Exploring quality improvement activity in general practice

Before joining the London School of Hygiene & Tropical Medicine in 2007, I’d spent 16 years as a manager in general practice – so between 1991 and 2007, I saw many changes to both general practice and to the job of the practice manager.

When I joined my first practice in east London, there were three target payments, when I left practice management there were over a hundred. Primary Care Trusts (PCTs) replaced Health Authorities, and have in turn been replaced by Commissioning Care Groups (CCGs), bringing with them networks, federations and large-scale collaborations. The Quality and Outcomes Framework has been introduced. Corporate providers have entered the picture through the Alternative Provider Medical Services (APMS) contract. The Care Quality Commission (CQC) now has responsibility for checking the quality of practices. In most of the practices I joined, I was the first practice manager the GPs had appointed. These days, I doubt there is a practice (out of the 9,800 in the UK) that does not have some form of practice manager, even if they are only part-time.

Practice managers have had to respond to these changes, whilst at the same time undertaking the full range of activities involved in running the practice. The job can be very reactive, as various practice mangers have described to me: ‘You’re expected to have eyes everywhere… Sometimes planning your day works and sometimes, you know, two computers go downstairs and you go crawling around on the floor and get covered in dust…’

The practice manager has increasingly become involved in clinical areas.

• When new policies or guidelines arrive, it is the manager who mediates their introduction into and impact on the practice. For example, they ensure the National Service Frameworks are introduced, that Caldicott Principles are met, and they deal with the Local and National enhanced services.
• The practice manager is responsible for managing the nurses, reception staff, health care assistants, cleaners and, although employed by the practice partners, the practice manager manages the time and workload of all GPs in the practice. Many of these functions that would have their own departments in other similar sized organisations, such as finance, HR and IT.

In recent years, they have taken on wider responsibilities outside the practice – such as sitting on the governing bodies of CCGs, working across several practices to provide IT support, and training.

It is also a very proactive role and becoming increasingly strategic – forward planning, taking part in service improvement, acting as boundary spanners with other organisations and helping to manage the increasing and changing demands of modern general practice. Despite this, they have until recently been the least visible member of the practice team.

Unsurprisingly, I welcomed the promise in the General Practice Forward View of £6m for practice manager development. However, for that money to be invested wisely and give good value, we need information on where it is needed and what for. For example, a small poll by the Institute of Healthcare Management found that 40% of practice managers who responded believed that quality improvement skills would improve their performance. Apart from polls like this, we know very little about who practice mangers are and what they do.

So, where is the research on practice managers? This is arguably a research gap that needs to be filled urgently. We know that good management is important to ensure good organisations.

As federations become more common, practices begin to collaborate more or work in at-scale organisations, the demands on practice managers will change and increase. We not only need to know what skills and experience modern practice managers need, but also what current skills and expertise they have that can be leveraged quickly to help lead the development of practices in these testing times. Unlike hospital managers, practice managers tend to be the sole manager in a practice so as more work is transferred from secondary to primary care, they also need to professionalise and up-skill.

At the London School of Hygiene & Tropical Medicine we are trying fill this gap. In 2017 we are undertaking a piece of research, funded by The Health Foundation, taking a snapshot of quality improvement work in general practice across the UK.

We will be undertaking a census of practice managers across the UK and, while surveying their quality improvement activities, finding out who they are and what they do. We want to know their length of service, route into the profession, qualifications, and training and support needs. Aside from a couple of small projects in the 1990s (and membership surveys by organisations such as First Practice Management), this will be the first large scale investigation into the population of UK managers. The research will provide the first real information on who they are, and be a solid basis for designing training and support networks. It will also help to inform how the £6m development fund is spent.

I hope that the research will help practice managers develop a profession for themselves, and as a basis for further research, highlight the importance of practice managers.

If you’d like to find out more about the study, please email me for further information.

Jennifer Gosling is an Assistant Professor in Management at the London School of Hygiene and Tropical Medicine. She is lead researcher for the Improvement in General Practice Services project.