Practice Managers: Jack of All Trades or Masters of Many?

Article by Andy Briggs, Managing Partner

If we jump into our time machine and nip back to 1950 to visit a GP, we will likely come across a male GP working from their home supported by their wife who worked as a receptionist, assistant and anything else that was needed – that might explain the basis for your job description!

OK, that’s a huge generalisation, but practice managers, as a role, didn’t exist.

The Royal College of General Practitioners wasn’t formed until 1952. GPs were initially simply paid capitation fees. It wasn’t until 1966 that new terms of service, 'the family doctor charter', were agreed.

The charter bought about changes in the way GPs were paid under a system that became known as the “red book”. The red book enabled GPs to claim up to 70% of the cost of ancillary staff plus 100% of premises costs.

GPs who took on the care of patients outside of core hours were paid additional fees. The charter was a turning point for general practice allowing GPs to improve their premises, employ staff and come together to form partnerships. This change, little more than fifty years ago, created the seedbed from which today’s practice manager role grew.

The introduction of general practice fundholding (GPFH) in 1990 required organisational and inter-organisational management at a higher level. IT wasn’t very prevalent.

When I joined my practice in 1993, computers were “dumb terminals” used mainly for prescribing and repeat prescriptions. Patient notes were still handwritten and lists of patients awaiting operations were based on T-cards. IT crept in and two systems ran side-by-side for many years.

Claims for reimbursement and items of service were paper-based requiring capable systems to capture the activity and process the paper forms for payment. Once payment was received the payments would be reconciled against the claims.

GPFH and increasing organisational complexity saw more managers being recruited. Many developed from existing administrative staff, hospital administrators, ex-forces or bankers, some were nurses. The breadth of background and experience within a group of practice managers has always appeared to be an immense strength.

For many, the role of practice manager was “a Jack/Jackie of all trades”. The speed at which the role of practice manager changed has been at the same pace as the changes to the NHS and the increasing expectations of patients. General practices range hugely in size and configuration resulting in an equally diverse

management requirement. In some practices the GPs are "visionary" requiring a very operational manager; in practices where the GPs are “hands off” the role may be both operational and strategic, but they all face very similar challenges. Managers in smaller practices may be more diverse than those in larger practices where multiple managers might share the diversity of work allowing for a degree of specialisation.

Practice management has grown massively since the days when the need was simply to ensure reimbursement was claimed for and received. The breadth of tasks continues to increase as general practice develops.

Over the past few years, there have been incentives for practices to work together, this is now formalised with the development of Primary Care Networks (PCNs). Managers now find that their complex role leading and motivating teams needs to be applied across several practices that often have different cultures and, sometimes, different motivations.

So, we agree that a practice manager’s role covers a wide range of tasks requiring many different skills. While many other jobs have equally broad requirements, I believe that the uniqueness of practice management is in the accountability and consequences for their actions.

To precis a famous quote – 'Any fool can make things more complex, it takes a touch of genius to make it simpler' and that’s the purpose of these support organisations.

Managers may be employed, partners or directors, but I have found that responsibility and accountability often sit on their shoulders alone. It’s not good enough to be a “Jack/Jackie of all trades” because the consequences of getting it wrong are often immense in their disruption and/or cost.

Managing staff is no longer limited to Betty the receptionist and Alison the secretary. Often multi-profession teams, some of whom may work with the practice but are employed by another organisation adds another layer of complexity and risk. The cost and consequences of getting it wrong are potentially horrendous and expensive.

Managing the building, often used beyond its designed capacity, has become increasingly complex, not just in the building infrastructure, its maintenance and repair, but room allocation and use. Back-to-back room use and hot-desking are tough enough without adding the human element of staff not wanting to vacate a room at the end of their session.

Poor financial management makes for a very tense time with the partners and accountants. Surely practice management includes the responsibility for other organisations paying the practice on time and using remittance advices that are comprehensible and linked back to something vaguely familiar?

Managers are often expected to challenge the behaviour of their “Boss”. Why isn’t Dr X adhering to the local formulary, “doing QOF (Quality and Outcomes Framework)”, reporting and engaging with significant events and assisting in the resolution of complaints? To keeping their practice viable, many managers are constantly reviewing:

• How can I improve productivity?

• How do I improve the financial performance ensuring that any additional services we offer are value for money?

• How do I improve the effectiveness of the practice?

• How do I ensure compliance and governance both in medical services and staff employment?

All of this is made more challenging due to:

• the constant changes demanded by the NHS

• the unachievable patient expectations

• the lack of clarity, ambiguity and conflicting guidelines in much of what is demanded from the practice

• often the lack of support for change from partners and staff who believe that change is optional.

