Tracy: I work in North Kirklees at the minute, but I previously spent 18 years in Calderdale as a practice manager, business manager and PCN manager. I've been a practice manager for about 22 years now. When I started out, I was the one and only practice manager there, and then the structure evolved. We had leadership from our GPs in key areas, finance, HR, IT, procurement, patient services and premises. I then took on a part-time ops manager, and trained them to deal with the day to day. I started becoming a little bit more strategic, procuring new contracts and doing things like that. I was also working to raise the profile of the practice and the quality of delivery.
Tracy: Before PCNs emerged, we had set up a group of practices. 11 surgeries had got together voluntarily, all in different localities. We formed Calderdale Group Practice. This was like-minded managers, GPs and partners getting together to do things at scale without actually giving up independent status or contracts. We did some amazing stuff. We shared accountants, telecoms, cleaning companies and saved about £100,000 in 12 months. We worked on clinical pathways, mandatory training and sharing of staff. Then along came PCNs. We left the Calderdale Group Practice to follow the neighbourhood footprint as it was the right thing to do. But it was a bit upsetting when we had come so far collectively together.
Tracy: I'd always done a bit of locum work with primary care trusts, CCGs, LMCs, GP federations and I really enjoyed it. I wanted to go off and do something a bit different, and maybe explore some training, consultancy and things like that. I'd done that informally for years, supporting new managers with mentoring and coaching. That's what I've been doing ever since, working with PCNs through the Locum Practice Manager community. It’s not a locum bank kind of approach. We’re a community with really strong membership and very like-minded people. However, I still work in general practice in North Yorkshire and West Yorkshire. This is great because I really do feel that the two or three days a week in general practice helps to keep you ‘live’ and up-to-date with everything.
Tracy: I think it’s a lot more open. We have people coming in now from retail banking, the military and the private sector and that’s really good. It's given us a bit of a shake-up. The strange thing about practice management for me though is it’s still a profession that's almost unregulated and not accredited. There's no formal professional body for us. We've got general management bodies but we don't have a practice manager professional body or anything like that. I've been working with NHS England for about four or five years on a practice management competency framework. We’re still not there yet. But I'd love to see that because I think that's a massive missing component in practice management.
Tracy: You're technically a managing director in most practices. You manage upwards, outwards and downwards. That's how I describe practice management. You are technically an MD or a CEO because you are at the heart of the practice and making a lot of decisions. Yet in some practices, you've got to get permission to buy stationery. While in others, you can recruit and appoint staff without any consultation at all, because they trust you to create the right workforce for that organisation. There are massive variances. It’s a role unlike no other! That’s how I describe it.
Tracy: There are a few. Firstly, we are independent businesses. So, it's about managing your business like any other, but with patients at the heart of everything. You have to put them first. The most valuable resource in your business is of course your staff. About 65% of your income is spent on staffing. It's the most expensive resource so it’s the one you need to get right. A challenge, I think, is the recruitment and retention of nurses, practice managers, partners and reception teams.
“Reception teams are the most underpaid staff and most valuable because they're on the frontline. They are completely undervalued.”
And with patient demand, we've created our own monster too. We have core hours between 8am and 6:30 pm, plus extended access, improved access and now, enhanced access. There’s a huge range of roles and a massive amount of choice of who you see for what. You're seeing specialists now, not generalists.
Tracy: For me, it's all about workforce development. You need a plan and it must be based on data. If I don't have evidence for change, I won't change something. If someone says, let's start doing the appointments this way, or let's introduce this new piece of software, it's like, hang on, have we got a need for that? What's the demand? Is our capacity lacking anywhere? It's about the right person doing the right thing and the only way you can do that is to audit your information. We've got amazing amounts of data in general practice. We code everything within an inch of its life. So gather that data, talk and listen to your staff. We meet regularly in huddles in our practice. Little conversations in corridors or huddles can generate bigger conversation. A lot of practices don't have the headspace for a workforce development plan. But you really do need to prioritise it because you will have senior nurses doing bloods, when in actual fact, you just need to increase your capacity a little bit on the phlebotomy side or your HCA, or GP assistant role. Assess what you need, and not just assume what you need. I think that's really important and it always boils down to communication. You've got to tell people what you're doing, otherwise it makes change really scary.
