Practice managers have been "completely under-represented" in discussions over the development of clinical commissioning groups (CCGs), a leading Department of Health (DH) figure has said.
Speaking at this week's Management in Practice Event in London (31 August 2011), Dr Jane Povey, a GP and the DH's Director of Clinical Engagement, said CCGs would be "missing a trick if we don't involve you all going forward".
Dr Povey is playing a key role in advising the DH's Commissioning Development Team, led by Dame Barbara Hakin, and is responsible for engaging GPs and other health professionals in implementing the government's commissioning reforms.
She told delegates that "professional engagement" was key to the DH, and added: "I want to be clear that I use the term 'professional', not 'clinical' here", and said that clinical commissioning was about "shared leadership with managers".
"It seems to me that practice management has been completely under-represented in the discussions so far," she said.
"The only way to get your GP to do anything differently from before is to get your practice manager involved. So we're missing a trick if we don't involve you all going forward."
Dr Povey said practice managers "have a huge role to play" in clinical commissioning, by "supporting GPs with their responsibilities. And if those responsibilities are going to be broader, there's even more to do."
However, one delegate accused the DH of paying "lip service" to practice managers, and claimed that the profession was being excluded from real involvement with CCGs.
Liz Reynolds, a practice manager from Surrey, told Dr Povey: "It's all well and good what you're saying, but on our board no manager is allowed to have a vote."
To loud applause from hundreds of assembled delegates, she added: "There are so many managers out there with accountancy backgrounds, management backgrounds, but [the DH] seems to think that clinicians are the only ones who can push this forward."
In response, Dr Povey said: "I very much hope that's not the attitude that's come across, but I understand what you're saying: that you want to see the action, not just the rhetoric."
She told delegates that the "bottom-up" reforms meant that the DH was not responsible for "deciding who is and isn't involved in CCGs" and added that the Future Forum report and the subsequent DH response had strengthened the need for GPs on CCGs to work more collaboratively with other professionals.
Dr Povey said: "I agree with you in that practice managers need to be involved and anyone would be missing a trick not to involve you more."
However, she sought feedback from delegates and other practice managers "to understand what you think would make a difference in the context of where we've got to with the proposed policy, what we can do to enable practice managers to be most effectively used and [whether] there's something around the strength of [having] a network, rather than you all fighting your corner locally."
She had earlier told delegates that input from practice managers is being sought by the DH-supported Clinical Commissioning Community (see below).
At a Question Time-style panel session later on, debate returned to the subject of practice managers' involvement with clinical commissioning groups.
David Sheppard, a managing partner of a practice in Cornwall, said it was "a travesty" there is not a formal requirement for a practice manager to be on CCG boards.
"I think it's insulting to our profession," he said. "I can't understand it, and it should change."
Another delegate, a practice manager from Essex, said that he felt so disengaged from CCGs and the direction of travel that he was considering leaving the profession. "It's become too much," he said.
The Clinical Commissioning Community is a resource, supported by the DH, set up to enable frontline clinicians and managers to share information and support. The Community is looking for practice managers prepared to be 'willing champions' to share their views and input as local commissioning groups develop.
If you would be interested in sharing your input with this group please email firstname.lastname@example.org and Management in Practice will pass on your details.
Clinical Commissioning Community
Your comments (terms and conditions apply):
"Definitely! There are two of us on our leadership group and I am now going forward hopefully for appointment onto the shadow board. We have been instrumental in working towards a new primary care offer, a LES for shared care, reshaping patient transport services and so much more. We are the ones who do the gap analyses for the clinicians on the board, and often point out what to us is obvious but what has been overlooked in planning and strategy. We are the link to other practices and key players in communication and engagement" – Val Denton, Weston Super Mare
"'High managerialism' took hold in PCTs and acute trusts across the country in the 1990s, with clinicians pushed to the sidelines. Further fuelled by political spin and the media, the medical profession has long since lost trust in management. The best judge of GPs' attitude to management is to be found in their own back yards: their surgeries. The salaries of the most senior manager 'trusted' by GPs to 'manage' their own practices, their Practice Manager, is about £40k a year. That's about a 1/3rd of what a full-time partner might earn. It hardly suggests that GPs place great value on or confidence in the role of managers. Surely if GPs already believed that they needed managers with the very best skills, experience and qualifications, they would have already recruited to lead and develop their own businesses. Average salaries would be higher to attract highly qualified staff. Practice Manager Partners would be much more commonplace in practices, if GPs thought it was important. CCG boards have been constituted entirely from GP partners in what was described recently to me by a CCG chair as a "cosy gents club". The same CCG chair that said "we won't be doing HR" suggesting that any task they say as 'management' was not important and they just wanted to keep the "fun things". They are unlikely to have an epiphany which recognises that CCGs won't work without high quality