Abstract
Introduction
This chapter looks at the people who work in, and make up, the primary health care team (PHCT). This includes different clinical professional groups such as doctors, nurses, therapists and also those essential members of the team who provide managerial and administrative support. This section will provide practice managers with the essential information they need about each member of the PHCT. Practice managers have responsibility for ensuring that the PHCT has the capacity and expertise to provide high quality care for the patient population and will increasingly be working with the primary care organisation (PCO) on workforce planning. Practice managers need to understand what each member of the team has been trained to do and how this translates into specific job descriptions, roles and skill mix. Good teamwork is essential and relies on each member taking on specific roles for which they have been trained and prepared. Recruitment of replacement and additional staff requires careful consideration, as there may be an opportunity to look again at the roles and responsibilities of all the team and consider a new skill mix. This may be vital in the face of tightening practice budgets in the next few years. It is also important to understand the role of the practice manager in monitoring the performance of individual team members, which may also involve registration with professional bodies such as the Nursing and Midwifery Council (NMC) and the General Medical Council (GMC). It is clear that practice managers need to understand what they can expect from each member of the team and how to support each of them in order to maintain and improve their skills.
Details about recruitment, employment and pay scales can be found in Section 4: Employing and managing people.
Doctors
Traditionally, the doctors in the team have worked in profit-sharing partnerships that own the business and employ the practice manager to help run the business and employ other staff. Partners are, however, increasingly the GP workforce is being replaced by salaried doctors within the practice. Salaried doctors are employed rather than being self-employed equity-sharing partners. They tend to be focused on clinical service provision whereas partners also have managerial responsibilities within the practice. There are also locum GPs who are self-employed or work for a locum agency and are paid by session and can be used sporadically by practices to cover absence or sickness. Salaried and locum GPs are generally less well paid then partners but can have more flexible working hours and hence many have portfolio careers with other interests. Salaried and locum GPs now make up 40–60% of the GP workforce depending on geography.
There are also retainer and returner scheme doctors who, in order to maintain their medical skills, work in a practice for up to four sessions a week. The practice is reimbursed part of their salary in return for clinical and educational supervision.
Teaching practices will often have trainee doctors at various stages of training from foundation doctors who are in their first year or two out of medical school, to GP speciality trainees who are more experienced and who are training to be GPs. They are normally supervised by a GP trainer within the practice. They generally see less patients then partners and salaried GPs as they are still in the process of learning, but by the end of their training they should be at the level of qualified GPs in terms of workload. Their salaries are reimbursed to the practice via the educational deaneries, and the GP trainer receives an additional trainers grant for the supervisory aspect.
Secondary care or hospital doctors such as plastic surgeons or ophthalmologists may work in the practice providing specialist services funded by the primary care organisation (PCO) as an outreach service. Increasingly, GPs are being encouraged to develop areas of special interest (GPs with Special Interests – GPSIs) and will be looking for opportunities to provide special services either for one practice or across a whole PCO.
All of the above doctors may work less than full time but everyone is part of the team of doctors.
The performers list
Performers lists were created by the NHS (Performers Lists) Regulations 2004 (available at Ⓦ www.legislation.hmso.gov.uk/si/si2004/20040585.htm).
The lists were previously held by PCOs and held names of doctors that were eligible to provide GP services. Previously GPs would only have to be on one PCOs list but could then work elsewhere in the UK. However due to the the Health and Social Care Act 2012, PCOs were abolished (see Chapter 9- Health care commissioning for further details). The duty to maintain the performers list now sits with NHS England and their local area teams and they are developing a single national performers list. The list is also the basis for collecting information on ongoing GP appraisal and revalidation.
Application to join a performers list
Applications must be made in writing to the NHS England local area team where the doctor works the majority of the time and include the following information:
Name
Gender
Date of birth
Private address and telephone number
Details of medical qualifications and where they were obtained together with supporting evidence
GMC number and date of first registration
Details of vocational training together with JCTGP certificate, Certificate of Completion of Training or equivalent
Details of medical indemnity cover
Chronological details of professional experience – include start and finish dates of each appointment and explanation of any gaps in employment or dismissals
The nature of the work the GP will provide within the PCO, e.g. contractor, armed forces GP, GP trainee, employed GP, GP partner, etc.
Names and addresses of two referees who can provide clinical references relating to two recent posts
Details of any outstanding applications to join other performers lists
Declaration of any criminal convictions (or proceedings which might lead to a conviction) and an enhanced criminal record certificate
Declaration of any investigation into professional conduct.
The NHS England local area team will also carry out Disclosure and Barring Service (DBS) Checks and may carry out additional checks to place the GP on maternity and child health surveillance registers within the PCO. These are additional checks to satisfy the GP is capable of carrying out antenatal care and child health surveillance on the local population. Once on the list, GPs must inform the PCO within seven days of any changes to any of the information listed above.
Refusal to accept a GP onto a performers list
The PCO may refuse to accept a GP onto the performers list if he or she does not meet the criteria laid down in the NHS (Performers Lists) Regulations 2004. In cases where there is dispute, appeals can be made by performers. This was organically through the Family Health Services Appeal Authority (FHSAA) but the FHSAA has now moved to the government unified tribunal structure and is known as the Primary Health Lists Tribunal Ⓦhttp://www.justice.gov.uk/tribunals/primary-health-lists.
Partnerships
Most practices are based on GP partnerships. Sometimes there is only one GP partner (known as a single-hander), but more often than not, a number of GPs group together in a multi-partnership practice. The partnership is a commercial arrangement to share profits. With changes in the GP contract in 2004, the PCOs hold contracts with the practice (hence the partnership) rather than with individual GPs. These changes meant non-clinicians could be partners within such partnerships as long as the PCOs approved. Normally they would require at least one GP to be a partner. The changes also introduced another type of GP contract called an Alternative Provider of Medical Services (APMS) (see Section 3: Contracts and finance) which allowed the PCO to hold contracts with limited companies, social enterprises and other entities. However, the vast majority of GP contracts are held with traditional partnerships. As with the performers list, these contracts are now held with NHS England.
Partnership agreements
Partnership calls upon a very high level of trust between the partners. Under the terms of the Partnership Act of 1890, in the absence of an up-to-date written agreement, a ‘partnership at will’ exists. This can be dissolved at any time, with potentially disastrous consequences for the work of the practice and the finances of the partners.
The arrangements between the partners need to be set out in a legal agreement. This ensures that all partners have a common understanding about money, leave and other potentially divisive subjects, and that arrangements for retirement are smooth. If a dispute arises between the partners, a well-drafted agreement can significantly reduce the emotional and financial costs of disagreement and dissolution.
When the partnership changes, a new agreement or a deed of variation to an existing agreement is required and should be signed before a new partner starts.
Medical partnerships are unusual in a number of respects, e.g. the purchase and sale of goodwill is by and large prohibited (see page 2-08). If your solicitor does not have experience in drafting practice agreements, consider a specialist.
Practices are strongly advised to study the BMA Basic Framework for Medical Partnership Agreements (see Ⓦ www.bma.org.uk or obtain a copy from your BMA regional office). Local Medical Committee (LMC) secretariats can also give advice. The BMA has a partnership agreement drafting service if the partners are BMA members. Alternatively, medical law firms can draft such agreements. It can be an expensive process but will end up being cost-effective if it can mitigate against an expensive legal dispute between partners in the future. The list below outlines important elements of partnership agreements, but is not complete:
Capital assets: definition, valuation, change of ownership
Expenses, separating the costs of running the surgery from those of ownership of the property
Definition of income (including non-NHS income such as co-op income and income from individual partners’ outside activities)
Principles on which partners’ profit shares are calculated
Statement of how income is divided, including whether items such as seniority payments and non-NHS income are allocated to the partner who brought them into the practice or are shared
Premises: basis of occupation, valuation, arrangements when partnership changes
Arrangements for payment of tax and identity of ‘nominated partner’ whose name appears at the bottom of the partnership’s tax return and who signs it on the partnership’s behalf
Indemnity to the nominated partner
Principles on which partnership decisions are made
Principles on which partners’ profit shares are calculated
Obligations of partners
Superannuation
Arrangements when partners are ill
Leave entitlements: holiday, sick leave, parental leave, study leave
Provision for the resolution of disputes
Dissolution of the partnership, whether by retirement, resignation or expulsion (‘green-socks’ retirement)
Provision to suspend a partner
Restrictive covenants on departing partners
Finally, given the speed of change in the NHS, arrangements need to be made for regular updating of the agreement. Small changes can be recorded in minutes of practice meetings but major matters require a deed of variation.
Partnership shares
In the past, shares decided at the creation of a partnership stood unchanged for years. Now, partners are likely to change their commitment to the partnership several times in their career for professional, family or health reasons. The table below is an example of how profit shares might change if one partner decides to cut his/her sessions down. Determining fair profit shares is no longer simple, but the practice should try to establish some principles based on time commitment and the weight of the various parts of the job.
New partner’s shares
It is the norm for new partners to start on a comparatively low profit share, taking two or three years to achieve parity i.e. 80% first year, 90% second year then 100% third year. A period to parity longer than three years may be construed as a hidden sale of goodwill. Sale of goodwill is prohibited for GP contracts (unlike in dentistry), however if the partnership owns a property it us usually expected that incoming partner will buy their appropriate share. This may mean taking out a loan to buy into the property alternatively some partnerships allow top-slicing of the monthly drawings of the incoming partner as a way for the incoming partner to pay for their share of the property over time.
Job-sharing partners
Job-shares are increasingly popular. Two part-time partners are independent of each other, but two job-sharers operate as one person, sharing patients (if personal lists), one diary, one in-tray and one vote. A successful job-share requires a common approach: similar clinical styles, philosophies and probably lifestyles, are important. A job-share between two women with young children is more likely to work well than one between a junior partner with domestic commitments and a senior partner taking on more golf as he approaches retirement.
There are no rules about how to organise a job-share, and it is up to the individuals to work out how they will act as one person to patients and colleagues. However, problems will inevitably rebound on the practice, and there are some essential points to be considered:
The practice needs to compare the economics of two part-time partners with those of a job-sharing partnership. Two part-timers will probably bring in more in terms of fees and allowances, but a job-share provides better continuity of care for patients.
Good communication between job-sharers is crucial, both on clinical and practice matters. For example, they need to decide who is responsible for passing on information.
The job-sharers need to decide with each other and with their partners which practice meetings both job-sharers are required to attend.
Patients need to understand that they may see both doctors and that they are interchangeable. This may create uncertainty at first, but when established the job-share gives patients a continuity of care which two part-time partners cannot provide.
Full-time partners need to understand that one half of a job-share does not provide unpaid holiday cover for the other!
