General practice will not remain “the jewel in the crown of
the National Health Service”, as it is often described, without
change. Indeed, given the onslaught of criticism directed at
this health sector by the media in recent times, it might appear that it has already
lost much of its sparkle and will soon be neither fit for
purpose nor sustainable.
The need for change was set out by NHS England in its March 2014 report, Improving General Practice - A Call to Action ( NHS 2 014). T he d rivers w ere identified as an ageing population, growing co-morbidities and increasing patient expectations, resulting in a large increase in consultations; increasing pressure on NHS financial resources, which will intensify further from 2015/16; growing dissatisfaction with access to services; and persistent inequalities in access and quality of primary care.
The argument for providing more personalised, accessible community-based services for patients to help improve community health and reduce avoidable pressures on hospital resources has been persuasively made, and the challenges faced in making this vision a reality widely acknowledged. It is currently high on the political agenda. But one of the many questions that remains unanswered is this: how engaged and supported are the workforce who will help deliver the new agenda?
The GP recruitment crisis has hit the headlines with increasing regularity over the past two years. In phase 1 of Call to Action, NHS England pointed out that while the numbers of full-time equivalent GPs had increased over the past ten years, the GP workforce had grown at only half the rate as other medical specialties and had not kept up with population growth.
Practice managers’ focus group, conducted by the IHM
Furthermore, a gradual increase in the proportion of GPs working part-time was creating longer-term sustainability pressures: the peak age band for female GPs leaving the workforce then was 35-39 years, whereas the peak a geb and for males leaving was 55-59 years. Within the wider general practice workforce there had been only a marginal increase in the number of practice nurses.
What was missing from this analysis was recognition of the difficulties also being faced in recruiting a significant group of people working in GP practices: the practice managers.
The role of the practice manager has never been more important. Their responsibilities, covering practice development and clinical governance, managing partnership issues, managing finance of the practice, patient and community services and human resources, put them at the centre of ensuring a quality primary care experience for patients.
In summer 2013 a survey of 471 practice managers under taken by recruitment agency First Practice Management (2013) revealed that a high percentage of practice managers were considering a new career. The survey found that 44% had already considered applying for a new job, 65% of whom said they would be seeking out a new career. Over two-thirds (68%) of the practice managers surveyed said they were feeling demotivated.
More than one in five of the managers surveyed cited workload as their biggest concern, with the remainder citing “ too much change”, “ a lack o f support” and “too much bureaucracy”.
Over the past year the Institute of Healthcare Management (IHM) has been running a series of focus groups with practice managers across England, and has found the situation largely unchanged. Perhaps unsurprisingly the results show that the main issue impacting on GPs - overwork – is also having a marked effect on practice managers’ job satisfaction and commitment to stay in this area of healthcare management.
As one practice manager put it: “In other organisations, HR, finance, premises management etc. would all be separate departments but we have to be ‘jacks of all trades’. It’s hugely difficult to keep abreast of all the changes – payroll developments such as real time monitoring; structural changes to finance and how payments are made; and developments in IT, which are supposed to help but often hinder us - to name but a few. Many of us are now working 12-hour days and at weekends. A decent work/ life balance is simply unachievable.”
Another said: “Historically general practice has been good at getting a lot done for less and that’s how we’ve shot ourselves in the foot. The government thinks we can deliver so much with so little. There has been a lot of goodwill around with doctors, nurses, practice managers and other staff all chipping in and doing extra. But if people are not enjoying their job, that goodwill diminishes - and it has.”
Among other common problems identified by focus group participants was a lack of understanding from NHS England “about what primary care really do” - the relationship between the two was described by many as “dysfunctional at best”; lack of leadership and/or support from the gP partners; demoralising attacks from the media; and lack of time or opportunities for training.
Perhaps most dispiriting was the perceived impact on patient experience. Time constraints, practice managers reported, meant that they had fewer opportunities to build relationships with patients.
The good news is that overall satisfaction with general practice services remains high – 86 percent of respondents to the GP Patient Survey (Ipsos MORI 2013) say that their overall experience is good or very good. However, the Care Quality Commission (CQC) points to the Chief Inspector of general Practice’s comments in December 2013 that there is a “small minority” of practices where there are serious failings in the provision of care, notably around access (NHS England 2014). A quarter of patients did not rate the overall experience of making an appointment as “good”; 26 percent of people did not find it easy t o g et through to the surgery by telephone, and this figure varied from 8 percent to 48 percent in different parts of the country (NHS England 2014).
So inspection of gP practices is now under way and the pressures on practice managers continue to build.
IHM is responding to the need for greater training opportunities to meet the challenges head on. Its starting point is a pilot programme for practice managers, run in partnership with the Primary Care Development Centre in Nottinghamshire. The programme has been developed from the Institute’s successful Vocational Training Scheme for practice managers in Scotland and the previous practice management programme in England.
The 14-week , blended learning model is designed to provide practice managers and aspiring practice managers with the essential skills and behaviours required to manage and deliver a great service. The programme is underpinned by the IHM Professional Practice Framework, and covers topics including managing finance, setting budgets, systems for funding health and social care, delivering the service, business and service planning, managing teams and team performance.
The programme will give practice managers a firm foundation o f management skills and knowledge, which will enable them to support and sustain the delivery of high-quality healthcare services, demonstrating an awareness of current and emerging trends in healthcare and the importance of incorporating the needs of patients in service design and delivery.
There is a clear need for more programmes and initiatives like this if practice managers across the country are to be expected to carry forward the vision of improved, extended and sustainable primary care services. They are the lynchpin of the complex health system and deserve more recognition and support for their efforts.
- Overall satisfaction with general practice services remains high, but there are increasing problems around access.
- GP practices lie at the hear t of a new vision of improved, ex tended and sustainable healthcare services.
- Recruitment of both GPs and practice managers looms large as workloads increase.
- Practice managers of ten feel disenfranchised and overwhelmed by change.
- More training and suppor t needs to be available to practice managers to help them face the challenges ahead.