managers working alongside clinicians them as respected and trusted professionals. GPs' experiences of managers at the PCTs and at acute trusts have long been mired in suspicion. The SHA and PCT demise is not seen as a concern by many GPs. It is still seen by many GPs as a good thing, without realising the pain and responsibility of running a large organisation coming their way soon. This also gives a problem for Practice Managers as the CCGs' need for professional management is not the same as needing practice manager representation on CCG boards. The term management is hopeless in describing the range and differences in the quality of people fulfilling the role of manager. The role is far less heterogeneous than that of a doctor. A doctor is a clear stamp of professional credibility, universally respected by all. Managers of all flavours still have much to do to achieve this level of respect. It is not Practice Managers per se that should be represented on boards but effective and skilled managers. Progressive, professional managers have a big responsibility to help lead others through the changes ahead. GPs should listen to the cacophany and wise up quickly to value of professional managers" – David McBride, Lancashire
"Of course practice managers should be involved. GPs don't always understand the business implications of change and it usually then falls to PMs to try and make impossible ideas work. If we were there when decisions were made and able to influence decisions at least we would be working on projects that are more likely to be successful" – C McRae, North West
"It is vital that there is practice management representation with voting rights on the CCG Boards. Many decisions made by clinicians do not take into account the practicalities of the work impact and feasibility within practices or the effect this can have not only on patient care but on the business as a whole, and particularly finances. We all know that general practitioners are the gatekeepers to the NHS and we must ensure, particularly with the tightening of the financial belt, that practices remain financially viable and able to cope with the ever increasing workload on practices. It is right that Quality in general practice is a key element of the NHS reforms and practices need to be in a good position to develop and improve services for their patients" – June Conklin, Southampton
"I cannot understand why they have excluded Practice Managers. We could lead on and undertake many of the managers roles that were previously done by Managers within the PCT's. They could easily support and train us up to undertake these roles, the GP's cannot undertake everything otherwise who will see the sick?" – Annie Jones, Barnet
"Just as there are GPs with different levels of financial and managerial skills, there are practice managers with different levels of these skills. It stands to reason that more PMs will have these skills than GPs and therefore by not having PMs on the CCG boards there will be a lot of valuable input lost. It is long overdue to give PMs the recognition and responsibilities that corresponds to the reasons that the position exists in the first place" – Dean Thompson, London
"Yes, GPs whilst excellent in medical fields, seem to be unable to look at the bigger picture and not aware of how much work a manager takes on board on their behalf. We are already receiving less and less support for the PCTs due to lack of staffing levels" – Janet Scott, Bolton
"All practices, differently resourced, must have a choice to send clinician or practice manager or both, to sit on board, as and when this suits individual circumstances of a practice" – Mohammad Rafiq, Boleyn Road Practice
"It appears that as usual Practice Management has been ignored as a potential source of extensive experience and knowledge. In our local area, the value of PMs' contributions has been recognised and for many years we have had PM representation on most of the important subcommittees and boards. However, if the structure of the CCG Boards is prescriptive, we are likely to be excluded from this vitally important forum. This would be a significant retrograde step and one which I am sure the establishment will in time regret. PMs bring with them a different perspective and skills set which I believe are vital to the success of the CCG Boards" – Jan Harley-Doyle, London
"If people were thinking there would be no need for a formal requirement it would have happened already. I am fortunate in the consortia which we belong to there is an almost even split in numbers and in project leaders. I do find that many many people have no idea what practice managers do in fact I am not sure many people know we exist let alone what we are capable of!" – Name and address withheld
"Practice managers are key when implementing change in general practice and nothing really happens without them being involved in the decision making process. It's only common sense that a Practice Manager should be involved
on the CCG boards" – Maxine Simmonds, Coventry
"If Commissioning Groups do not include a PM from the outset they will quickly realise that there is a gaping hole in their structure. Groups with foresight seem to be engaging PMs in the decisions being made on operational issues and to some extent strategic matters. It is a time of uncertainty and I expect that the experience that GPs leading the process have of PMs will significantly influence their decisions about how they are included. The departure of PCT staff will soon be a wake-up call to those who think that they can manage alone" – Name and address withheld
"Most definitely! In most practices it is the PM who is the pivotal point around which everything happens and usually is the person who understands the full picture and has a grasp of the business as a whole" – John Wilkin, East Sussex
"Yes, without us surely boards cannot effectively work. Our current PCT has two (myself one) at board level meetings as it was and is important for us to help shape the future of general practice in the City" – Frank Hunter, Leicester
"Absolutely. Ours is very enlightened - there are 2 of us in the executive board and there are only 7 members in total!" - Jeannie Bee, Lincolnshire