Job-sharing partnerships are becoming less common with the move from personal lists to open lists within an entire practice with associated division of administrative work between GPs. It is most likely practices will have a number of part-time partners instead.
Partnership breakdown
More and more partnerships are breaking down. Like marital breakdown, the process is painful, often acrimonious and usually costly. The practice manager is likely to bear a huge burden, ensuring that the service to patients is maintained and that staff are protected as far as possible from poor communication and bad feeling in the partnership, while inevitably acting as a buffer or go-between for the partners.
Reducing risk of breakdown – anticipation
Regular partnership meetings provide a forum for raising contentious topics. Ideally, this should be done outside of practice time to allow more time for discussion. They should be chaired and minuted so that no-one can dispute the outcome. Many practices have terms of reference for such meetings, outlining quoracy and voting rights. The practice manager may notice dissensions bubbling under the surface and be able to tackle them inside or outside the meeting. It may also be apparent that a partner is stressed, and if this can be addressed it may reverse a deteriorating situation (see Section 7: Basic management techniques).
If the situation deteriorates, a well-worded practice agreement will cover most eventualities.
If external help is needed, LMC secretaries are in a good position to conciliate.
Managing dissolution
If arbitration is required, it is best to have professional arbitrators. Consider the Advisory, Conciliation and Arbitration Service (ACAS helpline Ⓣ 08457 38 37 36 Ⓦ www.acas.org.uk), or a lawyer with knowledge of partnership law and NHS Practice. Parties must be bound by the arbitrator’s decision.
Practice manager’s role
The cost to the practice manager can be immense and does not stop when the partnership has come to an end. New arrangements need to be set up, and managing the effect on the staff of a difficult past and an uncertain future can be very demanding. Practice managers need to ensure that their own needs are met, through the support of colleagues and by taking adequate time off.
Discrimination in partnerships
Partnerships are not exempt from provisions of the Sex, Race or Disability Discrimination Acts. Practices must not either directly or indirectly discriminate against a partner in a practice or discriminate when appointing a partner to the practice.
In cases of discrimination, an application must be made to a tribunal within three months of the last act of discrimination. Arbitration may still be a way of dispute resolution, but should not delay application for the tribunal – the tribunal will often grant a period of time to allow for arbitration once the application has been received.
The BMA will not represent members in partnership disputes, but will consider representing partners in discrimination cases. Alternatively, partners who feel they are being discriminated against can get advice from the Equality and Human Rights Commission (Ⓦ www.equalityhumanrights.com).
Sale of goodwill in primary care
In accountancy terms goodwill is defined as: ‘An intangible asset which provides a competitive advantage, such as a strong brand, reputation, or high employee morale. In an acquisition, goodwill appears on the balance sheet of the acquirer in the amount by which the purchase price exceeds the net tangible assets of the acquired company’.
Unlike other businesses, the sale of goodwill in general practice has historically been prohibited – and has been so since the NHS was established in 1948. At that point the Government opted to compensate GPs for giving up their right to sell goodwill in order to become part of the NHS.
Regulations were reviewed, however, following the introduction of the new GMS contract in 2003, when the Department of Health considered that that ban did not apply to certain alternative providers of primary care because they were deemed subcontractors.
Additionally, the categorisation of services changed with the new contract, which provided clear distinction between essential, additional and core services, and although the regulations do not directly affect general practice as we know it, they may have some effect on other organisations that may either be loosely linked or offshoots from general practice (i.e. providers of services for commissioning clusters).
The Primary Medical Services (Sale of Goodwill and Restrictions on Subcontracting) Regulations 2004 state that the sale of goodwill in a medical practice that has a list of registered patients will not be permitted in any circumstances. However, the sale of goodwill will be allowed by contractors that do not have a list of registered patients.
The following are examples of organisations where the sale of goodwill would be allowed:
Out-of-hours services as out-of-hours providers would not normally be expected to hold their own list
Doctors’ cooperatives who do not hold lists
APMS
Additional and enhanced services
Legal organisations set up to provide medical services (even if they are set up by a GP) providing they are a separate legal entity to the GP’s medical practice where he/she holds a list.
Practices should seek the advice of their accountant before embarking upon any discussions regarding the sale of goodwill.
Further information
BMA. Focus on Sale of goodwill. London: BMA, 2004 Ⓦhttp://bma.org.uk/practical-support-at-work/gp-practices/focus-on-sale-of-goodwill
The Primary Medical Services (Sale of Goodwill and Restrictions on Sub-contracting) Regulations 2004 Ⓦ www.legislation.gov.uk/uksi/2004/906/contents/made
Alternatives to partnership
Traditional medical partnership has come under increasing strain in recent years, and there is a growing interest in alternative models such as partnerships purely for ownership of property, executive partnerships, limited companies and partnerships along the lines of lawyers’ partnerships. A particular new trend is that of Local Medical Director (LMD) or salaried partner. With the drive of increasing primary care provision in the NHS Next Stage Review 2008, a large number of APMS GP contracts became available with a range of NHS and private providers tendering for the contracts. Such organisations would make a GP within the new practice the LMD. As well as seeing patients they would take clinical and managerial leadership within the practice and be answerable to the main organisation executive. Pay would be enhanced with performance related bonuses, but at the end of the day, they are salaried to the organisation. This demarcation between equity and property sharing partners and LMD/salaried partners is now becoming evident in large NHS practices. This has compounded the fear that a two-tier workforce is developing.
Retirement and succession planning
Retirement of a GP is an upheaval for a practice and needs to be planned well in advance, however distressing it may be for long-established doctors to see themselves being written out of the story. There are particular issues for single handed practices. It is not unreasonable to start planning five years before the due date.
The retirement of a partner is an opportunity to consider the future of the practice. Many PCOs will be considering it too, with APMS in mind, and may approach the practice. The practice needs to be sure about the future the doctors and their team and patients wish for the practice, and to take steps to protect that vision. The GPC regards a stable partnership as important security against threats to practices, and recommends that practices take a long-term view and invest in appointing partners even if the short-term advantage appears to lie with appointing salaried doctors.
The best way single-handed doctors can protect the practice they have built up is to appoint a partner, an automatic right for GMS practices but not for those with a PMS contract. The alternatives are to merge with a neighbouring practice, to negotiate a takeover by a private provider, or to allow the PCO to take over the practice and either disperse the patients among neighbouring practices or to tender the practice out as an APMS. Doctors need to consider whether offers they receive constitute an illegal sale of goodwill. Single-handed GPs coming up to retirement should discuss the options with their LMC, especially if they wish to continue clinical work in some capacity.
All practices should check their GMS contract/PMS agreement with the PCO to ensure that all partners are named.
A good partnership agreement is an important protection for all partners and the practice. The BMA website has lots of information and advice on this topic Ⓦ bma.org.uk.
Any GP coming up to retirement is advised to prepare professionally, financially and personally for the change of state. Various organisations hold study days for those coming up to retirement.
Single-handed GPs
Single-handed doctors represent the best and the worst standards of general practice. At their best, they provide a very personal and responsive service that is much appreciated by patients. There is also sad evidence that the isolation of GPs practising alone has sometimes allowed not only poor standards but criminal activity to go undetected.
Some GPs will prefer not to be in partnerships, and both patients and the profession will defend their choice. However, it is incumbent on GPs practising alone or in very small partnerships to reduce the risks of isolation and to demonstrate that they meet external standards. With the advent of formal GP Revalidation, CQC registration and every increasing budgetary constraints, many see that small practices will struggle with future challenges. The advent of large super-practices may provide economies of scale but intimate knowledge of patients and continuity of care may be put at risk.
No GP is entirely alone; practice managers have an important role in ensuring that standards are met and in making outside contacts. Locums, assistants and those providing out-of-hours cover should be fully engaged in assessing and improving the practice’s performance. Administrative staff and patients can also contribute.
Sharing reduces isolation and often offers economies of scale while allowing the single-handed practice to maintain its individuality. Sharing premises with other practices, a rota or co-operative arrangement for out-of-hours cover, sharing the setting of standards and audit with other practices, and co-operation over PCO clinical governance activities are all examples. For GPs and their staff in isolated areas, e-education and virtual discussion groups can be set up.
The Family Doctors Association provides information and support for single-handed practice teams and practices with up to three full-time GPs (or up to 7000 patients on its list): Ⓦ www.family-doctor.org.uk
Sick doctors and poor performance
One in 15 GPs will have a problem with alcohol and drugs at some time in their lives, and others will suffer significant physical or psychiatric illness. GPs are nearly four times more likely than the general population to commit suicide.
Doctors often conceal their problems; admitting problems at work is difficult for high achievers for whom work is a source of self-esteem. Men tend to turn to self-medication with alcohol and drugs; women tend to develop depression.
Risk factors for poor performance include being the focus of a complaint, emotional conflict at home or at work, chronic illness and burn-out. ‘Rust-out’—boredom—may also affect performance. Signs include poor time-keeping, calling in sick, deteriorating standard of clinical care, breakdown in relationships with staff and patients, and accidents.
The practice manager may be the first to suspect a problem, or another member of staff may raise it with their practice manager. There is no contractual obligation or established mechanism for managers to report their employees, but there is clearly an ethical duty to patients. The following steps are suggested:
If a practice manager suspects that a doctor is underperforming the first step is to try and address it with him or her and provide appropriate support. The organisations below provide confidential help to doctors, and doctor welfare is an important part of LMCs’ functions.
If the doctor denies the problem, the practice manager should go to the senior partner, or to another partner if the senior partner is the problem. The GMC has placed an obligation on all doctors to ensure that patients’ welfare is not put at risk by poor performance, however caused.
The manager of a single-handed practice is in a very difficult position. The LMC may be able to advise and support the manager. Each PCO will have a medical director who is the accountable officer for the GP performers list and they can also be contacted for issues regarding under-performing doctors.
Example
A single-handed doctor was becoming increasingly stressed. The practice manager tried tactfully to explore the effect of the stress on the doctor’s clinical care and on staff relationships, but the doctor denied any problem. The PM kept careful note of what was going on and then tried again, putting her observations in as non-threatening a way as she could. Eventually the doctor broke down and admitted that he was drinking to reduce the stress, opening the way to help.
Planned team building is likely to be needed when the doctor returns to work after rehabilitation.
