Leading the modern practice the ever-expanding role of the Practice Manager

A year ago, the leading editorial in the British Medical Journal heralded the opportunities for improving health outcomes with the new GMS contract but predicted that the transition would not be smooth. The new contract begins this month but some important questions remain unanswered. In this article Paul Midgley highlights the help Practice Managers need to seize the opportunities that the new contract presents, in the knowledge that this will boost your access and sales.

BACKGROUND The four key aims of the General Practitioners Committee when they entered negotiations on this contract 2 years ago were:

  • Improve (GPs’) working lives
  • Attract extra funding into General Practice
  • Improve recruitment and retention
  • Improve services for patients

The success of the contract from a GP’s point of view will be judged against these aims. Practice managers have a crucial role in managing change in their organisations and will find many opportunities within the new contract to improve things for both patients and staff, and increase income.

KEY CHANGES COMPARED TO THE OLD CONTRACT The fundamental changes are listed here.

  • Practice-based contract with PCT – individual lists will cease
  • Funding based on patients not doctors
  • End to 24 hour responsibility
  • Choice of services to offer
  • Quality-based incentive scheme
  • Enhanced services shifting services from secondary to primary care
  • Predictable higher monthly income = improved cash-flow = better business planning

The final point is perhaps the most important driver of change, as the running of the practice business should be facilitated by PREDICTABLE monthly inflows of EXTRA cash. This stability allows for better, longer – term business planning around services, people and premises.

NEW SOURCES OF FUNDING FOR PRACTICESThis is an important chart as it clearly emphasises where changes are most likely to occur – where the greatest amount of new money is available. This highlights the huge importance of the Quality Framework (QOF) to practices. QOF’s value to the practice could rival income from the Global sum once they achieve high QOF points levels. It also highlights the importance of using the Quality Preparation payments and QuIPP payments (for summarising notes) to re-design internal processes to maximise QOF points. These payments are not there to top up the GPs’ income!  Some existing funding pots have been increased significantly (Seniority and pensions for GPs). There is some re-branding of existing monies (Directed enhanced services, Local Enhanced Services). Other new sources of funding other than QOF include a small amount for National Enhanced Services (many PCTs have not commissioned these this year!).

Know what enhanced services your local PCTs have commissioned. Ask any practice manager!

There are new schemes to help repay grants, rent etc on premises. Practices will pay less on IT (responsibility for maintaining and upgrading IT now rest solely with PCTs). If you want to know more about practice funding under the new contract, read the Statement of Financial Entitlements (http://www.bma.org/ap.nsf/Content/Hub+GPC+contract) so you are clear.

END RESULT – Practices who continue to offer their existing range of services should therefore benefit from an increase in annual income and more predictable monthly income.

WHICH SERVICES WILL PRACTICES OFFER? Practices have agreed with the PCT which services the practices will provide over and above the basic requirements of Essential services in 2004/5. Their PCT will have confirmed which of the Enhanced services the practice will be commissioned to provide in 2004/5. Practices should already be thinking ahead to 2005-6, and discussing internally, and with the PCT, which National Enhanced Services (NESs) to provide in 2005/6, as PCTs will look to increase the range of NESs that are offered in year 2 as they shift funds away from hospital providers.

If your drug can help practices provide Enhanced Services, start discussions with the Practice Manager/partners/leadership team to identify the extra services they could offer, examine the required Quality specification and estimated income, and decide which if any would be worthwhile helping the practice bid for should the PCT find the funds to commission these services from within primary care. For more information about the range of enhanced services, see the BMA website (address above).

KEY ROLE FOR PRACTICE MANAGERS – CHANGE MANAGEMENT AROUND QOF A key NEW role for practice managers is to lead the practice to achieve the maximum points possible under the QOF because points mean prizes! Some practices (paperless, ex-fund holding or early wave PMS for example) really do expect to achieve maximum points in 2004-5 and larger practices will benefit from six-figure boosts to their income. A practice’s big incentive to strive for maximum points in 2004/5 is the link to year two’s monthly ‘aspiration payment’. 60% of year one’s ACTUAL points value will be paid monthly over year two at the much-increased pounds per point rate. Even average sized practices, performing to a high level (over 850 points) will benefit from six-figure boosts in income in year two.

