Lecturer in Primary Care
University of Essex
Allan leads a range of courses at Essex University that are designed to develop knowledge and skills in health services management. Allan has a special interest in the governance and organisation of primary care and the evolving role of the general practice manager. Allan's 25-year career has included a broad range of clinical and managerial posts in Australia and England, including general and occupational health nursing, health promotion, and clinical development management for a primary care trust. Allan admits to missing the Australian sunshine but now calls Suffolk home. A keen gardener, he has become a dab hand at making compost!
Are practice managers the Cinderellas of primary care, or has their contribution to the development of primary care services simply been ignored? This is a difficult question to answer, and not made any easier given that the contribution of the practice manager to the development of general practice is virtually invisible in the research literature. An investigation of variations in general practice development in southwest England in the early 1990s concluded that employing a practice manager was the simplest developmental activity to implement.(1) This appears to be a widely shared view – a survey observed a 35% increase in the employment of practice managers between 1990 and 1993.(2) Unfortunately, these early reports do not indicate how this expanded workforce contributed to the development of general practice.
Later studies suggested that although awareness of the potential contribution of the practice manager to practice administration increased during the 1990s,(3) in general, practice managers continued to be restricted in their ability to delegate or undertake proactive planning, and continued to experience limited levels of autonomy and authority.(4)
A report on fundholding in the north of England supports anecdotal reports from practice managers that the brief period of GP fundholding in the early 1990s did open up new opportunities for greater autonomy and engagement with strategic planning.(5) Unfortunately, these opportunities were restricted to a minority of practice managers, and it is fair to say that the gradual professionalisation of practice managers during the 1990s was mostly the result of topdown structural reform of general practice, rather than a product of an emergent professional identity within the workforce.(6)
The observed variations in the role of practice managers may have been especially influenced by two specific factors. First, the primary employment relationship for the overwhelming majority of practice managers is with their employing practice and not the NHS. As there has always been considerable variation in the size and structure of practices, the conditions of employment and job descriptions of practice managers would realistically be expected to vary more than those of general management staff employed by NHS trusts or health authorities.
Second, I would argue that before the introduction of the new General Medical Services (GMS) contract in 2003, there were no effective mechanisms for strategically influencing or systematically evaluating the internal management of general practices. Consequently, the role of the practice manager has, until recently, largely been defined by, and the product of, a unique combination of local organisational values and work practices.
Conversely, I would argue that the combined effect of the recent rapid expansion of electronic records systems and the embedding of practice administration criteria in the rewards framework of the new GMS contract has created the perfect environment for a major reappraisal of general practice management and the role of the practice manager. Practice management has at last moved beyond a job description to emerge as an occupation that will be defined by recognised competencies and a shared professional identity.
It would appear that although the role of the practice manager has evolved relatively slowly during the last 15 years, the pace of change has increased significantly since the introduction of the new GMS contract, thereby bringing this professional group into a much more prominent position in the primary healthcare team. It is also clear that the characterisation of practice managers as the Cinderellas of primary care has, in part, been due to the poor documentation of their contribution to the development of general practice services. Furthermore, the educational preparedness and level of qualification that would enable practice managers to fulfil the role expectations that the NHS and employers appear to share continues to be largely unexamined.
Professional qualifications for a professional role
Practice managers are the strategic link between the NHS and general practice, yet it is remarkable how little is known about their readiness for the challenges they face. Until recently, there have been few validated benchmarks to guide the development of an agreed framework to define work-related qualifications for practice managers. The breakthrough in this unsatisfactory situation has been provided by two important developments: the publication of a competency framework for practice management,(7) and the introduction of a new NHS pay system, Agenda for Change (AfC).(8)
The competency framework for practice management was published as an annex to the new GMS contract in 2003. This framework provides a useful guide to the level of skills managers should display, and the professional development that will be needed where gaps are evident. The AfC initiative provides a national pay framework linked to a job evaluation scheme and a knowledge and skills framework (KSF), which defines and describes the knowledge and skills that NHS staff need to apply in their work in order to deliver quality services.(9)
Although the overwhelming majority of practice managers are not directly employed by the NHS, and are therefore not bound to the AfC framework, the early profiling of the role is an indication of its importance in facilitating the modernisation of primary care services.