Sources of help
The Local Medical Committee
Sick Doctors’ Trust—provides early intervention and treatment for doctors suffering from addiction to alcohol or other drugs, thus protecting patients while offering hope, recovery and rehabilitation to affected colleagues and their families Ⓣ 0370 444 5163 Ⓦ www.sick-doctors-trust.co.uk
BMA Counselling Service and Doctors for Doctors Unit—counselling and personal support. Helpline Ⓣ 08459 200 169 Ⓦ www.bma.org.uk/doctorsfordoctors
National Clinical Assessment Service (NCAS)—exists in England, Wales and NI to work with poorly performing doctors. It only takes referrals from the doctors themselves or their employers Ⓣ England: 020 7972 2999; Northern Ireland: 028 9266 3241; Wales: 029 2044 7540 Ⓦ www.ncas.nhs.uk
In HOPM see also
Section 8: Patients, Staff as patients
Section 2: The primary health care team, Whistleblowing
Overview of NHS Pension Scheme
The NHS pension scheme has been in existence for many years, although GP practice staff only became eligible to participate in the scheme from September 1997. Membership is voluntary, however, both GPs and practice staff will automatically become members of the scheme from the commencement of their employment unless they explicitly opt out.
The NHS Pensions Agency is responsible for managing the scheme with the support of employing organisations. The agency is based in Fleetwood and is more than happy to offer advice to both employing agencies and employees.
The scheme is particularly complex, which has been further complicated by the changes that came into place in April 2008, as there are now two schemes in operation. New employees joining a practice after April 2008 will automatically be eligible to join the New NHS pension scheme. If however, you were already a member prior to this date you will be required to decide whether you prefer to receive the benefits of the old system or transfer to the new. The benefits are significantly different and employees and employers are advised to read all of the information that is presented to them regarding their pension entitlements before expressing their choice. There has been further changes planned to the scheme due to the Government Public Sector Pension review between 2010 and 2013. These are due to be implemented from April 2015. There will be numerous changes including changes to retirement dates and levels of contributions. Much of this detail is yet to be released. Further information on the new scheme can be found on - http://www.nhsbsa.nhs.uk/Pensions.aspx.
It is due to this complexity and to the time of transition that we find ourselves in that the authors have opted only to provide a brief overview of the NHS pension scheme as they feel that this is an area that requires specialist advice, which only the NHS Pensions Agency or specialist pensions advisors will be in a position to do.
However in brief, both the schemes are open to:
All NHS employees aged between 16 and 75 years, including non-GP partners, but not including general dental practice staff
GP practice staff
NHS medical, dental and ophthalmic practitioners, including trainees, some locums and assistants
Staff working for an out of hours provider, which has registered as an NHS pensions employing authority
Some scheme members who leave the NHS to work for approved organisations outside the NHS, e.g. hospices.
As the employers representative it is generally the practice manager who has responsibility for managing the scheme alongside the practice payroll system and as such he/she will be responsible for:
Ensuring information relating to the scheme is passed on to the employees of the practice
Publicising the scheme
Administering the scheme including maintaining of pension records and paying over the contributions.
Practice managers are advised to ensure they regularly update their knowledge within this area. There are specialist companies who can offer packages of support in this area.
Some of these organisations will also administer the pension scheme for you.
Further information can be found at:
The NHS Pensions Agency via Ⓦ nww.pensionsagency.nhs.uk (via NHS sites only)
The NHS Business Services Authority via Ⓦ www.nhsbsa.nhs.uk/885.aspx
Employed GPs
Salaried GPs now make up more than 40% of the GP workforce and in some areas up to a third of consultations are with locums. GPs who are not partners in a practice are no longer the no-hopers of general practice. Increasing numbers of experienced GPs are choosing freelance or salaried work, and employed and locum GPs are now found at the highest levels of the profession.
Some employed GPs obtain a regular salary from a practice or other community health service provider. These salaried GPs may be partners in the practice and thus have management responsibilities and/or a share in the premises or may be employees who solely fulfil a clinical role. For GPs working within practices, funding for their posts is included in the global sum payment or the PMS equivalent. The exceptions are GP retainees, flexible career scheme GPs and returner scheme GPs (see below) for whom a practice receives partial reimbursement, separately from the global sum payment, via the PCO.
Model terms and conditions for salaried GPs employed by GMS practices and PCOs were published in April 2003 with the supporting documentation for the new GMS contract (available from Ⓦ www.bma.org.uk). The NHS (General Medical Services Contracts) Regulations 2004 made these terms and conditions a minimum legal requirement for all doctors employed by GMS practices or PCOs after 1 April 2004. The revised retainer scheme contract due in 2005 will follow the same model. Practices are not obliged to bring existing contracts with salaried GPs in line with the new contract conditions, but it is good employment practice to do so.
PMS practices are NOT bound by these constraints but failure to follow the minimum terms and conditions of the model contract is likely to result in poor recruitment and retention of employed doctors.
Salary levels
The Doctors and Dentists Review Body (DDRB) has suggested a salary range of £53,781 to £81,158 (from April 2010). GMS practices and PCOs have the flexibility to offer more but cannot offer less. Employed GPs should receive an annual increase in line with recommendations from the DDRB and, in addition, an annual uplift reflecting increased experience. The outlook for salary levels is not great for salaried GPs, as there has been public sector pay freeze for two years ending in 2013. This has been followed by a1% cap on public pay increases. In real terms this is a cut in income. However, unlike partners whose drawings may go up and down depending on practice income, a salaried GPs income should always be fixed.
Features of the model contract
Job plan: This outlines the employee’s normal duties, workload and non-clinical roles that must be undertaken in work time
Hours of work: Full-time is defined as 37.5 hours/week (9 sessions of 4 hours and 10 minutes). Pay should be adjusted pro rata. The employee is protected by the Working Time Regulations and therefore cannot be required to work more than 48 hours a week unless he or she agrees to sign a waiver form. An entitlement to 6 weeks of holiday per annum is included within the contract.
Bank holidays: GPs employed part time are entitled to pro rata time off in lieu of the eight bank holidays and the two extra NHS statutory days, irrespective of the days of the week they work. Thus employees who work Mondays may have to pay back time, those who work midweek will be entitled to extra time.
Rights to benefits, e.g. maternity leave or sickness benefit: These are based on duration of service within the NHS – not just on time with the practice or PCO. This includes time working as a locum as long as the GP was on a performers list.
Continuing Professional Development: Employed doctors are entitled to one session per week protected time for continued professional development. This is adjusted pro rata for part-time employees to a minimum level of eight sessions per year for GP retainers and flexible career scheme GPs. Some of these sessions may be used for attendance at practice clinical meetings and awaydays, contributing to preparing practice protocols, etc.
Education: employed GPs are entitled to apply to the practice for a share of the funding that is included in the global sum for educational purposes.
Annual appraisals: These must be undertaken through the PCO by each employed GP and the costs of these (including costs of locum cover to enable a GP to prepare for the appraisal) must be met by the responsible PCO. These appraisals should be undertaken in working time. If that is not possible the employed GP should be reimbursed for the time in addition to usual salary or given time off in lieu.
LMC levies: The employer must pay the LMC voluntary levy for the salaried GP.
Locum GPs
Locums are freelance, self-employed GPs. Good locums are much sought after. The further in advance you can arrange a locum the better, but in an emergency you will find it less difficult to find help if you know locums in your area, and are known by them.
Are you employing too many locums?
Every practice needs extra doctors occasionally. If you are plugging gaps with locums for more than the rare emergency, it will pay the practice to take a strategic look at doctor availability and the need for appointments and to come up with a better solution. The workforce planning text later in this chapter gives a guide to the issues the practice should be addressing. Paradoxically, a locum hired to reduce workload can actually generate workload with excessive referrals and investigations ordered and poor treatment plans lead to patients re-attending. Hence a good locum is worth their weight in gold.
Sometimes a doctor within the practice can take on more work for a while, for extra pay/ profit share. This saves on training, there is no learning curve, and it is less work than employing someone new. However, it is important to ensure that this doctor is not becoming overloaded, as burnout is a real risk. Alternatives are employing an additional salaried GP or expanding the practice with an additional profit-share partner.
Build up a file of doctors available for locum work. If locum GPs contact the practice, ask for their CV and invite those who look good on paper to visit the practice. A lot can be learned about whether they are clinically suitable (ask a partner to judge this) and whether they will fit in. If the paperwork is checked at this point, you have only to pick up the telephone and hope they are free when you need them.
How to find a locum
If you need to look elsewhere, work your way through this list:
PCOscan supply you with the name, GMC number and date of birth or registration of doctors on its Supplementary List. Some PCOs may have a locum bank and be able to provide contact details. .
Local non-principal groups often produce a list of jobs and of GPs looking for work. To find your local group contact the National Association of Sessional GPs (NASGP Ⓔ
Locums and vacancies are advertised on the NASGP website (Ⓦ www.nasgp.org.uk).
Local postgraduate centres or GP Specialty Training Schemes (aka VTS) programme directors often know of former registrars looking for work.
Other practices. Word of mouth is often the way to find the best locums.
The LMC office may know of people, or have advertisements in its newsletter or website.
Advertisements in the GP press and websites.
Agencies will always find you someone, but at high cost.
Paperwork
Much of this can be done electronically or by phone. It is important to note that the CQC would expect the same checks that you would carry out on employing someone permanently to be the same as contracting someone on a temporary basis. This may seem over the top, but in fact it does make sense as they are seeing your patients, and you need to ensure they are fit and proper to do so.
A checklist ensures that nothing is missed.
Are they legally fit to practise? Check the following:
GMC registration. You do not even need a doctor’s GMC number to check them on the GMC website (Ⓦ www.gmc-uk.org) or to contact the GMC for the information (Ⓦ www.gmc-uk.org/about/contactus/contact_3.asp). Alternatively, ask the doctor for their certificate.
Current medical indemnity certificate.
Certificate of Completion of Training (CCT), which has replaced the Joint Committee of Postgraduate Training in General Practice (JCPTGT) certificate, or equivalent certificate from another EU state or evidence of equivalent experience or ‘acquired rights’. If you are doubtful about a doctor’s eligibility to practice, contact the RCGP and the GMC.
Check that there are no complaints or disciplinary procedures outstanding against the doctor.
References must be taken up, although a locum may be employed for 14 days while this is being done. Note that employers are required to check locums’ references annually.
Up to date DBS check certificate
Note that inclusion on the performers list guarantees all the above, except scrutiny of references. However the locum should be able to provide you copies of the main documents, and it would be best to ask for copies. If the locum works for a specific locum company, you can ask for copies of the documents or a letter from them confirming they fit all the relevant CQC requirements relating to workers.
Are they right for your practice?
Curriculum vitae.
References should be checked.
Note their phone, fax and mobile numbers and e-mail address.
Note their availability. If you know Dr Brown is always working at the hospital on Tuesday afternoon, you won’t make useless calls. Keep the list up to date.
Agree what they are to do:
The practice manager must make clear arrangements with the locum. Asking someone to ‘do a surgery’ without specifying times and expectations is a recipe for bad feeling. Agree what they are to do, and the fees, in advance. Tricky areas can include additional payments for home visits or admin work. The NASGP has a draft booking form on its website (Ⓦ www.nasgp.org.uk or see below). Even if you choose not to use it, it is a useful checklist.
