A day in the life of a practice manager: The elephant in the room

There's not just one elephant in the room, but a whole herd trampling towards general practice, says Heike Burnett.

Practice manager Heike Burnett

Those readers among you who notice my first name will realise that English may well not be my first language and a carefree childhood was had elsewhere.

Despite decades in this lovely land just occasionally certain phrases come along the meaning of which is a slight mystery to me, for example ‘I am over the moon’, ‘Really? How did you get there?’, ‘Devil’s Advocate’, ‘when did you meet him and why are you still here?’ or ‘the elephant in the room’, a phrase I hear more and more in general practice.

In a meeting I attended with the senior partner sometime ago the elephant was mentioned. I finally plucked up the courage to ask him the meaning when I noticed him trying not to burst out laughing. He manages to note on a bit of paper ‘a problem’ – when I realise an entire herd of elephants trampling towards me.

I zone out from the meeting for a while and order my herd. The main elephant, the elephant matriarch if you like, continues to be funding of services. Although some increases are coming through, none of it stands in any relation to practices having to deal with 90% of NHS contacts and the increasingly older and more complex population needs.

Enhanced services are offered to any qualified provider and unless a practice belongs to some kind of federation with a patient base of 500k+, chances are the funding will go to a provider who believes to be much better placed to provide patient services. A year or two later we find these services come back to general practices as surprisingly the funding was insufficient to continue and only general practice appears able to pick up the pieces.

The little elephants

Which brings me on to the sister elephants: CCGs, federations, super practices, other provider vehicles. We know from the GP Forward View that practices, the little elephants, need to huddle up if they have not done so already. Many CCGs are running deficits and may not be able to support their member practices much longer. In some areas back in 2012/13, several practice leaders were brave enough to form federations, marvelled at by many, only to find months later that they too were no longer able to manage funding in a way that provided sustainable services to patients.

Talking about ‘sustainable’, no sooner had CCGs started to get some grip on running general practice, NHS England had a meeting and decided integrated care was the way forward. Along came 44 sustainability and transformation plans, a distant herd of elephants we see across the grasslands of general practice, whose way forward appears to be an accountable care system or even accountable care organisations like Vanguards or Multispecialty Community Providers.

For these to function are we calling for some neighbouring elephants to join us or will there be a shift for some from the CCG to the ACSs/ACOs/MCPs? Will what remains of the CCG have to huddle up with surrounding remaining CCGs and form, well, a PCT?

Are you still with me at this point because most practice managers I know lost sight of this elephant in the room a long time ago and got on with the day job.

We must not forget the extended-family elephants in community services. Changes implemented elsewhere are always acutely felt on the telephone or at the desk in every practice. Patients do their best to keep up with the changes, but often revert back to the family doctor they have known for years.

I often wonder what my 93-year-old grandmother would have made of calling one number for the community nurses, another for her medication or a minor illness assessment whilst also navigating the maze that is hospital contacts from a recent stay. I am not too proud to admit that I am beginning to struggle with the increasing fragmentation of services and often seek our marvellous medical secretaries’ advice.

Occasionally we find ourselves in the company of visiting elephants, called ‘champions’ today, something different tomorrow. Every organisation now requires a dementia champion, a health champion, a safety champion, a give-the-patient-anything-they-ask-for champion.

May I champion the notion that we do away with ‘champions’, and guardians for that matter, and simply continue with what we are here to do and do best - look after our patients in the same caring and holistic way practices have always? It saddens me that many young doctors no longer wish to become a GP, to experience the variety the profession offers and care for people from cradle to grave.

What do we learn from all of this? Nothing at all! Just like elephants migrate and gather year after year and the older generation teaches the younger one, general practice will journey, evolve, gather and continue in some shape or form and go on to produce clinicians, nurses and people who will care for patients in the community. Patients will be blissfully unaware of the herding ‘elephants in the room’ and that is probably how it should be.

Applause drags me back to the meeting – time to go home!

  • Heike is a practice manager in East Grinstead, West Sussex

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