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Thursday 27 October 2016
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Leader of the pack

It’s important to outline a strategy for management and leadership skills in order for a practice team to thrive

Following the passing of the Health and Social Care Act 2012, general practice needs to consider its capacity and capability to respond to the intended transfer of many services from secondary care into the community. This transfer requires the business leaders within general practice to refocus their strategies as both independent contracted organisations, and as members of clinical commissioning groups (CCG).
To explore this need further, this article looks through a ‘competencies and values’ theoretical lens, at how general practice leadership teams can apply their business management and leadership skills, and how education is used to support their business related development.

General practice clinical leadership has been well documented in terms of clinical service redevelopment; however there appears to be few studies relating specifically to general practice, business management and leadership skills.

Traditionally, general practice management has taken the form of organisational administrators, with strategic support coming from UK government bodies such as health authorities (HAs) and primary care trusts (PCTs) with little change since the inception of the NHS in 1948. Since the abolition of PCTs, general practices have had to up their game managerially, and ensure they have appropriate in-house capabilities for meeting strategic needs. This appears to be evolving in two forms:

  • General practitioners are either taking strategic management responsibilities of their organisation themselves or through the buying in of strategic business managers from a provider perspective.
  • While CCGs are taking responsibility for redefining strategy from a commissioning perspective across the wider primary care sector.

Meanwhile, current GP training focuses predominantly on clinical skills and not covering to any extent business management, arguably leaving GPs under qualified to meet the demands of the Act, there remains a considerable need for business managers to take control of primary care organisations.

Subject to these recent NHS reforms, general practice must work differently, starting by looking at the exposed gaps in the different business models applied to primary healthcare organisations and in terms of changing from an independent contractor to a federation. The skill set required to lead these organisations must also be developed. By raising awareness about, and implementing a management and leadership qualities framework (as seen in Table 1) in relation to an organisational/educational strategy, individuals can be mapped against their existing skills. That will therefore identify those skills unaccounted for, which could then be used to target educational development plans. In addition, the leadership team may choose to map themselves to a qualities framework to aid in their personal development plans.

Primary care management
The role of general practice has developed quite considerably in its 67 years where most importantly in 2004, following the agreement by the British Medical Association (BMA) to the new General Medical Services (GMS) contract that relieved general practitioners of their duty to offer 24-hour care to their registered patients by introducing out of hours (OOH) services while also offering GPs additional income based upon the Quality Outcomes Framework (QOF).

However, in return the new GMS contract lays out strict organisational expectations that includes the close monitoring of staff roles, of which practice management is noted as being “a critically important function”. The new GMS contract continues with the following statement: “Practice managers will have an increasingly important role as they become the experts in the operation of the new contract, including all the new mechanisms outlined in this guidance.”

Clearly this puts practice management at the top of primary care organisations, and heavily involved in any future strategic developments. It can be argued that this suggests that central government aims to increase its hold over GPs’ powers through such managerialist initiatives; however, paradoxically, managers are increasing their influence in the NHS albeit to increased criticism from the general public; suggesting the focus of the NHS is moving from clinical to administrative.

In terms of director level competencies, it is possible to identify, categorise and prioritise the competencies that directors require to be more effective in their roles. In the context of director level competencies (senior GP leaders), there are a number of key competencies that relate to the distinction between management and direction, which should be considered in conjunction with the responsibilities of directors as set out in the Companies Act 2006.

The guide, Good Practice for Directors – Standards for the Board (Institute of Directors, 1995) shows a number of attributes required by a competent manager/director. These have been categorised into six headings: achievement of results, analysis/information management, communication, decision making, interaction with others and strategic perception.

It is suggested that competency development should contain an overall narrative definition, plus three to six explicit ways to exhibit the competency within the organisation. In order to be useful, competency models should provide specific behaviours the individual needs to emulate, as well as offering an explanation of the expected business outcomes and benefits produced by that competency. It could also be argued that organisations need to know what competencies to target before they can develop, implement, and evaluate appropriate training programmes designed to augment those competencies.

Existing and emerging GP leaders and managers must recognise the importance of values in terms of how they relate to the delivery of primary healthcare and how it relates to those emerging primary healthcare organisations from both an individual and organisational perspective. Leaders and managers should pay particular attention to how values affect patient care during current financial austerity, rate of change, and quality improvement.

The book Tribal Leadership, by David Logan, John King and Halee Fischer-Wright, describes shared values at stage five, as being the pinnacle of all tribal stages, where the whole tribe have come together based upon their values and with a shared aim to achieve their ultimate cause. These shared values can empower relationships between providers and commissioners and between related professions, leading to an advancement of priorities beyond politics and morals towards shared goals and strategies.

Qualities framework
The qualities required of leaders related to general practice are complicated and fraught with conflict. As ‘providers’ of healthcare, general practices must demonstrate the ability to offer high-quality healthcare to their patients, while the qualities required as members of the CCG, in terms of ‘commissioners’ of those services, must demonstrate efficiency and value for money. Importantly, it is required at all times that they must show due diligence in relation to conflicts of interest.

It can be surmised that general practice leaders see the need to hold business skills within their own organisations as necessary, but see the need to hold these same skills for their membership of the CCG as unnecessarily imposed. However, in order to help understand these needs a qualities framework seen in Table 1 below can be used as an example of how to aid general practice leaders in their planning of ‘qualities’ attainment applied to either role.

A set of competencies should support each domain in relation to each quality, where an individual can rate themselves as basic, intermediate or advanced for each within that scorecard. By totting up the number of competencies the overall rating of that quality, and should be recorded on the framework.

From this graphical scorecard it can easily be seen which qualities require further development.

If primary care leaders adopt the use of educational frameworks such as that seen in Table 1 then they can be assured that they will be best placed to attain success; whatever that may be.

Colin Tate is a director at Primary Care Manchester Ltd.