Money
The BMA is no longer allowed to publish guidelines, but the rates recommended are published in the journal Medeconomics, this was previously distributed free but is now an on line subscription service (http://www.medeconomics.co.uk/).
Allow for inflation. Be prepared to negotiate and to be generous, especially in an emergency or on New Year’s Eve.
Locums can join the NHS superannuation scheme. Their employer’s contribution, was until April 2013, paid by their PCO, and all that was required of the practice manager was to confirm their income by signing Locum Form A, which the locum would produce at the end of each month. rom 1 April 2013, GP practices in England and Wales are responsible for the employer’s pension contributions of the locums they engage. In Scotland and Northern Ireland, employer’s pension contributions for locum GPs are unchanged and will remain the responsibility of the PCOs. Under the new pension regulations, it is the ‘employing authority’ (i.e. the practice) that must pay the employer’s contribution. Practices must pay the 14% employer’s pension contribution (which is calculated using 90% of the locum fee) on top of any locum fees for locum GPs who are contributing to the NHS pension scheme from 1 April 2013 onwards. Practices have been prospectively compensated for this by a 0.15% increase in the GMS global sum and PMS equivalent. There has been a fear this may lead practices to be more knavish in the rates they pay, or use locums less, but this is yet to be evidenced. For further information see - http://bma.org.uk/practical-support-at-work/pensions/survival-guide-des-locum-superannuation-practices.
For further information see Ⓦ www.nhsbsa.nhs.uk/pensions.
Locums are usually self-employed, but consider obtaining their National Insurance (NI) and Schedule D numbers in case of a query from the Inland Revenue. Occasionally, locums opt for employed status, and any locum employed on a regular basis for more than 3 months is likely to be treated as such. In these cases the practice is responsible for deducting tax, NI and superannuation.
It may be possible to claim from the PCO for locum costs to cover sickness which leaves the existing partners with a very high patient load. Contact the PCO for details. They are not obliged to pay and it is at their discretion. Different PCOs had different rules relating to such payments. NHS England is trying to establish a national framework to ensure equity across the country. However, in the current tight fiscal situation it seems like the criteria will be quite strict to access such funds.
Freelance GP Agreement/Booking Form TABLE
: The NASGP Code of Good Practice states “practices and non-principals should formally agree terms of employment”.
: This form is to help GP Freelance GPs and their employing practices to reach agreement on conditions and terms of employment.
: We recommend that the Practice Manager completes this form after making initial arrangements and sends to the Freelance GP as soon as possible.
© NASGP 2001 PO BOX 188, Chichester, West Sussex, PO19 1FP www.nasgp.org.uk Page 1 of 2
NASGP members may legally tailor this form to their own needs
We will pay you our mutually agreed sessional rates including mileage where applicable. Fees from private work will be paid at % of the fee received by the practice.
Except in exceptional circumstances, you must give us at leastiii________days notice if you need to cancel any sessions.
Except in exceptional circumstances, we will pay you a cancellation payment as a proportion of your expected fee if we have to cancel within iv_________days of a session.
We will abide by the above agreement and to the NASGP Code of Good Practicev
An up-to-date Standardised Practice Induction Packvi will be provided.
Name
Signed
I will abide by the above agreement and to the NASGP Code of Good Practice
Name
Signed
We will be extremely grateful for any feedback, suggestions or advice that you may have to help us provide a better service for our patients and to make your working conditions more comfortable.
iThe name of the GP who is being covered
iiWhich [branch] surgery?
iiiWe suggest 14 days
ivWe suggest 14 days
vAvailable to all NASGP members or from our website at www.nasgp.org.uk
viCan be ordered through the NASGP website at www.nasgp.org.uk
© NASGP 2001 PO BOX 188, Chichester, West Sussex, PO19 1FP www.nasgp.org.uk Page 2 of 2
NASGP members may legally tailor this form to their own needs
Induction of locums and other doctors new to the practice
Risk reduction and value for money
Locums are expensive. Getting value for money does not just depend on their qualities; it involves some investment. The more familiar new doctors are with your systems and the better organised the practice is, the better job they can do. Make sure they are welcomed, and that they are thanked at the end of their stint. A locum who has enjoyed working for you and feels valued is likely to go out of their way to help you out in an emergency. And if they are more than occasional, invite them to practice meetings. They will learn about you, and you may learn some useful things from them! Remember that today’s hired hand may be tomorrow’s salaried GP or partner.
Example The locum’s nightmare
Arrive in plenty of time so I can get organised. Will I be in the untidy doctor’s room that has most things if you hunt long enough, or at the neat chap’s desk, who appears to practise without needing a sphygmomanometer, patella hammer or BNF? Hope the receptionist who understands the computer is around because signing on here is always tricky. Has the printer plenty of scripts? Last time it ran out and it took 10 minutes to find someone who knew where they were and how to load them.
First patient has come for smear. Good, speculums to hand. But no fixative. Try to find practice nurse. Meanwhile queue builds up. Next patient demands Calpol. At least the computer shows that this is a practice which is willing to prescribe it.
Physiotherapy referral. They’ve given me a Good Locum Guide but it was written five years ago and all that’s been done since then is to shove in bits of paper about pathology services over the millennium holiday and outbreaks of meningitis in 1998. Undertake to refer patient and make a note to ask a partner after surgery where and how.
Pregnant woman worried about baby. Sonicaid? Ring only partner in the building. Usually kept in nurse’s room. Not there. Well, it must be in someone’s consulting room. Choice is a hunt through five consulting rooms on three floors, listen with my ear to her abdomen, or send in to maternity unit.
I’m now 25 minutes behind. This patient has come because she has been told she can’t have any more medication until she has seen a doctor for review. There are no chronic conditions on her computer summary but her medication suggests she has asthma, heart disease and depression. Where to begin??
The fancier you are with your admin workflow and phone system, the more difficult it will be for a novice to use it. Except in a one-off emergency, invite locums round beforehand, or be prepared to pay them to sit in on a partner for an hour or two so they can learn about your clinical software (essential if they have not used it before) and your systems, and see the practice’s style first hand. Be prepared to give new locums longer appointments until they are familiar with the systems.
Practice induction packs
It is well worthwhile compiling an information pack, which will help all new clinicians including registrars. A standardised practice induction pack is available from NASGP (Ⓦhttp://www.nasgp.org.uk/download/spip/practice_pack_flier.pdf bulk discounts available). Some PCOs will have induction pacts outlining referral pathways for hospital and community services and most practices now have websites which give a lot of useful information. Whatever form you choose, make someone responsible for compiling the guide and keeping it up to date. Essential information includes:
Who’s who (doctors, attached staff, administration staff)
Telephone numbers including bypass line, and how to work the phone system
Simple guide to your computer system and how to use it. Who can help if they have a problem (this is becoming less of a problem as most practices tend to use one of the few approved systems i.e. EMIS, VISION, SystemOne)
Information about how things are done and how to get them done
Where to find equipment, people and (most important) help
Arrangements for repeat prescribing
Practice headed paper, pathology forms, referral pro formas, sick notes, etc.
For visits, street map, bleep, phone and keys, if necessary
Obligations and performance
Practices are obliged to ensure that the CMO’s urgent communications are passed to locums.
Try to keep locums you use regularly informed of practice developments, and give them feedback on patients they have seen.
If the practice is unhappy about a locum’s performance, the locum should be told. If there are serious concerns, you need to invoke your local poorly performing doctor procedure through the PCO or LMC. See NASGP’s website (Ⓦ www.nasgp.org.uk/download/reports/complaints/involving_sessional_gps_in_complaints.pdf) for their document on how to involve locums in complaints.
Locums see a lot of practices. They are often part of a network and the word – good and bad – soon spreads. The RCGP Toolkit for Managing GPs Whose Performance Gives Cause for Concern obliges locums to blow the whistle on poor performance (Ⓦ see www.rcgp.org.uk).
Pensions for GP locums
Pension Scheme regulations became effective on 5 April 2002, which opened the scheme to freelance locum practitioners. Effective from 1 April 2003, GPs who are already NHS Pension Scheme members will be able to ‘pension’ their GP locum earnings. They can choose to include backdated earnings for NHS locum work undertaken since 1 April 2002.
This means that:
GP (‘practitioner’) and hospital doctor (‘officer’) members of the NHS scheme can apply to pension any GP locum medical practitioner work they do. Doctors must be on a performers list as a GP locum, on the GP medical list or a named performer or provider in PMS.
Any NHS GMS, PMS or PMS+ work can be pensionable, provided there is a clear and direct transaction for the work between the locum and the employing GP practice or absent GP. GPs who are already members of the NHS Pension Scheme must keep their NHS GP locum earnings and contributions separate from any other GP pensionable earnings. Tax relief can be claimed at the usual rate on the contributions paid.
It is important to remember that not all locum work is pensionable, for example, GP locum work that has been arranged and paid through a third party (such as a commercial deputising firm, a commercial agency or a cooperative) and private (non-NHS work) performed on behalf of a GP is not pensionable under the NHS Pension Scheme. It may be worth pointing this out to a locum GP if as a practice you are requiring a locum for such purposes.
GP locum benefits/contributions
The value of the NHS Pension Scheme is approximately 20% of pensionable income although the cost to a NHS GP is only 9–11%. Bearing in mind that this attracts tax relief so the real cost is lower. GP locum work builds up NHS scheme membership in the same way as for assistant practitioners.
All the pensionable income earned throughout a GP locum’s career will be up-rated (dynamised) each year along with other pensionable practitioner income and then totalled at retirement. This total dynamised career income is then multiplied by a factor of 1.4% to produce the pension. A GP locum will also receive a tax-free lump sum, which is normally three times the annual pension.
Practice managers should expect GP locums to send the forms GP locum A and B to them for the NHS work complete, for certification with their invoice at the end of each month.
References and further information
For information about pensions for GPs see Section 2: The primary health care team, and for practice staff pensions see Section 4: Employing and managing people.
Retainer GPs and GP returners
The retainer scheme is a long-running scheme designed to help GPs with domestic commitments remain within general practice. In November 2002 the Department of Health introduced another scheme – the GP returners scheme. Both schemes combine a service commitment with education and support in order to attract qualified GPs back to the profession and/or retain them within it. Doctors on the flexible career scheme may annualise their sessions, e.g. working more sessions for part of the year to be entirely free of commitments for the rest of the year. Both the practice and the GP will need to negotiate and agree arrangements before the contract is signed.
GPs on these schemes are salaried GPs and may not be offered terms and conditions less favourable than the model contract (see Employed GPs). Practices receive a subsidy via the PCO for their employment costs in addition to the usual staffing budget. This subsidy reflects the educational nature of the posts.
