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Thursday 29 September 2016
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Room at the top?

Feature: Commissioning

As clinical commissioning groups get off the ground in England, many practice managers are taking up positions on the executive boards – while others feel they have been ignored. Stuart Gidden reports…

Practice clusters in England are now, at the least, taking tentative steps to establishing new clinical commissioning groups (CCGs). The name is a rebranding of 'GP commissioning consortia' to reflect the inclusion of other healthcare professions, including hospital clinicians and, yes, managers.

This has highlighted wider arguments over who exactly should sit on CCG boards and why; arguments increasingly being conducted as CCGs start to move away from their 'shadow' status and executive members are elected or appointed.

A recent Health Service Journal (HSJ) investigation revealed that in 51 of the 335 emerging CCGs in England, GPs and practice managers dominated the boards.(1) Two thirds of these CCGs have at least one practice manager on their boards.

The HSJ report suggested patients and secondary care clinicians were being "excluded from the closed shop" of CCGs. However, feedback from MiP readers suggests that, far from having a role on the shop floor, many practice managers feel precisely the same sense of exclusion as those hospital medics.

In a recent MiP online survey, 41% of practice managers in England felt they had been "overlooked" by CCGs, on top of 31% who said that while some practice managers had been approached, this wasn't enough. At the MiP Manchester Event in June, a significant proportion of delegates expressed anger at being excluded from commissioning involvement – "there's a feeling from our GPs that a practice manager's place is back in the surgery, not in consortia," Dr Steve Bradder, Practice Director of Holywell Medical Group in Derbyshire, told delegates.

"There is no indication that practice managers will be allowed to join the CCG board," says Dr Bradder. "Turning down offers of assistance from myself and other practice managers and using excuses like 'it is a clinical group' – even though patients and local authority reps are involved – can only lead one to the conclusion that there is a reluctance to include practice managers."

Variation in uptake
David Shaw, Practice Manager of Marden Medical Centre in Kent, also believes his local commissioning group has overlooked his profession's potential input. "They've explicitly said there's no room for practice managers on the board," he says.

In Yorkshire, Mike Robinson, manager of Rotherham Road Practice, voices a similar experience. "We're not involved at all as practice managers," he says. "We were told by the primary care trust (PCT) that it could only be GPs who would be sitting on the board."

By contrast, at a CCG in Gateshead responsible for 210,000 patients, three out of nine elected board members are practice managers. As one of those board members, and the executive lead for practice development, Val Hampsey has a significant role on the CCG in overseeing its 34 practices' information, training and development requirements.

"The culture of Gateshead is very collaborative," says Mrs Hempsey. "All practices were in the same practice-based commissioning (PBC) group and are now in the same consortium."

But while she is used to taking a leading role in commissioning, she admits being at times bemused by different attitudes she finds elsewhere. "I think boards that do not include practice managers will struggle to deal with some of the key issues they are uniquely placed to deal with – for example, information, data, communications and patient and public involvement. I attend meetings across the country with a varied mix of professionals present, and am always pleased by the impact practice managers have – so I'm nonplussed when practice managers from other areas are not invited."

System evolution?
Of course, it's to be expected that CCGs will vary in make-up across different areas of the country. What's interesting is that, like Mrs Hempsey, Messrs Shaw and Robinson were both heavily involved in PBC consortia. But unlike in Gateshead they have not seen any continuity in their roles when moving to CCGs.

"I've been saying since PBC that this is joined-up thinking, we need to forget the employer-employee remit at this level," says Mr Shaw. Pre-PBC he was actively involved on the board of a 23-practice fundholding consortia in London.

Mr Robinson was the chair and managerial lead of Barnsley PBC consortia. He is dismayed this experience has not been aligned with the new structure. "We had a very good system in PBC and that should have been used as the catalyst. Practice managers have a valuable contribution to make, particularly those that took the lead with PBC," he says.

By contrast Jacqui Tonge, Practice Manager of Abbey Medical Centre in northwest London, who is an elected board member of her newly formed CCG representing 49 practices across the Camden area, says PBC was "a bit of a non-starter here". She now finds herself far more empowered.

With more than 20 members on the previous PBC board, she says it was difficult for her voice to be heard on occasion. The new CCG board, on the other hand, consists of herself, seven GPs, a nurse, and public health and patient representatives. "It's much smaller and you are expected to contribute, you are expected to have a voice," she says.

Value added
Clearly CCGs with practice managers at board level are benefiting from their experience. In Northamptonshire, the Nene Commissioning group covers 71 practices serving a population of 625,000. The group, which has a track record of commissioning new and improved health services since its establishment under PBC in 2007, has two practice managers on a board of seven.

Jo Kiely, Practice Director of Burton Latimer Medical Centre outside Northampton, is Nene Commissioning Group's Director for Public and Practice Engagement. She says CCGs not using their practice managers' experience are "definitely missing a trick because practice managers bring a different perspective. They often bring a sort of 'reality check' in terms of the ideas that come from GPs as they have a business perspective of what that idea will actually mean to a practice."

Rebecca Thornley, Associate Director of Primary Care Commissioning, echoes this view. "Practice managers encourage GPs to look at the bigger picture for business growth and market competition – often actively encouraging clinical leaders within their teams to branch out and look for opportunities to shape services and look at improved models of care."