Many of the changes required to maximise QOF need a multidisciplinary approach, so full buy-in is needed from the practice team. Practices should invest their ‘Quality Preparation Payments’ and ‘QuIPPS’ into training, protected time, and extra hours for summarising during 2004 to help get the team informed, plans developed and skills developed.

Healthcare Partnership’s most popular training workshop this year has been ‘Maximising Practice Income through your Practice Development Plan’ and we expect this to continue throughout 2004.

QOF PAYMENT All QOF points convert into cash. Achievement payments will be paid to practices in April 2005 from a DoH master computer system (QMAS) which reads from all the major practice IT system suppliers (e.g. EMIS, Torex, Vision). This means that practices will only get paid for what QOF work has been done if their IT system faithfully records and reflects this work.

A key role for Practice Managers is to get everyone up to speed on IT – a failure to do so means their practice will earn less QOF money than it should.

Details of consultations with patients occurring outside the practice also need to be entered onto the practice computer – currently many are not. You could help here – why not provide paper copies of the relevant templates for doctors/nurses/health visitors doing domiciliary visits so they can collect the necessary information relevant to the patient’s condition for the QOF? Finally, for the 10 chronic diseases, the pounds per point will also be determined according to the practice’s disease prevalence compared to national data. Once QMAS goes live (August 2004), practices’ disease registers data will be collated across the UK, and then by dividing the register by the list size, to give disease prevalence. Practices with relatively high disease prevalence compared to national average will need to work harder to achieve the targets set in QOF so will get higher payments per point; those with lower than average prevalence will receive less per point.

LEADING ON LEARNING UNDER NEW GMS – FUTURE OF PHARMA SPONSORSHIP A practice’s ‘Global Sum’ now covers ‘protecting’ time for PDP, PPDP and appraisal preparation. PGEA NO LONGER EXISTS! PCTs may continue to provide Protected Learning Time sessions – if they do, practices will fight to use this time for practice-based sessions wherever possible, though clearly PCTs will still want to run localitywide sessions where essential briefing and training is required.

What do you need to do to continue to support learning events?Work closely with PCT education and training leads, GP tutors and PLT organisers so you know what events are planned for the year ahead. Work closely with Practice Managers in target practices to ensure you know the practice’s learning needs, and support their inhouse training sessions. Help them put together their PPDP (or work with an external supplier, e.g. Healthcare Partnership) so you can really understand their needs and identify solutions. Practices will use their practice-based PLT to plan ahead, to train staff in line with their PDPs, or the practice together on its PPDP/joint learning (e.g. Significant events audits). These events offer sponsors a great opportunity to really understand customers better and develop close joint working.

LEADING IM & TResponsibility for IM&T maintenance, and purchasing of new kit (hardware and software) becomes the responsibility of PCTs under the new contract. For IT-literate practices, this may be viewed as hugely constraining, but for the majority of practices, this will reduce costs significantly and SHOULD still provide as good if not a better level of IT support service. PCTs will enter into pan-PCT service level agreements PHARMACEUTICAL FIELD ISSUE 4 2004 33 Contact Healthcare Partnership on 0870 2413506 or by email at enquiries@healthcarepartnership.com for details of our training and development services, for testimonials from our extensive list of satisfied customers and for opportunities for sponsorship in your area. Copies of the Practice Management Competency Framework can also be obtained from Healthcare Partnership. with IT suppliers providing better service than would be possible for individual practices. For practices with poor IT, this is very good news as they won’t have to pay for a shiny new GMS compliant system. IT is important for 2 reasons – firstly achievement of QOF points depends on it, secondly, as a stepping stone to Patients Electronic Health Records by 2010. Practices are being encouraged to move paperless as soon as possible hence the funding support for summarising through QuIPPS and the target of 60% by 31st March 2005 for a QOF payment.