Retainer GPs
The retainer scheme allows trained GPs to continue working and keep up-to-date while taking a career break. Retainers can provide invaluable assistance to a practice, but it must be remembered that they are not cheap assistants. This is an educational post, and the subsidy the practice receives is in recognition of its educational obligations.
A GP can be a retainer for only 5 years. After that many will be looking for a salaried post or partnership; again, employing a non-principal can be an investment for the practice.
The retainer scheme is described under ‘GP retainer scheme’ in Section 5, Education.
Your local Deanery will supply information about local arrangements for retainers and the standards required of a practice applying for a retainer. The Deanery usually inspects practices before approval to employ a retainer is granted.
For a model contract for retainers see Ⓦ www.bma.org.uk or contact your BMA regional office.
For information about financial aspects, contact your PCO.
Much of the information in the locum section is applicable to employment of retainers.
GP returners
Qualified GPs who have taken a career break may wish to spend some time in a supervised post while they regain confidence in their skills and update their knowledge. In England and Wales, the GP Returners Scheme offered practices a grant for providing a returner with a refresher training post for six months. The central funding for the scheme was withdrawn in 2006 but the scheme was so successful that some deaneries and PCOs have kept schemes going with local funds.
For GPs trained in the UK returning from abroad (after more than two years away) the rules have become more draconian. The Committee of GP Education Deaneries (COGPED), who represent the deaneries, introduced new rules in 2011 which mean returning GPs will have to re-sit a number of medical exams akin to the MRCGP and may well have their English skills re-tested even if they came from an English-speaking country.
Employing GPs from abroad
In the past, recruitment of GPs has not always been easy and many practices looked at recruiting GPs from abroad. Since 2000, there has been increased numbers of GP training posts hence more qualified GPs coming into the market. This initially meant practices did not need to look abroad as much. However, as increasingly more GPs are opting to work flexible hours, on a part-time basis or retire, this may become an issue again. Before a GP from abroad can practice in the UK, he or she must be registered with the GMC and be on a PCO performers list.
Since 2002, the GMC has been able to grant full registration to doctors who hold overseas primary medical qualifications, as long as their primary medical qualification is recognised by the World Health Organisation. Internationally recruited general practitioners who are seeking employment within the NHS must apply under Article 11, which will allow them to be entered onto the GP Register established by the GMC.
European Economic Area (EEA) and Swiss doctors, having completed training within the EEA and Switzerland are eligible for immediate full registration with the GMC. Non-EEA doctors must have their training and experience assessed by the GMC.
GPs from the EEA and Switzerland
European legislation states that citizens of the EEA may live and work freely within any member state. This means no formal checking of English language skills or medical experience and skills would be required. Healthcare Professionals Crossing Borders is a European-wide partnership of healthcare regulators working together to develop improved information sharing and collaborative approaches on regulation within the European Single Market.
In the past, professional bodies did not hold adverse information about a doctor’s fitness to practice, but recent agreements facilitated by the GMC will help to ensure that this information follows a doctor as he or she moves around Europe under its ‘free movement’ provisions. The main reason for this is to reduce bureaucracy for the migrating professional while maintaining patient safety.
There have been some high profile cases of EEA doctors with poor English skills doing OOH work, where patients have come to harm. Due to the strong public and professional reaction to these cases, the Secretary of State for Health in 2011 announced responsible officers in PCOs would have powers to ensure EEA doctors’ language skills were vetted, and give the GMC new powers to take action against doctors with a poor grasp of English. However some argue this still does not address the issue of clinical competence of EEA doctors, which unlike internal medical graduates (see below), is not tested. This issue will always be difficult to resolve to all parties satisfaction due to EU employment law.
GPs from outside the EEA and Switzerland
For international medical graduates who do not benefit from European law, doctors must apply to the GMC for registration, which is an arduous process. It involves:
Acceptance of their primary care qualifications against fixed criteria
English capability assessment – the International English Language Testing System (IELTS) is used. An overall band score of 7 and a minimum score of 7 in each of the areas tested (speaking, reading, writing and listening). The IELTS test will only be considered valid for a period of two years
Fitness to Practice Declaration – a self-declaration form
Certificates of Good Standing – from each of the medical authorities the doctor has worked for
Evidence of Knowledge and Skills – Evidenced by passing an exam (Professional and Linguistics Assessment Board [PLAB]), a suitable post-graduate qualification, or sponsorship by a recognised institution
– To be eligible for full registration with a licence to practice the doctor must have satisfactorily completed either foundation year one in the UK, or a period of pre-graduate or postgraduate clinical experience.
Further information: Ⓦ www.gmc-uk.org/doctors/before_you_apply/imgs.asp
Nurses
Introduction
There are many nurses who are members of the PHCT, grouped into a number of different nursing disciplines. The role they play within the PHCT is dependent on their initial training and, conversely, the curriculum of their initial training should match the job description of the job for which they are trained. Therefore, if a practice manager is to fully understand the potential role of nurses they need to understand the content of their initial training programme and the expected level of knowledge, skills and attitudes indicated by the various nursing qualifications. If they also take into account any further training and experience then they should understand the expected abilities of different nursing disciplines. Much of this information is also contained within Section 5 on Education but we have repeated some of this material here where it has relevance to understanding the different roles of specialist nurse practitioners.
These include practice nurses, district nurses and health visitors. All nurses employed to work in community settings must be qualified nurses and be registered with the Nursing and Midwifery Council (NMC). The NMC’s main function is to protect the public, and it maintains records on all qualified nurses. All registered nurses must abide by the NMC standards for education, practice and consent Ⓦ www.nmc-uk.org). Student nurses and nurses undertaking post-registration courses may also work in the community, but all students must be supervised by a suitably qualified member of staff.
Specialist practitioners
The NMC has agreed that health visiting, district nursing, practice nursing, community mental health nursing, community children’s nursing, learning disability nursing and school health nursing should be defined as specialist nursing practices. In order to be deemed a specialist practice, a specific course of study should exist to train the practitioner for that nursing discipline. The educational programme is determined by the NMC and delivered in higher education institutes.
The specialist nursing practitioner courses require that all community students learn together for no less than a third of the course, to develop their understanding of one another’s role and to enhance closer working in practice.
Public health nursing and health visitors
Health visitors are normally employed by a trust. It is a statutory requirement that practitioners must have undertaken a course in public health nursing or health visiting prior to working in this area. It is the only community nurse qualification that is statutory and which can be registered. The educational programme that potential health visitors follow was revised in 1995. The Council for the Education and Training of Health Visitors (CETHV) drew up the principles of health visiting in 1977. These principles are:
The search for health needs
The stimulation of awareness of health needs
The influence of policies affecting health
The facilitation of health-enhancing activities.
The four areas of practice that are included in the education programme are:
Clinical practice
Care and programme management
Clinical practice development
Clinical practice leadership.
The indicative content of the programme includes:
Introduction to meeting specific targets
Accident prevention across all age groups
Specific interaction with groups and individuals for management of life stresses
Meeting the health needs of black communities and multi-ethnic groups
Child protection and violence in families
Development of parenting skills
Development of community and practice profiles and the use of these in determining resources and priorities in health-care strategies
Child development, surveillance of child developmental behaviour, sleep management
Knowledge of mental illness and interventions
Assessment of the needs of vulnerable people or those at risk of mental illness; early detection and appropriate intervention
Knowledge of strategies for effective referral to mental health practitioners
Role of the public health nurse in prevention and recognition of substance misuse and early intervention in the care of people who misuse substances.
District nurses and nursing in the home
It is possible to work as a community nurse without having to undertake further study; however, only those who have undertaken a specific course of study can use the title ‘district nurse’. District nurses are usually employed by a trust. The four areas of practice that are included in the district nursing education programme are:
Clinical practice
Care and programme management
Clinical practice development
Clinical practice leadership.
The indicative content of the district nursing educational programme includes:
Collaboration with other agencies, including referral procedures
Planned and opportunistic screening of at-risk groups, acting as case-finders
Management of clinical conditions and development of strategies to effect appropriate nursing interventions
Health needs analysis of practice populations
Development and use of practice profiles, the importance of epidemiological and demographic data in determining resources required for effective nursing interventions
Knowledge of mental illness and interventions; assessment of the needs of vulnerable people or those at risk of mental illness; early detection and appropriate intervention
Knowledge of strategies for effective referral to mental health practitioners
Budgetary management in formulating care packages to meet health and social needs
Role of the nurse in the home in prevention and recognition of substance misuse, and early intervention in the care of people who misuse substances.
General practice nurses
Although most practice nurses do have specialist training, it is possible to work as a practice nurse without having undertaken any specialist course of study. Practice nurses are usually employed by individual practices and there are several levels at which they work:
Practice nurse
This level of practice nurse:
Delivers nursing care
Runs clinics
Provides health promotion advice
Carries out immunisations and smear tests
Inducts new staff
Has knowledge of chronic disease management, general health care, family planning and well woman care.
Skills include communicating information to and reassuring patients, as well as planning home visits. The practice nurse will give injections and other surgical interventions; assess and manage the care needs of patients; implement clinical policies and readjust protocols to meet need. They will also make judgements on changes to drug treatments and may refer patients to hospital.
This level of nurse works largely independently and their work is managed rather than supervised. They are able to demonstrate their duties to less experienced employees and supervise students, and can undertake surveys or audits. They may occasionally participate in research and development, clinical trials or equipment testing.
Further information relating to pay bands are available on the RCN website Ⓦ http://www.rcn.org.uk/support/pay_and_conditions/pay_rates_201314
Specialist practice nurse
This level of practice nurse:
Delivers nursing care, including running specialist clinics
Educates patients
Carries out immunisations and smear tests
Inducts new staff.
A nurse working at this level carries out the same duties as a practice nurse, but will also have specialist clinical knowledge. The qualification required would be a degree plus post-registration training (ENB or equivalent). These nurses require skills to assess and interpret specialist clinical conditions, and have the ability to plan home visits, run clinics, organize their own work, give injections and perform other surgical interventions. They assess and manage care needs for patients, while implementing clinical policies and readjusting protocols when necessary.
Specialist practice nurses are accountable for their own professional actions and are capable of initiating action within broad clinical policies. Such a nurse would be able to demonstrate their own duties and supervise students; undertake research in their own specialism; carry out complex audits; and become involved in clinical trials.
Nurse practitioner (highly specialized nurse)
This level of practice nurse:
Assesses patients
Plans and implements care
Provides specialist advice and maintains records
Is a lead specialist in a defined area of nursing care, also providing specialist education and training to other staff and students, and undertaking research and lead clinical audits in his or her own specialist area.
A nurse working at this level will have professional knowledge acquired through a degree plus state registration, supplemented by diploma level specialist training, experience, short courses and CPD.