Ms Thornley says practice managers are "essential" to clinical commissioning success: "They have strategic insight into the needs of their practice populations, strong awareness of how services can be moved out of hospital successfully and should be actively engaged with patient participation."

Indeed, primary care trainer Wendy Garcarz argues that it is particularly in the area of achieving cost reductions through the movement of acute care into community settings where practice managers' "real business acumen" can play a crucial role.

"Option appraisals, cost benefit analysis and business cases will be needed to justify such shifts and many practice managers have excellent track records in producing these documents for investors and bank managers – not just PCT tick-box templates," she says.

Furthermore, Mrs Hempsey believes CCGs are making a costly error if they neglect practice managers' talents. "What they will have to do is buy in that sort of expertise from outside, and it's going to cost mega money," she says. "Why bother when you can get a lot of that expertise within their own practices?"

The varied nature of practice management can be something of a double-edged sword – Ms Garcarz says there is "still too much variation in the competence and capability of many practice managers to carry any real weight with key policymakers" when it comes to arguing for the profession's place on CCG boards.

At the same time, as many practice managers come from other business backgrounds, this can be invaluable to consortia. Ms Kiely was previously a PCT associate director: "Another practice manager on the board has a background in corporate issues and setting up businesses, so we both had additional skills that we brought," she says.

The be all and end all?
While practice management involvement with CCGs is clearly desired and valued, is it really so important to be on the board? Healthcare leaders from all sides believe that board-level involvement has been overstated.

Professor Steve Field, NHS Future Forum Chair, told MiP: "During the listening exercise, everyone we met seemed to want to be on the commissioning board, and everyone seemed to feel left out. But it's not just about being on the board, it's about facilitating networks and the leadership role within each practice." (See interview this issue).

Dr Laurence Buckman, Chair of the BMA's GPs' Committee, even argues that being on the board means having less influence than advising it. "I don't think there's any need for practice managers to be on the board," he says. "The board is a very small organisation there to oversee the governance arrangements for the commissioning group. You need very few people on the board."

He adds: "You need to have practice managers involved in the decision-making process. But the interest everyone has in being on the board… 'If you're not on the board, you're nobody' – actually the board is merely a governance structure, it's the people below that that matter."

Mrs Hempsey agrees in principle with this viewpoint, despite considering this reductive view of the board "rather patronising… but, yes, the executive board makes sure things happen, but actually where it happens is in the practices," she says.

Echoing Ms Tonge's earlier view that smaller boards work more effectively, Ms Kiely says the "immediate thought" of interested parties that "we must try and get ourselves a place on the board" is simply not practical. "You can't have lots and lots of different representatives on one board," she says. "It's got to be of a size that's focused and functional, and you can't include everybody in that."

On the other hand, Ms Garcarz argues that past healthcare history suggests boards have a "significant powerbase" where decisions affecting practice managers will be made. If, she says, the profession does not have a presence at board-level, "my fear is that practice managers will be given a lot of the leg work, data analysis and planning detail to do but the real decisions will be taken in an arena that they will not be party to."

Of course, CCGs have a far greater role than playing host to all interested parties. As Ms Thornley says: "Boards certainly won't make many decisions if they spend all their time worrying about who sits on them.

"Seats on the board are not there to reward professional factions or to create a patronising model of inclusiveness. If a practice manager has the vision and the personal qualities to win a place at the table, that's great. If they are better deployed in an operational role closer to the coalface, that's just as good," she says. "My personal view is that most boards would benefit from having a practice manager on them, but I would never want to make it mandatory."

Risks of disengagement
Indeed, while some express an appetite for a formal requirement for practice managers to sit on CCG boards, this doesn't seem a view shared by those who remain supportive of practice management presence. Lynne Jones, a practice manager from Oxfordshire, says, this would be "a step too far".

While not on a CCG board herself, she says she is happy to be represented by a fellow practice manager who has been elected by the countywide practice managers' committee to be an interim board member prior to a formal election. Six locality groups, run by GPs and practice managers, feed back to lead representatives on the board. In this way, she says, the CCG gets "a practice manager viewpoint on what is happening at board level."

Ms Kiely's CCG in Northamptonshire also operates in localities. "There's many different ways practice managers can be involved and obviously it depends on how the CCG is structured," she says. "There's opportunities for managers to get involved at locality level as well as at board level."

The real issue, it would seem, is not whether practice managers have a role on their CCG board, but around the disengagement that could occur if their involvement is not sought early on. If CCGs are the new PCTs, Mr Shaw worries that history could repeat itself. "For years general practice in this area has had this 'them and us' with the local PCT," he says. "I feel by starting off in this way we're going to see the same approach [with CCGs], which I feel won't work."

Dr Bradder says he is already seeing such "divisions" in his CCG, and that "without a good deal of transparency and honesty, and inclusion not only of practice managers but also of others involved in primary care, those divisions could become chasms."

He is sceptical about how this will pan out. "What is potentially treatable now may become terminal very quickly. It will not only be a 'them and us' attitude but possibly an attitude of positive unco-operativeness."

Ms Jones, however, remains upbeat that the profession's value will ultimately be acknowledged. "Even if people don't recognise upfront that practice managers are necessary, they will come round to that view," she says. "They will realise they need that input." 

Reference
Lewis S. Consortium boards are 'closed shop'. HSJ; April 2011: p. 4-5.