LEADING RECRUITMENT AND RETENTIONPractice managers face a huge challenge to recruit and retain good staff. With more and predictable monthly income, practices can afford to employ more or better paid staff. This involves a people capability review. Are the right people doing the jobs most suitable to their skills? In the past, it was a catastrophe if a GP left the practice and they couldn’t recruit as it affected practice income. This drove many practices into PMS. Now, this is no longer an issue, and retirements and resignations present an opportunity to review how the same level of service can be provided by utilising other professionals (e.g. nurses) to take on the bulk of minor illness and routine chronic disease management, and freeing up their time by recruiting or training up administrative staff to perform basic health checks, taking blood pressures, etc. Many (PMS) practices in difficult recruitment areas have been forced to innovate along these lines and have developed successful models for a broader-base of service provision. Clearly this requires that there are nurses to recruit or a willingness to be trained, and the funds and training available. Practices need help with this training – PCTs don’t have much funding so it either comes from Global Sum, or an alternative source – Pharma! Are you ready for this?

LEADING PRACTICE MANAGER AND TOP TEAM DEVELOPMENT The new contract heralds the way for a more complex practice organisation with a greater income stream, more staff, certainly more regulated and IT based. nGMS Annex C (practice management competency framework) recognises the pivotal role played by Practice Management team. This framework will help practices benchmark their current performance to systematically plan to develop the skills required to move the practice towards a more corporate business approach. It will help identify what new skills are required in new recruits to senior positions. An integrated management team may involve the practice manager at the centre providing vision and momentum to the rest of the senior managers (which may well include GPs, senior nurses, IT managers and possibly others in a large practice). Clearly, this will be a challenging transition for many practices and external facilitation of Practice Management Competency development is advisable. It also provides an opportunity for you to help. If your company is unable to provide this for practices, contact Healthcare Partnership for help. The importance of non-GP members on the practice leadership team is recognised in the new contract allowing non-GPs to co-sign the contract alongside at least one GP. Some PMS practices are already led by non-GPs – the new GMS Contract allows GMS practices to provide parity for indispensable non-GPs , opening the way to them becoming partners.

PRACTICE MANAGER EDUCATION Practice managers have a big responsibility to develop themselves. PCT-provided protected time, for example for monthly Practice manager forums, should become a standard commitment in their diary. Increasingly these meetings may be extended to incorporate specific training to develop key areas around the competency framework. PCTs, the Modernisation Agency and NHS University will all provide more qualification-based learning opportunities for those practice managers keen to development themselves (but not the funding!). Ambitious practice managers will seize this with both hands and develop themselves. This will increase their bargaining power at salary review and could prompt an invitation to become a partner in the business if they really excel.

CONCLUSION – WHAT HELP DO PRACTICES NEED FROM YOU?Practice managers never have been busier, so if you understand their priorities, you will know where you can help your key practices most. Where should you think about helping?

  1. Sorting out IT software, ardware and training. Do you or your company have knowledge or skills in this area?
  2. QOF Help the practice decide how they will achieve the QOF points they have aspired to. Can you support an away-day ideally leading to an updated PPDP? Can you help them develop Chronic Disease Management clinics?
  3. What staff job changes will they required to run new or better services? Help them put a recruitment and training plan into action (PPDP is a good place to start). Your company’s experience around recruitment and training could be useful.
  4. What are their management team’s competencies and skill gaps? Support them to take some time out as a management team to work through the competency framework to establish a baseline and key areas for development. Use this to define recruitment and training needs and areas for future support that you can provide them. If they need to expand or move, can you help them put a business case proposal together so they put their case in the most persuasive way possible? Perhaps your Healthcare Development manager can help with writing a business case.

There has never been a better time to work collaboratively with key customers as their needs change and opportunities beckon. Get help from internal company resources to keep your costs down, but be aware that some practices may have a problem with ‘getting into bed’ with one company, and indeed may not be happy for company personnel to facilitate their business planning due to the sensitive nature of issues that may arise. If this is the case, an external agency such as Healthcare Partnership may be preferable. We can also help your budget stretch further by involving other sponsoring companies to cover the cost. Contact Healthcare Partnership on 0870 2413506 or by email at enquiries@healthcarepartnership.com for details of our training and development services, for testimonials from our extensive list of satisfied customers and for opportunities for sponsorship in your area. Copies of the Practice Management Competency Framework can also be obtained from Healthcare Partnership.