Tracy: There's programmes and pilots I have been involved with. At Calderdale, we used a platform where you can manage patient data and run a workforce tool alongside it and get the two to talk to each other. It basically said, ‘You've got X number of blood tests going on in the practice and you need X number of hours for a phlebotomist’. It was very intuitive. But at the time, lots of practice managers couldn't get their head round the IT, learning and the training. In general practice, we do struggle, because most of us don't have such a thing as a training budget. You make the money available for training. Not like the larger organisations that have training departments, training plans, budgets and all of that. Plus, you need the time.
Tracy: For me, the best way to find out about things is to get out there to those events. Get to Best Practice, get networking and get discussing things on forums. There's some great forums now for practice managers, nurses and PCNs. You’ll probably have a better voice when challenging things too. We've discussed things with our PCN and said we want this and by getting other managers onboard in our PCN, we can make things happen and get GPs on board. It’s great when you've got clinical IT champions in your region too.
“If you just raise your head like a meerkat every now and again and see what's going on, you do get to know what's happening.”
There’s some great innovations out there that you can take on a practice level, or as a PCN. You can start adapting new ways of working, mindsets and open up your options. But I know it's hard because most practice managers are absolutely swamped. I think that's why we're losing a lot of practice managers to be honest. They've just got too much to do.
Tracy: I see a very different way coming for general practice that's going to massively impact the role. As I mentioned, I would like to see accreditation, alongside experience and knowledge. I do think we need validation. I would also like to see some consistency, which kind of goes against the grain of the partnership model. I like the idea of independent businesses delivering high-quality care, which is what we've done really well on a very low budget. But for me, it's gone too far now. You've got really poor practices. You've got really great practices and all those in between. That must be impacting patient care. So, I'd like some standards in place. CQC can go in and say yes you’re outstanding but it doesn't capture it for me. I don't see there being a salaried model or the end of partnerships. But what I would like to see is the at-scale model, and not just running under a contract for PCNs. It needs to be at scale, but not too big. They've said 50,000 patients is big enough and I think that's about right. Practice managers in all of this will need to change and adapt.
“You don't have to ‘know primary care’ to manage a primary care organisation anymore.”
People are coming in from the outside with real skills that are transferable. And we have to be more accountable because partners are expecting more. We're running their businesses.
Tracy: PCNs and practices and are embracing technology and are seeing the benefits very quickly. Practice Managers are actually asking me what AI technologies they can use. I think automation is going to really drive general practice in the future. We've got to get away from this automatic inheritance of ways of working and start being open to other technologies. That's something we did really well as a group of practices. One practice would do something and share how it felt ‘hands-on’. So, it was almost pre-validated by someone actually experiencing it. As 11 practices, we all shared the best bits and all the great ideas with each other. But obviously technology has to be easy to implement. I think sometimes ICBs have a different opinion of how easy something's going to be to implement because they're a bit too detached from how it really feels on the ground.
Tracy: Remember there's different elements. There's more opportunities around being a finance manager, HR manager, procurement manager or being an IT manager. Because if we look at this across the wider footprint, we're doing it with PCNs, so why can't we do it with other aspects? Why can't we share these roles? Why can't people specialise? Also, remember that you don't just need to fully commit yourself to the practice. There are other things out there. There's lots of four day working going on now, which is great. Whether it's nurses, administrators or GPs, they're off doing other things as well.
“One of our practice nurses is a chocolatier for example. Why can't you do that? Why can't you do things that bring you joy?”
The final thing I'd say is, no matter how big or how small your practice is, it's not a job for one person anymore. It doesn't need to be two managers. You just need to know how to delegate, take responsibility and share that leadership. Get that right and it will work.
Tracy: We're definitely getting better. I feel it’s just a bit sad that we've had to have a QI indicator to tell us to do it and to attach money to it. But to be fair, it's made everyone sit up and take it really seriously. I also think we need to celebrate success as well. We're not very good at that in primary care. We get embarrassed to say we're doing something really good. It's not all doom and gloom.
To find out more about Tracy visit her LinkedIn page here. To learn more about the work that Locum Practice Manager do, visit their website.
Learn more about how Suvera can support your practice, PCN or ICB here.
