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Sunday 23 October 2016
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Leader of the pack

The practice manager has a great responsibility in the day-to-day running of a surgery. So it’s no surprise that their skills and knowledge have been snapped up by clinical commissioning groups 

A few years ago I was telling an NHS manager that I was on the governing body of our clinical commissioning group (CCG). Their immediate reaction was: “But you’re not a voting member of the governing body.” I can understand why I got that response. To many people we’re the ones who make sure people turn off the lights, deal with complaints and sort the rota. There are many in the NHS who assume the same: the GPs are the ones making all the decisions; we just make some notes in their meetings and type them up.
I am a fully ‘paid up’ voting member of our governing body, but I don’t quite fit. I’m not a GP, though I take a practice view on things, I’m not an executive officer; but my day job isn’t a million miles from theirs, and I’m not a patient representative. So, what am I doing as a member practice manager for NHS Newark and Sherwood CCG.
When I came to practice management five years ago it was an opportune time; CCGs were just being formed from Practice Based Commissioning (PBCs). I joined a practice that I felt was outward looking and keen for me to get involved more widely. I joined a PBC group (Newark and Sherwood) that had practice managers involved throughout, without the ‘baggage’ of having gone through seemingly endless reconfigurations. My naive optimism and fresh eyes were well received and I was forgiven the ‘stupid’ questions I had to ask at first.
At the very first PBC meeting I attended a group was formed to look at how we would turn a PBC into a CCG. Willingness and the need for practice managers got me on that group. Right from the start, it was almost an assumption that we would have a practice manager on the board. From our forum of 13 practice managers I was elected to represent them.

So, what do I bring?
In some respects my views can be similar to GPs, instinctively thinking about the impact on general practice, though without the clinical expertise. But there are a lot that GPs are generally far less familiar with. It’s not their job to know all the nuts and bolts of their practice. A practice manager can be better placed to understand operational implications for a practice. For example, the reality of bringing together the requirements of Information Governance, the duty of care to share data, the IT challenges and the workload implications for practices.
Specific to my role, I represent the governing body to our practice manager forum and vice versa. Before meetings I try to identify the areas where practice managers are most likely to have input and concern and ask them for their views. There are standing items on the governing body agenda for the elected representative; and for GP representatives to bring matters on behalf of those we represent.
Outside of the formal meetings, I have had input in developing a primary care quality framework; helping the CCG to identify information such as quality outcomes framework (QOF) data and Information Governance toolkit returns; and trying to make sure additional work for practice managers is kept to a minimum.
I also chaired a large multi-organisational committee to commission and embed a new approach to managing patients with long-term conditions. The project was called PRISM (Proactive Risk profiling, Integrated care, Self-Management). It brought together a large number of providers, from secondary care, community, third sector and social care and we commissioned integrated care teams that work together with practices to treat those most at risk of unplanned hospital admissions. This project has since made huge strides in helping to treat people close to their homes and help avoid unnecessary hospital admissions. It is now a key part of a major transformation programme called the Better Together programme.

Extra responsibility
Being on the governing body of our CCG has stretched me personally and professionally but it is an interesting role and professionally beneficial. Helping to oversee a budget of £150 million has been eye opening – particularly learning about the principles of risk management and good governance, alongside the challenges of public engagement and commissioning from a large number of providers. It is a world away from the day job but it has helped me to apply principles. It has kept me at the forefront of the challenges facing the NHS locally and nationally and kept me aware of issues that impact a practice.
As a practice, we’ve always taken the approach that it’s important to be involved in things beyond our four walls, especially when it comes to the CCG. It’s easy to sit on the sidelines and complain about what’s happening, or not happening.
The current clinical commissioning system has given us an opportunity for practices to take a leading role in commissioning and shaping the way healthcare is provided. In Newark and Sherwood CCG, about a third of all GPs are involved in clinical leadership roles. I’ve seen first-hand the way that GPs can keep a governing body focussed on the patient and keep the link between what we think is happening and what’s actually going on with their patients.
As well as being good for me personally, and for our practice, it’s good for our profession. Practice managers aren’t the minute takers and rota organisers anymore.
The modern practice manager has to strategise – thinking beyond the immediate crises and take the long view. We are the ones who need to be leading innovation and development in practice. The caricatured practice manager belongs nowhere near a governing body but the reality of the job we do, and the challenge we’re stepping up to, means the governing body of our CCG is right where we belong. I hope my involvement in our CCG demonstrates this.
I am glad to have the role but when I am wading through hundreds of pages of papers on a Saturday morning in preparation for the next public meeting, it doesn’t feel quite so exciting!
My initial naïve optimism has been confronted by the reality that there is also so much outside of our control. I’m really proud to be part of all that we’ve achieved as a CCG, but there are areas where it is frustrating that despite our best efforts, improvement can often be difficult to see.
It’s the nature of commissioning; you can commission services and support; and challenge providers, but you can’t do the thing itself. It is for that reason I’m glad my day job is still on the provider side; where I can very directly and quickly make improvements for patient care.

So what does the future hold?
Crystal ball gazing is always a tricky sport but in the NHS we can be sure of one thing – it won’t be easy. There will be financial challenges, increasing demand and the whole health and social care community will feel the pressure.
The role of CCGs looks set to evolve. Primary care co-commissioning (CCGs commissioning primary care on behalf of NHS England) and increasing close links with social care presents an opportunity to join all the key elements of the system together in a new way. This is the focus of the Better Together transformation programme in Mid Nottinghamshire. Whole system transformation is essential for the NHS to survive and primary care will play a pivotal role.
As GP practice members, we find ourselves in an interesting position. In the day job we’re running our independent businesses, in the evening we’re looking strategically at how primary care needs to change in the wider transformation. We’re caught between CCGs ‘telling us’ what we need to do (which we don’t like) and struggling to step up to face the challenges ourselves. We can sit back and complain or we can be at the table with the commissioners, shaping the future together.

Matt Doig, practice manager.
This was written when Matt Doig was a member practice manager for NHS Newark and Sherwood CCG. He has since left the practice and the CCG and taken up a new opportunity at another Nottinghamshire practice.