The nurse is able to communicate very sensitive condition-related information to patients and their relatives, and provide empathy and reassurance. He or she is also capable of assessing and interpreting specialist acute needs and taking the appropriate action; and has the ability to plan specialist nursing service provision including education, training and cover. Nurse practitioners can develop specialist protocols; assess, develop and implement specialist nursing care programmes; and give advice to patients and relatives.
Nurse practitioners are accountable for their own professional actions, not directly supervised and are lead specialists for a defined area. They provide specialist training and education, undertake research and lead clinical audit in their own area of work. Although usually employed by individual practices, nurse practitioners are increasingly being employed by PCOs to provide specialist services across the PCO.
Further information on job profile and training an be found on the RCN website Ⓦ http://www.rcn.org.uk/__data/assets/pdf_file/0003/146478/003207.pdf.
Team adjustment
If you are lucky enough to recruit an experienced nurse practitioner then it is likely that the arrangements for seeing patients will need to be completely changed, and the autonomous role of the nurse practitioner in the diagnosis of undifferentiated patients understood and accepted by the rest of the team. Arrangements for signing prescriptions and immediate access to advice from a doctor will need to be considered. In practice, both patients, doctors and other team members will probably need time to adjust and for all to feel confident that the nurse practitioner not only knows the limits of their competence but works within them.
Patient adjustment
Particular care should be taken when introducing the concept of the nurse practitioner to patients. Patients will need information about the new service, the nurse practitioner as an individual and the training received that enables them to undertake a diagnostic role in the practice. This information could be given through newsletters, leaflets in the waiting room or the new nurse practitioner could give a presentation on their role at a community or Patient Participation Group meeting. Initially, patients might feel that they have had to settle for seeing a nurse when they wanted to see the doctor but this will change as the nurse practitioner establishes a reputation. This process will be greatly helped if everyone else in the practice is seen to respect the nurse practitioner’s opinion. Receptionists are influential here and GPs can do much to help establish this reputation if, when called in for further help in a consultation, they are seen to listen to the nurse practitioner’s assessment of the situation. Joint surgeries where the nurse practitioners and a GP see patients together and the GP provides confirmation of the nurse practitioner’s clinical diagnosis can be helpful provided the GP is able to take a back seat! As the nurse practitioner becomes more experienced they are likely to become increasingly competent and confident in dealing with a large range of situations, provided they have had the opportunity to discuss and learn from each new case. Experienced nurse practitioners are extremely valuable members of the team and can make a substantial contribution to the work of the doctor team.
The nurse practitioner in training
If one of your practice nurses is keen to train as a nurse practitioner then it may well be in the interests of the practice to encourage and support them, even financially. If you are supporting one of your nurses on a nurse practitioner degree course then they will require one of the doctors in their practice to act as their clinical mentor or trainer. The nurse will also need to have the opportunity to practice new clinical and diagnostic skills. This may mean a big change in how other members of the team and the patients perceive the nurse practitioner and arrangements for seeing patients will need to be reviewed so that the nurse practitioner increasingly sees undifferentiated cases that need a diagnosis. This may mean reducing commitment to their traditional practice nurse role such as cervical smears and family planning. They will need ongoing clinical supervision and educational support similar to a GP registrar in the early stages.
As the demand for nurse practitioners grows and more courses involving degrees and diplomas are developed, then there will be an increasing need for the Nursing and Midwifery Council (NMC) to provide professional regulation to ensure consistency between the educational programmes and the maintenance and monitoring of standards of practice.
The nurse practitioner role will only flourish if it is built upon a basis of sound partnership with GPs who do not see them as a threat but as a valuable asset. This mutual respect will have to be earned through good clinical knowledge and quality care that positively influences patient outcomes. The practice manager has an important role in supporting this process.
Case study
Practice X was supportive when one of their valued practice nurses expressed an interest in taking a nurse practitioner degree. She would reduce her hours in the practice for a few years in order to study and one of the partners agreed to be her clinical mentor.
At first all was well but gradually it became obvious that she needed more educational input. The partnership was not unanimous in deciding to allow the GP mentor to give tutorials instead of a surgery but it was agreed slightly reluctantly. The GP mentor became increasingly enthusiastic about the new role of the nurse practitioner but other partners felt that it would always be quicker to see patients themselves rather than working through a nurse practitioner. Some partners still thought that she was being trained to be a better practice nurse and continued to refer patients to her for family planning.
Her new role was carefully explained to the patients through the practice newsletter and this was reinforced by the receptionists who had great respect for her knowledge and skills. However, the receptionists still viewed her as part of the practice nurse team. The patients were quick to adjust to her new role but the rest of the primary health care team took longer to adapt.
In order to adjust perceptions, the training nurse practitioner was given regular opportunities to debrief with all the partners.
Attitudes slowly changed and she got her degree.
Some months later she had an appraisal and it became clear that she was not happy with the work she was doing. Her appointments were constantly filled with cervical smears, family planning and even requests for phlebotomy. The receptionists were called together and her role and expertise were explained. Although some aspects improved she found herself volunteering to help the practice nurses when they were under pressure as she was the leader of their team.
The practice was very disappointed when she handed in her resignation but the practice manager was very supportive and said if she changed her mind she was welcome to return. Nine months later she returned to the practice in a new role. As part of the doctor team she shared the responsibilities of a new triage system that assessed, diagnosed and treated all patients needing same-day treatment. Every morning she worked alongside one of the partners and patients were allocated randomly. If she came up against a more challenging situation it was agreed that the doctor would see the patient with her, therefore turning it into an educational opportunity. Her booked appointments in the afternoon were filled by patients who requested to see her. As patients began to understand her role and expertise they have come to see her for a huge variety of problems both chronic and acute and it would be difficult to tell the difference between her surgeries and one of the GPs. Now firmly established as one of the doctor team she feels that her training and expertise is being used appropriately. She believes that her time away from the practice was needed to enable her to change her role and the practice values her skills extremely highly.
Nurses with a special interest
Running in parallel to the development of the GP with a special interest (GpwSI) is the advent of the nurse with a special interest (NwSI) initiative. Both posts see the health professional supplement their important generalist role by delivering a high quality, improved access service to meet the needs of a single PCO or group of PCOs. They may deliver a clinical service beyond the normal scope of general practice, undertake advanced procedures, or develop services. They do not offer a full consultant service and do not impact on access to consultants by local GPs. Further training and experience required to become a NwSI will depend on the role of that nurse.
Further information:
NatPaCT. Ⓦ www.natpact.nhs.uk/cms/165.php.
Nurse prescribing
Independent prescribing means that the prescriber takes responsibility for the clinical assessment of the patient, establishing a diagnosis and the clinical management required, as well as responsibility for prescribing (where necessary) and the appropriateness of any prescription. Doctors, dentists and some nurses are independent prescribers. There are currently two types of independent nurse prescriber:
Nurse Independent Prescribers are specially trained nurses allowed to prescribe any licensed and unlicensed drugs within their clinical competence. In 2006, nurse prescribers were given full access to the British National Formulary (BNF) and this has put nurses on a par with doctors in relation to prescribing capabilities. As of April 2012 nurse independent prescribers will be able to prescribe controlled drugs within their competence and regularise the practice of mixing medicines that include controlled drugsiv.
a. Community Practitioner Nurse Prescribers are a distinct group under independent prescribers. They consist of district nurses, health visitors and school nurses who are allowed to independently prescribe from a limited formulary called the Nursing Formulary for Community Practitioners which includes over-the-counter drugs, wound dressings and applications.
2. Nurse Supplementary Prescribing is based on a voluntary prescribing partnership between a doctor (independent prescriber) and a nurse (supplementary prescriber) where the supplementary nurse prescriber has the ability to prescribe any drug listed in a patient-specific clinical management plan once the patient has been diagnosed by a doctor. There are no legal restrictions on the clinical conditions where the supplementary prescriber cannot prescribe and this is most beneficial for nurses caring for patients with long-term conditions like diabetes and asthma.
Reference - RCN - http://www.rcn.org.uk/__data/assets/pdf_file/0008/443627/Nurse_Prescribing_in_the_UK_-_RCN_Factsheet.pdf
More detailed information on independent nurse prescribing can be found on the Department of National prescribing Centre’s website: Ⓦhttp://www.npc.nhs.uk/non_medical/.
Continuing professional development for nurses
See Section 5: Education, Continuing professional development
Clinical grading
Clinical grading is the process of determining the grade and hence financial remuneration allocated to a particular role or job. When determining the grade that a particular role carries, consideration should be given to the knowledge, skills, education and level of responsibility required for the role. It is important that roles are graded rather than individuals.
Skill mix
Skill mix refers to the process of ensuring that the right professional skills exist to meet the needs of the population served. Skill mix is most frequently referred to in nursing; however, the concept has relevance for all staff groups working in primary care. Job vacancies offer an opportunity to review the skill mix of the team and to make changes if necessary, rather than simply to replace old staff with new staff possessing the same abilities. Ensuring you have the correct skill mix to meet population needs can be a complex process and should include:
Defining the relevant population
Identifying the health care services the population requires
Determining the knowledge, skills and competencies required to meet the identified needs
Defining the level of responsibility required within the role(s)
If the primary care team decides that different or additional skills are needed, the above review is then translated into a job description and personal specification for the new role. In nursing the new job is graded in line with the responsibility it carries. Addressing skill mix should not be seen as an opportunity to downgrade posts or to save money, although this may be an outcome. It should be viewed as an exercise in quality assurance, to meet the users’ needs more effectively.
Health care assistants
Health care assistants (HCAs) play a significant role in supporting general practices. HCAs are often recruited to perform a number of delegated procedures in order to make best use of clinician physician’s time and to bridge the gap where there are shortages of other professional staff. Following the introduction of the Quality and Outcomes Framework and a number of enhanced services, additional opportunities have been created for staff without nursing qualifications to engage in this work.
The Royal College of General Practitioners suggest that HCAs can be involved in the following tasks in general practice, and should ideally work alongside nursing or clinical colleagues:
New patient registration
Blood pressure checks
Urinalysis
Height / weight / BMI
Ordering supplies / stock control
Cleaning sterilisation equipment
Phlebotomy / venepuncture
Ordering vaccines
ECG recording
Peak-flow measurement
Spirometry
Audiometry
Smoking cessation
Restocking of clinical area
Health promotion
Supporting practice nurse triage
Minor-illness clinics
Assisting with minor operations
Infection control
Health checks
Summarising patient records
Acting as a chaperone
Helicobacter testing
Patient recall
Helping with specific long-term conditions, e.g. diabetes, asthma
Although there are no national minimum entry requirements, HCAs would usually have a good general education and some experience in a caring role. Training mainly takes place on the job but HCAs would normally have the opportunity to obtain an NVQ qualification in health and social care.
