DPhil BM BCh DRCOG
A late entrant to medicine, Judith has tackled everything from
teaching in a comprehensive school in Liverpool to running a volunteer programme in PNG before she trained in medicine. She was a partner in a semirural Home Counties practice for 10 years and has been a sessional GP in inner London since 2001. Judith has contributed to the Handbook of Practice Management since 2001, and is also involved in working to help clinicians and nonclinicians find ways of involving patients that benefit both sides
To GPs, finding the ideal practice manager is a bit like finding a spouse. They wade through a pile of CVs, keeping their spirits up by promising themselves that one will describe their perfect, flawless ideal. Right up to the shortlisting, hope triumphs over experience. Only when they have interviewed a number of well-qualified candidates, who are normal human beings, are they forced to face the fact that no one person can meet their ideal.
Perhaps the best way to work out what doctors particularly want from their new practice manager is to find out what they thought of the previous one. Do they want a carbon copy of a paragon who was apparently strong in every aspect of the job, or is their overriding concern that the next manager should excel in areas where their predecessor was weak?
The job description may tell a story. One that has been carefully written, with levels of skill and responsibility clearly defined, suggests that the GPs have thought about what they want. If there is a strong emphasis on particular aspects of the job, who is meeting the other needs? Or have they been overlooked because the partners are so desperate to make sure that their next practice manager can keep track of finances that they have forgotten there is no one left in the practice who understands the computer system?
The General Medical Services (GMS) 2004 contract competency framework dissects the huge number of tasks expected of a practice manager and analyses the administrative, managerial and strategic aspects of each. If the partners don't produce the framework, a manager should, to establish a clear idea of which competences are most important to the doctors, at what level of operation. Since there is no one on earth who could meet every competency, it is also important to know who is filling the roles the practice manager cannot or is not expected to play, and how that person fits into the hierarchy. If the doctors cannot decide, a future manager is on a hiding to nothing.
Whatever else GPs may want, they will all have a vision of a practice that runs like clockwork, with satisfied patients who arrive on time and don't vomit or make racist remarks in the waiting room; happy staff who always go the extra mile and give up their free time to run audits; nurses who remember every jab and smear; a computer that never, ever, runs slowly; and profits that warm the heart. It isn't realistic, and they know it, but hope helps them get up each morning.
A few doctors will still be looking for no more than a competent administrator. Even if the job title is misleading, the salary won't be. But even in very small practices, the burdens of modern contracts are such that most GPs will be looking for someone to take a strategic role. They want to be able to concentrate on their primary role of seeing patients. And there are ever more patients wanting to be seen.
But the old tasks do not go away. Computer systems may be more reliable but, like people, they are usually promoted up to their level of incompetence. Who has redundant computer capacity for more than a few months after a major upgrade?
In the increasingly common paper-light practices, patient care comes to a stop if clinicians can't access the notes or print a prescription from their terminal. But GPs need to understand that, if it is the practice manager who is being called down to sort out the computer every time someone presses the wrong key, he or she will be unable to concentrate on strategic tasks that require uninterrupted thought.
Do all the partners want the same things from their manager? Probably not: for each doctor the emphasis on different aspects of the job will depend on their own skills and interests, or lack of them. But are partners' expectations mutually contradictory? The battlefield here is likely to be over the manager's level of responsibility. The manager may be caught in a power struggle between partners who have different ideas about the future of their practice. One scenario is the practice with one very strong GP whose partners have a rather different philosophy but find that even in an apparently democratic decision-making structure they cannot influence practice policy. Pity the practice manager who discovers he or she is a pawn in that game.
Nevertheless, even in the most unified teams, managers have a role in negotiating between partners and ensuring consistent behaviour. For instance, one partner doesn't charge nice Mrs Jones for a private letter; others forget to enter in the electronic notes when they give a flu jab. Given the importance of standardised use of Read codes for earning QOF points, most GPs allow themselves to be led, bullied, or even named and shamed, over computer entries. Addressing the more personal foibles is the real challenge.
The new GMS contract promised an end to bean counting. The reality is that there is a whole new range of beans to count, and many of them are clinical. A clinical background is not essential for the person managing this part of the contract, but it certainly helps to understand what the clinical indicators mean in practice, especially when it comes to the difficult business of balancing the collection of points that earn good money with points that reflect the sort of care doctors feel is important.
Understanding the staff
Practice managers need to understand how the history of the organisation has influenced its present-day culture. If GPs feel helpless to change a long-established but unhelpful pattern of behaviour – reception staff for whom the workplace is a therapy centre, for example – a new manager will be called on to do the job. The support of the doctors in breaking up unprofessional cosy habits is essential.
For GPs do have cosy habits, and they often revolve around time off. If Dr Jones is now a grandfather but still expects three weeks off in August, the practice manager is usually the person who has to bite the bullet and get the partners to negotiate a system of priorities so that those with children at school get a fair chance of being on leave when their families are. Perhaps Dr Jones is unaware of the wonderful birdwatching in South Africa in October?
Another similarity between practice managers and GPs' spouses is that they can both share the role of being a back-up memory. In a world in which GPs are involved in activities outside the practice, whether it be childcare, tree surgery or exercising their special interest in transplant surgery or eczema, practice managers are increasingly often the only fulltime member of the primary healthcare team, and ensuring continuity and handover is crucial. But doctors should not think it extends to remembering their appointments, obligations and anniversaries for them.
Consultants have been at war with hospital managers for years. GPs have not – yet – been dragged into the heat of the battle between clinical and financial imperatives. The day when a practice was a cosy family may have gone, but most people who manage a practice see enough of the waiting room and the patients to remember what the business is there for. Doctors and practice managers share the struggle to provide the sort of service that meets patients' real needs. Perhaps, more than anything else, GPs want to preserve this sense of common purpose.