The words 'practice manager' might not appear anywhere in the government's Health and Social Care Bill but, rest assured, Whitehall has not forgotten you. On a bleak February morning in his Cambridge constituency office, Health Secretary Andrew Lansley is in a defiant mood, bristling at the suggestion that practice managers have been excluded from his highly publicised reform programme.
"When we talk about 'general practice', do they not include themselves?" he counters. "The white paper is littered with references to general practice, not just GPs. Practice managers are not left out when it comes to general practice; they are integral [to it]."
By way of evidence, he points to the burgeoning ranks of commissioning consortia – there are now 117, covering two-thirds of the country. Mr Lansley claims there are numerous examples of practice managers becoming a "key part of the administration of consortia" and that in some cases they are leading the charge. "I mean, everywhere I go practice managers are forming part of the teams making up consortia," he says.
Of course, Mr Lansley is not the only one at pains to point out the importance of practice managers to the reform programme. Dr Clare Gerada, chair of the Royal College of GPs, is one of the key players in the reform debate, and she's just as keen to make sure they don't get left behind.
"Practice managers are really crucial," she says. "They are going to have to ensure that the practice continues to function if the doctors are off commissioning. They are also going to have to translate policy details down to practice level, as well as developing a system in practice to feed back to consortia. This is a really good time for excellent practice management."
Dr Gerada says that the job would be a balancing act between delivering an excellent service to patients through continuing care and access to service, and finding ways to be involved in commissioning consortia. She believes that practice managers are ideally placed to do this.
"Let's not kid ourselves, the crucial turning point in general practice was when we invested in professional practice managers. They have transformed general practice and are going to be really relied on to help run commissioning and have it going on at the same time as delivering excellence."
But if practice managers are indeed going to take centre stage, as Mr Lansley and Dr Gerada suggest, what kind of government support can they expect? Not much, it would seem.
The Department of Health (DH) is leaving it to GPs – practice managers' employers – to organise any training regarding the consortia. "Practice managers will be doing the same as before, managing the practice. They should get any information or training from the GPs that employ them – it's not something we are dictating," says a DH spokesman.
Stepping into the breach is the RCGP's Centre for Commissioning, which is running practical half-day workshops for effective commissioning across the country until April. The workshops cover public engagement, assessing health needs, local care pathways and using resources more
In addition, the NHS Alliance Practice Managers' Network is planning on publishing guidance for practice managers in May.
The other areas causing particular consternation for the intrepid practice manager is the potential removal of practice boundaries (they're expected to be abolished in April 2012 and the government will be publishing guidance in due course). Fears of requirements for home visits (involving travelling greater distances), mass migration from one practice to another and administration headaches abound. Among MiP readers, this particular part of the legislation caused concerns, becoming one of the most commented stories on managementinpractice.com
But Mr Lansley is confident that this won't lead to infighting and a scramble for patients, as feared by some, and that a "workable and sensible" solution from a general practice point of view can be reached.
"I don't expect particularly to have conflicts," he says. "We are looking for patients to exercise choice about the practice with which they are registered.
"This is not a wholly new phenomenon. It's just that the bureaucratic constraints on this are greater than they need to be. We have responded to the consultation [Your choice of GP practice] that the previous government did on practice boundaries, in particular dealing with the issue of home visiting by making sure we don't ask unreasonable things of practices," he says, adding that the removal of boundaries would work much better in the context of a more robust and integrated urgent care response in each area.
Mr Lansley is not expecting patients to take to the streets and start "shopping around" for a GP surgery. "The essence of general practice is often one-on-one 'relationship medicine'. Many practices have a substantial proportion of their population who are registered and remain with them for many years, and I see no reasons why that should change.
"Clearly some people do move, and don't move very far. That's true particularly in urban areas, [where patients] don't want to move practice and there's no good reasons why they should," he says. "If 'relationship medicine' works – which it does, there is a strong evidential basis for a family doctor relationship – the choice of GP if anything should enable that to be supported, rather than undermine it," he says.
However, many practice managers and GPs will remain unconvinced that scrapping boundaries is a good idea. Indeed, Dr Gerada expects lots of movement from those who can pick and choose, while the elderly and mentally ill will remain where they are.
"Mr Lansley may say 'GP practices are a bit like a bank, you don't tend to move unless there is a reason', [but] we will get internal tourism fuelled by the most agile and vocal who will register with a practice which is offering a service they want," she says. "We make it work already for patients who can't access care close to home through temporary residency and special cases."
The RCGP promotes a registered list with federated practices, still within a geographical area. Patients can register with any practice within that area, allowing for more choice while "running a health service that works for everybody", rather than "lock stock and barrel removal of practice boundaries which have been in place since before the beginning of the NHS," says Dr Gerada.
She also feels it may encourage those who choose a practice a distance away from their homes to present at Accident and Emergency, which is something both the government and primary care providers are trying to avoid.
Nevertheless, she does agree with the health secretary that there will be no need for competition in this scenario, as "there is more than enough to go around".
"I don't think it's going to lead to conflict, as GPs and practice managers will be working together as federations. They need to think of themselves not as isolated practices but as part of a federated healthcare system supporting each other and sharing back-office functions," she says.
"What I would say is: focus on what we know works. Focus on access and continuity of care, and let's do everything we can to provide a high-quality general practice."