With such a challenging and diverse workload, accompanied by high levels of accountability, managers need the support of great teams. Managers are very often the leaders in their practice and may well be, or become, the leaders within PCNs. Just as there needs to be good leadership, there also needs to be good “followership”. Followership is a straightforward concept. It’s not about being shackled and blindly following the leader.

Excellent followers are empowered, motivated and focused on the success of their organisation, their team and their role. Everyone supporting each other, including leaders, to deliver high-quality care and everyone taking responsibility for the success of the organisation as a whole.

Followership is also about taking on the leadership role when it is required. The job of a leader is not to create more followers, it’s to create more leaders. Effective managers don’t just rely upon their practice team, they will have a wider team of supporting partner organisations who help the manager shoulder the burden.

To precis a famous quote – 'Any fool can make things more complex, it takes a touch of genius to make it simpler' and that’s the purpose of these support organisations.

As an example, accountants are relied upon to a varying degree, depending upon the manager’s financial ability. Accountants should not baffle anyone; they should be able to help everyone to understand the financial picture.

One practice I worked with wanted help following an acrimonious partnership split. I discovered that they had never understood capital accounts and referred to them as “funny money” and had left their capital accounts behind when they split, not realising that it was money they had put into the business and paid tax on!

An expensive lack of understanding.

Management tools and resources are equally important. Bespoke payroll packages or outsourcing the payroll. Websites where policies and protocols can be downloaded and even ones that will write policies for you if they don’t have the subject you are looking for. All of these resources are designed to make life easier and, hopefully, develop as the needs of practices develop.

One such resource that made an immediate impact upon me as a practice manager is Blue Stream Academy, when they launched the eLearning suite for GP practices. Not only did the eLearning suite hit the ground running, but it continued to develop.

The company welcome and respond to feedback about their product, making it better and more useful with every new version they release. They keep an eye on the future to ensure that the suite of training always has the modules necessary before they are needed. The eLearning suite is configurable to each practices’ needs and met my requirement of making a complex issue less complicated. The management dashboard allows training to be tracked for all staff. Being web-based, it is accessible to staff from home. This is particularly useful when employing new staff to enable them to complete some basic training before they set foot into the premises.

On the day that new staff arrive the manager can see they have completed and passed several modules such as Fire Safety, The Principles of H&S, Infection Control (non-clinical), Equality & Diversity, Display Screen Equipment, GDPR, Induction, Information Governance etc. This ensures that new staff have acquired a level of understanding and insight into the practice and some of the requirements of the role.

Just as patients are frustrated by every person they have contact with, asking them the same information, then so managers become frustrated by entering the same information into many different stand-alone systems. The eLearning isn’t connected to payroll or the rota system or HR files and so forth. Staff details must be entered into several different systems. Changes to staff details need to be replicated in many systems.

Don’t we all wish for a single, integrated system that covers a great deal of the HR complexity to make our life easier?

Those wishes are beginning to be granted with the introduction of Blue Stream Academy’s HR System that is designed to take the headache out of many aspects of staff management.

Duplicating staff data is eliminated because it links to the eLearning suite pulling basic staff data from that. The initial version of the HR system didn’t just include the ability to add staff details but also rotas and rota management.

In my experience, rotas have always been problematic, often paper-based, it’s very easy for misunderstandings to occur as staff have the wrong version of the rota. The system not only allows the easy creation of rotas but displays it to the member of staff when logged in and emails it to them.

The entire system is accessible from home, smartphones and tablets. Holidays are booked through the system and approved by a manager. Running totals for holiday, pending and refused requests are all shown.

Other absences are added by the manager. All this information is available through the dashboard and also through a comprehensive reporting system.

As if that’s not enough problems to solve for managers, Blue Stream Academy has since released further enhancements, solving more challenges and reducing the need for paper records.

Additional details about staff, including a second phone number, gender and ethnicity, will be available in the system for HR purposes. A new feature will make it possible to upload and link documents to a user’s HR profile. Users will also be able to edit their basic contact details, but not their work or leave details.

When creating a rota, the system will automatically pick up when staff have holiday, other absences and training scheduled. This feature will then create warning notifications on the rota for HR administrators.

HR Administrators will be able to create leave for users plus there will be features to add further details for leave or absences. However, in my view, the greatest benefit of this system is knowing that it will continue to develop and continue to make life easier for managers. The system solves real-life problems that managers have while improving productivity and effectiveness and supporting the delivering of compliance.

I am told that Blue Stream Academy has the vision of creating a single hub to deliver solutions for managers as they continue to be “Jack and Jackie of all trades and masters of many."

Andy Briggs

Andy spent 25 years as a practice manager and managing partner in a large semi-rural GP practice, during which he met the challenges of the ever-changing NHS environment.

Active within practice manager groups, practice based commissioning and CCGs, he now works within the system supporting practices to meet the new challenges of extended access and Primary Care Networks.