members or sharing dual roles across commissioning and provision. They have the experience and knowledge to be management leaders alongside clinical leaders.

Supporting clinical commissioning
Practice managers can effectively performance manage contracts with secondary care and the quality outcomes of practice populations. Robust benchmarking can be delivered at practice level and reviews undertaken regularly to ensure that change is delivering the right results. They can also influence the effective decommissioning of services where these are not working well or where health needs or clinical practice change.

Developing skills and competencies within practice clinical teams, including nurse practitioners and nursing teams, will also help support the new care pathways. Where managers negotiate partnerships with secondary care consultants, services can be delivered locally in new ways.

Opportunities for the future
All of this presents opportunities for practice managers in the future – whether by supporting commissioning and informing new patient pathways, or performance-managing outcomes. They will be key energisers and supporters of clinicians, working to ensure that their doctors can be involved in the redesign of services without endangering business as usual.

Practice managers will be essential in negotiating the shift of services into primary care and redesigning care teams to deliver services closer to home. They will also be responsible for identifying ways that savings can be redeployed and ensuring that all clinicians contribute to the leadership and vision for the future.