The AfC job evaluation scheme has at last validated the level of qualification applicable to the work of practice managers. Managers of small practices are assessed as requiring the knowledge and skills that would normally be associated with a higher national certificate or higher education diploma level, while managers of larger group practices are recommended as requiring the equivalent of an indepth higher education diploma or a bachelor's degree. This places practice managers in the same banding for knowledge and skills as practice nurses and a number of other allied health professionals (see Table 1).
Taken in combination, these two initiatives provide a long overdue benchmark for the development of recognised qualifications for practice managers. The competency framework provides a structure for developing curriculum content, and the AfC job evaluation provides the structure for setting the appropriate academic level of courses.
A number of important implications are associated with a qualifications benchmark for practice managers. First, having established a benchmark it would be reasonable to expect the NHS to then promote this to employers as a recommended reference point for the framing of practice manager job descriptions and the development of training and education programmes. Inexplicably, this is not the case.
Instead, the NHS Careers website refers only to an NVQ-level diploma course that does not have direct equivalence to the level of qualification identified in the AfC job evaluation. Although the course in question is highly respected, and has had wide appeal in the past, NVQ and academic qualifications are designed for different purposes and are not meant to be regarded as interchangeable.
Second, as much of the success of primary care reform is clearly linked to good practice management, it would seem reasonable to assume the NHS would give a high priority to identifying how many practice managers possess the recommended level of qualification set out in the job profile, and how many practice staff are working towards achieving qualifications for entry to the role. Unfortunately this does not seem to be happening at either a national or Strategic Health Authority (SHA) level. Practice management workforce development appears to be a low priority for the shrinking network of NHS workforce development confederations.
Third, education providers need to ensure that they match the level of the courses and programmes they offer to the AfC job evaluation and the NHS skills escalator. Again, this is an area where inconsistency abounds. The National Primary Care Development Team (NPDT) publishes a directory of training and development opportunities that are judged as being suitable for practice managers.(10) The directory maps a range of courses or degree pathways against the four levels of the NHS skills escalator. This mapping suggests that the academic level of many of the management courses currently available do not correspond to the level of qualification identified in the AfC job profiles. Many courses recommended for practitioner level are taught at higher education masters level, and some courses recommended for advanced practitioners are at NVQ level.
Educating the workforce
Despite the publication of a national benchmark for practice management qualifications more than two years ago, professional education in this area remains in a muddle. Practice managers are receiving inconsistent advice from NHS organisations with regard to the availability and appropriateness of training and development programmes, and higher education institutions and education providers continue to offer a portfolio of educational products that are difficult to interpret, and illmatched to need.
There are no magic wands or handsome princes in this tale, but a happy ending is within our grasp if a few simple reforms can be achieved. There is an opportunity here for the relevant professional associations to lobby NHS organisations and educational providers to communicate more effectively, with the aim of developing a wider portfolio of educational products for practice managers.
At present, many of the products on offer are generic management courses repackaged to attract a wider audience, and, as discussed earlier, many of the accredited learning programmes are delivered at the wrong level. In order to redress this anomaly, education providers need to become better acquainted with the knowledge and skills benchmarks for the practice manager's role, and better informed about practice managers' needs in relation to work-related education.
There is a dearth of basic information relating to the educational profile and preferences of practice managers, so it is encouraging that research is currently being conducted by the University of Essex, with a view to broadening our understanding of these preferences.
Finally, practice managers will need to engage in a more robust dialogue with their employers with regard to their professional development. The success of this dialogue will rely in part on practice managers and employers becoming better informed about differences in the framework for NVQ and academic qualifications, and more astute in identifying which types of qualifications will make the most useful contribution to professional growth and the development of the practice and patient services.
Can one size fit all?
Without appearing to parrot the government's "national priorities, local solutions" mantra, I emphatically do not believe in a one-size-fits-all approach to practice manager education, although I do believe there are many advantages in having a widely recognised framework for practice management qualifications, and that appropriate benchmarks now exist for the content and level of educational programmes.
This opens up a plethora of opportunities for the development of a wide range of educational products and programmes that will appeal to the diverse needs of this professional group. Practice management, and the role of the practice manager, may now more than ever before be guided by and evaluated against a set of national standards, but the success of educational and professional development arrangements will continue to rely upon the engagement of local stakeholders, and the quality of local responses.