Whilst HCAs are currently unregulated and unregistered the major medical defence bodies normally offer free protection. It is very important for practices to remember that GPs are vicariously liable for any delegated tasks.
The salary of HCAs varies according to their qualifications, experience and range of duties. In many practices, reception staff have been trained to perform a variety of HCA duties and their pay structure remains within the pay for administration and clerical staff.
The following websites give comprehensive details about training and development of HCAs:
Ⓦhttp://www.nhscareers.nhs.uk/
For additional information: https://nationalcareersservice.direct.gov.uk/advice/planning/jobprofiles/Pages/healthcareassistant.aspx
Physicians Associates
Physicians Associates (previously Physician Assistants) (PA) are health professionals with a postgraduate qualification who can work in a variety of healthcare settings under the supervision of a trained doctor. The DH describe them as “a new healthcare professional who, while not a doctor, works to the medical model, with the attitudes, skills and knowledge base to deliver holistic care and treatment within the general medical and/or general practice team under defined levels of supervision.”
Currently, UK physician assistant students spend 50% of their time in theory and 50% in practical work, with clinical attachments usually in general practice, medicine, paediatrics, obstetrics and gynaecology, and clinical psychiatry. All graduates take a national examination resulting in a postgraduate diploma in physician assistant studies and entry to the physician assistant managed voluntary register. The UK Association of Physician Assistants and the universities concerned have also committed to running a recertification knowledge test at six yearly intervals.
Reference
BMJ 18/07/12; Physician assistants: friends or foes to doctors? Ostler, Vassilas, Parle
Indemnity
PAs require professional indemnity coverage. The cost of this coverage is typically paid for by the employer. Currently, the Medical Protection Society (MPS), Medical Defense Union (MDU) and Medical and Dental Defence Union of Scotland (MDDUS) will provide professional indemnity for those PAs working in general practice.
What can they do:
Perform Physical Examination
Take Medical History
Patient Education
Interpret ECG
Take Bloods
Obtain ECG
Suturing
Psychiatric Assessment
Pelvic Examination
Incision and Drainage of Abscess
Joint Aspiration / Injection
Surgical First Assisting
Nerve Blocks
Lipoma Removal
Currently PAs are currently unable to prescribe medications in the UK.
Reference
Ritsema TS, Paterson KE. Results of the Second Annual UK Physician Associate Census, May 2012
Delegation and referral to other health professionals
The mix of skills in health care teams is growing, and patients are seeking treatment from outside conventional health practice. Both these factors make the issue of responsibility for patients’ management increasingly important.
Doctors
GPs can demonstrate that they retain responsibility for care by reviewing patients.
The boundaries between delegation and referral are blurred. In either case the GP and the practitioner to whom the patient is delegated or referred both have a duty to ensure that the practitioner has appropriate skills, has adequate information about the patient, and is given and respects an appropriate brief. GPs need to bear in mind that the status of the practitioner determines how patients can seek redress for damage and also whether the referrer may share liability.
Allied health professions
The allied health professions (AHPs, formerly professions allied to medicine) are subject to statutory regulation. Like the General Medical Council, their regulatory organisations set standards of education, practice and conduct, maintain a register of practitioners and deal with misconduct. Practitioners’ professional titles are protected by law: only registered art therapists can call themselves art therapists.
The AHPs and their regulatory bodies are listed below. AHPs include physiotherapy and chiropractic. The DoH is considering the registration of acupuncture and herbal medicine.
Registration is considered a guarantee of competence so GPs may safely refer patients to appropriate practitioners. Patients have redress through the registering body in the event of an accident.
Practices considering employing allied health professionals need to consider:
GPs often expect too much and know too little about colleagues’ disciplines. A meeting to discuss realistic expectations of referrals and to explore the range of services a practitioner can offer is essential.
Will the practice employ the practitioner or buy sessions from an existing organisation?
How will referrals be made? How will appointments be made? Who will deal with queries?
If the practitioner is to use practice premises, will changes to the fabric of the building be required? If equipment is required, who will provide and insure it and where will it be stored?
Do reception, the waiting room and car park have the capacity to absorb the extra demand?
Will the practitioner have access to patients’ notes? Providing access ensures that the practitioner has the necessary medical information about a patient, and integrates their consultations into a single medical record. Will the practitioner record the fact of a consultation or full details? Confidentiality issues need to be agreed.
Avenues of communication and opportunities for case discussions should be arranged.
The practitioner’s professional indemnity insurance must be checked.
Contract review should include examination of workload and outcomes as well as terms.
Chiropractors
General Chiropractic Council Ⓦ www.gcc-uk.org; Ⓣ 020 7713 5155
Opticians
General Optical Council Ⓦ www.optical.org; Ⓣ 020 7580 3898
Osteopaths
General Osteopathic Council Ⓦ www.osteopathy.org.uk; Ⓣ020 7572 2737
Pharmacists
Royal Pharmaceutical Society Ⓦ www.rpsgb.org.uk; Ⓣ 020 7735 9141
The
Counsellors
Around 50% of practices have access to counselling services for their patients. Many employ counsellors. Clinicians will also be asked for advice on private counsellors. Many PCOs will have lists of local services.
Counsellors are not subject to statutory regulation, but can register with or be accredited to several recognised bodies which guarantee qualifications and ethical standards and exercise disciplinary control (see below).
Practices employing counsellors need to define the range of problems they wish a counsellor to see and to ensure that the counsellor’s training and skills meet the brief. Agreement needs to be reached on time limits to therapy (often set at six sessions), onward referral or referral back to the GP of patients who prove to have problems more appropriately dealt with by another professional. Agreement is also needed on access to patients’ medical records. Patients may have strong views about this, and it is usual for the content of a counselling session to be confidential unless information revealed puts someone at serious risk.
British Association for Counselling and Psychotherapy Ⓦ www.bacp.co.uk; Ⓣ 0870 443 5252 (accredits counsellors, publishes ethical standards and code of conduct, and handles complaints against practitioners)
Counselling Ⓦ www.counselling.ltd.uk (counselling charity offering registration)
Homeopaths
Homeopathy is not available on the NHS in all areas of the country, but there are several NHS homeopathic hospitals and some GP practices also offer homeopathic treatment.
Homeopathy is usually practised privately and homeopathic remedies are available from pharmacies.
A 2010 House of Commons Science and Technology Committee report on homeopathy said that homeopathic remedies perform no better than placebos, and that the principles on which homeopathy is based are ‘scientifically implausible’.
There is no legal regulation of homeopathic practitioners in the UK. This means that anyone can practise as a homeopath, even if they have no qualifications or experience. A number of professional associations can help you to find a homeopath who will practise the treatment in a way that is acceptable to you.
Example
A practice appointed a nurse with homeopathic training. She explained what her training involved, what problems she was equipped to treat and how treatment would work. The GPs, with varying degrees of enthusiasm, worked out with her a protocol for delegation of patients suitable for, and keen to try, homeopathic treatment. She agreed that if she saw a patient she felt was suitable, she would consult a partner before starting treatment. A session was set aside for her homeopathic work, a patient questionnaire was developed and a review date set. Patients were informed by leaflets and notices in the waiting room and through the practice leaflet.
British Homeopathic Association Ⓦ www.trusthomeopathy.org; Ⓣ 0870 444 3950
The Faculty of Homeopathy regulates teaching and practice of homeopathy by state registered healthcare professionals Ⓦ www.trusthomeopathy.org/faculty; Ⓣ 0870 444 3950
Society of Homeopaths Ⓦ www.homeopathy-soh.org; Ⓣ 01604 621400 (registers homepaths)
Alliance of Registered homeopaths Ⓦ www.a-r-h.org; Ⓣ 08700 736339 (registers homeopaths)
Complementary, alternative and traditional medicine
These practices are based on theories other than the orthodox science of western medicine. Views on what is orthodox change with time: osteopathy became orthodox in 1993 (with the passage of The Osteopaths Act), and acupuncture is moving that way. Legal changes generally lag behind public acceptance.
‘Complementary’ and ‘alternative’ are often used interchangeably, although strictly speaking a complementary therapy is used in addition to orthodox treatment (e.g. aromatherapy for surgical patients), while alternative medicine provides a parallel service based on a different body of knowledge (e.g. herbal medicine). Traditional medicine is the orthodox discipline of another culture, e.g. Ayurvedic medicine in India. The all-embracing term ‘fringe medicine’ is sometimes used; it suggests a lack of acceptance from the medical hierarchy.
Some orthodox and complementary therapies encourage voluntary registration of practitioners, but the only control over most traditional therapies is general legislation. This is concerned with limiting the potential for harm rather than identifying benefit.
Patients may consult non-orthodox practitioners in addition to their GP, they may go to them when orthodox medicine has not helped them, or they may come to the GP when traditional practice has failed them. Patients are attracted to non-orthodox practitioners because their therapies are thought to be ‘natural’, and they seem to have time and a capacity to listen and to take account of the whole person, which GPs are felt, rightly or wrongly, to lack. In an age in which many do not trust science, some patients feel that anecdotal evidence of efficacy is more meaningful for the individual than scientific trials. For immigrants, their traditional medicine is familiar and provided by practitioners who share their language and culture.
Example Successes and failures of alternative medicine
A GP was called to see a previously well-controlled asthmatic who was having a severe asthma attack. He discovered that she had become unhappy at the idea of being dependent on inhalers, so she consulted an alternative practitioner who gave her some therapy and advised her to stop her inhalers.
A new patient was dependent on large quantities of medication for her frequent disabling migraines. She had found prophylactic medication unhelpful and was not prepared to try it again, but reluctantly agreed to be referred to a neurologist in exchange for continued prescribing of her tablets. However, before she saw the neurologist she wrote to her GP to say she had consulted an alternative practitioner and now had very few migraines so she no longer required medication.
In the early 1990s, traditional Chinese herbal medicine appeared to offer a safe and effective alternative to strong steroids for control of severe eczema. It is now known that some of the preparations themselves contained strong steroids.
Issues for practices
Clinicians may not be in sympathy with the therapies patients choose, but they need to remember that patients have the right to make choices and doctors have a duty to safeguard their patients. Recognising that doctors are more open-minded than they used to be, patients are becoming more confident that they can discuss using non-orthodox practitioners without censure.
Many patients in areas with ethnic populations will be consulting traditional practitioners. Clinicians need to be aware of common practices in their ethnic populations, and to be prepared to work with communities on safety issues.
Patients may ask GPs for advice and seek permission to use an alternative practitioner. GPs may not wish to give advice, but they might discuss with patients how to select a suitable therapist, drawing attention to registration, costs etc.
GPs who suggest, refer or delegate to non-orthodox practitioners need to be satisfied that the patient stands to benefit, so they need to know something about the therapy, to be confident of the practitioner’s competence, and where appropriate to supply adequate information about the patient.
GPs who suggest, delegate or refer patients to practitioners who are not statutorily registered might share liability if a patient suffers damage.
GPs who offer non-orthodox therapies are accountable to the GMC and nurses who do so to the NMC, so patients can seek legal redress against them in a case of damage.
Should a practice wish to employ a complementary therapist, the advice under ‘Allied health professions’ above and in section 4 of the Handbook (Recruitment and employment) applies. In the absence of statutory registration, it is particularly important to check whether the practitioner has indemnity insurance, to agree the limits to the practitioner’s clinical activities; also to arrange feedback and to inform patients about the practitioner’s role.
Practices which give space in their premises to non-orthodox practitioners will be seen as endorsing the practitioner.
Further information can be found at:
British Complementary Medicine Association: an umbrella association for 60 disciplines which promotes voluntary registration and code of conduct and disciplinary procedures Ⓦ www.bcma.co.uk; Ⓣ 0845 345 5977
BMA 7/1999 Referral to complementary therapists can be viewed at: Ⓦ www.bma.org.uk
Zollman C, Vickers AJ. ABC of Complementary Medicine BMJ Books, 2000
Practice managers
Since the introduction of the 1990 ‘New GP Contract’, practice managers have emerged as one of the most important members of the primary health care team. The emergence of fundholding in the 1990s and the rapid expansion of primary care services meant that practice managers had to constantly change and update their skills accordingly. However, practice managers continue to vary in terms of the responsibility given to them. There are still many practice managers working throughout the country in smaller practices who are in effect working as practice administrators with the GPs tending to make the majority of the strategic decisions. In contrast, there are a number of practice managers who have been recognised as a vital part of the organisation and have gone on to become non-medical partners.
The current GP contract and variations (PMS, APMS) of this contract require practice managers to be much more highly skilled than was necessary previously. For example, for the first time, practices are properly rewarded for initiating a wide range of practice management and quality initiatives (see section 3). Practice managers need to have greater IT and data analysis skills to cope with the large areas of clinical data which is now required by PCOs. It would also be helpful if practice managers had some general knowledge about the clinical domains in order to be able to facilitate discussions amongst clinicians about how best to ensure that maximum points are achieved.
The competency framework
For the first time practice management has been properly recognised through a GP contract. Appendix C of the contract provides a competency framework for practice management. The reasons why this appeared in the contract documentation are not altogether clear. However, what is clear is that the NHS takes practice management seriously and is offering GPs and PCOs a yardstick by which to measure the competency of those leading GP services.
Job descriptions
Job descriptions for practice managers will vary according to the size of the practice and the level of responsibly granted to the practice manager. Most job descriptions, however, will be centred around the following headings:
Some practice managers work in a strategic role and will be responsible for running a structure that might have ‘heads of departments’. They may not necessarily be involved in day-to-day operational matters but will head up a team. This kind of manager is often at the forefront of many of the UK’s larger practices often with 10–20,000 patients.
The extent to which a practice manager will be able to get on with the job with minimal input from the partners will vary from practice to practice. It must be very clear from the outset which kinds of decisions will involve the GPs and which will not. Many practice managers have had frustrating jobs because in practice they were not managing but administrating!
The following job description is offered as a good starting point. It is by no means a model job description as the role and function of practice managers varies so much. However, it can be used as a starting point and developed alongside the competency framework.
Annex C: Competency framework for practice management
Example job description
To ensure the smooth running of the practice through efficient systems of management to include human resources, financial management and to delegate tasks appropriately. You should have a good knowledge of employment law and GP contractual obligations and how they will affect the practice.
You should be constantly aware of how to improve administrative systems in order to deliver the highest quality of patient care.
1. Personnel management:
1.1 Recruitment of new staff by following the stages of recruitment complying with all current legislation
1.2 Ensure that all staff have an up-to-date contract/written statement of terms and conditions of employment
1.3 Ensure all staff receive the appropriate induction training
1.4 Conduct annual performance appraisals for all staff
1.5 Ensure that all staff have up-to-date job descriptions and personnel records
1.6 Ensure that all staff are aware of practice policies and protocols
1.7 Responsibility for ensuring that all staff have received the appropriate training and their development is regularly reviewed
1.8 Keep adequate records of all staff training including
1.9 Ensure that all staff are aware of and follow Health & Safety policy
1.10 Ensure that all staff are aware of procedures regarding patient confidentiality
1.11 Ensure that all staff are aware of grievance and disciplinary Procedures
2. Practice finance:
2.1 Operating the PAYE system for all staff and making appropriate returns to Inland Revenue and the Pensions Contributions Agency
2.2 Dealing with any queries that may arise regarding the PAYE system, SSP or SMP
2.3 Manage/maintain all practice accounts and prepare the same for the accountant/auditor
2.4 Liaise with bank and accountant
2.5 Reconcile the quarterly statements
2.6 Ensure that all claims are accurately completed and forwarded to the PCT
2.7 Ensure that accurate records are maintained for audit
2.8 Review target payments to ensure maximum income is generated
2.9 Ensure that all money owing to the practice is recovered promptly
2.10 Prepare budgets and a cash flow forecast
2.11 Maintain an efficient petty cash system
2.12 Review procedures to maximise practice income
2.13 Advise partners on the appropriate drawings
3. Change management:
3.1 Organise Practice and Primary Health Care Meetings and ensure that agendas and minutes are circulated as appropriate
3.2 Ensure that the proposals from relevant meetings are actioned within agreed time scales
3.3 Ensure effective communications with all team members including updating staff notice board
3.4 Maintain, update and distribute all practice procedures and protocols
3.5 Produce a business plan and annual report in accordance with the aims and objectives of the practice
3.6 Attend all Primary Health Care meetings; discuss and implement proposed changes with other team members
3.7 Audit all quality systems and produce recommendations i.e. complaints procedure, appointment systems etc. to ensure a high standard to patient care
4. Recording systems:
4.1 To ensure that computer records are accurate and back-up systems are operating effectively according to the Data Protection Act.
4.2 Administer and record searches
4.3 Ensure that stationery and supplies are adequately maintained and recorded
4.4 Maintain insurance policies for partners, premises and equipment
4.5 Attend and record partner’s meeting and book locum doctors as required
5. Security systems:
5.1 Ensure building is safely maintained
5.2 Ensure that the building and property within it is secure at all times
5.3 Ensure security of personnel records and filing systems
5.4 Maintain the service of equipment including autoclave, alarm system
5.5 Responsibility for recording and supervising external visitors
This job description may need to be revised from time to time as the practice develops.
(This job description is taken from: Hamid and Davies. Efficient Systems for General Practice Administration. London: RSM Press, 2003)
Training for practice managers
There are numerous training opportunities available to practice managers that range from short courses, NVQ programmes, traditional AMSPAR diplomas and university undergraduate and postgraduate programmes. The Handbook of Practice Management would like to develop a list of such programmes. Please feel free to contact the authors if you would like your course listed (c/o Joy Brooking;
AMSPAR
Tavistock House North
Tavistock Square
London WC1H 9LN
Tel: 020 7387 6005
Fax: 020 7388 2648
Institute of Health Care Management
46 Grosvenor Gardens
London SW1W OEB
Tel: 020 7881 9235
Fax: 020 7881 9236
It is very important that practice managers keep their skills up to date and be open to learning about new ways of working. The recent developments in primary care mean that successful practice managers will be the ones who are willing to embrace change and lead their practices through what has now become a radical development of primary care services.
Appraisals
Like all members of the primary health care team, practice managers should subject themselves to an annual appraisal. As the employer, GPs should be willing to take part in a practice manager’s appraisal. However, the authors recognise that many GPs may not have the skills or experience to effectively appraise a practice manager and it might be necessary for the GP to work along side another practice manager, PCT manager or independent consultant to properly review the work of a practice manager.
Relationship with the PCO
In many practices, the practice manager will be the main liaison point with the PCO.
Practice managers should be willing to work in a collaborative nature with their PCO but
always considering to keep the practice interest at heart.
Becoming a non-medical partner
A number of practice managers have become partners in their practice. The first to take on this role came in the mid-1990s following the introduction of the 1990 GP Contract. Many GPs felt that managing the business was becoming a complicated affair and, in some practices, it seemed necessary that one of the partners should be responsible for the general management of the organisation. It was also not a coincidence that those practice managers who were recruited to help practices implement the 1990 contract would by the mid-1990s have been involved in fundholding and looking for ways of developing their careers within primary care.
Becoming a partner is a serious matter and carries some financial risks, so it is important to establish why the practice manager is going down this route. For some, partnership means that the practice manager’s status in the practice is secure. It can be seen as a genuine career move. In the same way as many GPs see general practice as a career for life, practice managers who have become partners no longer feel the need to go up more traditional career ladders, but instead see the business of general practice, and their financial stake in it, a legitimate place to be for themselves.
Different types of partnership available to practice managers
There are commonly two types of partnerships available to practice managers. Some practice managers have become salaried partners. This means that the practice manager can have the full organisational and decision making rights like any other partner, but remains salaried and does not ordinarily have a share of profits. However, it is possible for a salaried partner to receive a basic salary and also receive a bonus based on the profitability of the practice. The advantage of this model is that the salaried partner retains all the benefits of employment rights and does not carry the same financial risk as other full profit-sharing partners. The disadvantage is that not carrying the same level of risk and not making the same capital investments as full partners may appear to weaken the position of the salaried partner.
A full profit-sharing partner, however, will usually be fully self-employed and income is solely dependent on the profit of the practice. Employment protection rights are surrendered, though most modern partnership agreements will contain most of the employment conditions of salaried personnel. Full profit-sharing partners are also expected to make a capital contribution. This could be as simple as building up a capital account (a sum of money to ensure that the practice has enough cash flow to meet its financial needs), or raising large sums of money to buy into a practice. Whilst this might be costly, there would be the potential for capital growth in the property.
Pension rights
The NHS Pension Scheme was opened to non-GP partners following the 2003 GP Contract. Initially, her Majesty’s Revenue and Customs would not agree to extend the special waiver that allows GPs to contribute to a professional pension scheme, despite being self employed, and to still receive tax relief on those contributions. However, the A-Day legislation has enabled non-GP partners to claim tax relief on their NHS superannuation contributions. However, the rules are complex and the authors advise that professional guidance is sought before going down this route. The pension contributions of salaried partners are more straightforward because there is an employment contract in place.
Partnership agreement
Whether a practice manager becomes a salaried partner or a full profit-sharing partner, it is very important that the partnership agreement is clear about the roles and expectations of both a medical and non-medical partner. For example, some practice manager partners do not have voting rights over clinical issues unless the clinical issue makes an impact on the organisational, or financial status of the practice.
All partners, whether medical or non-medical, need to have appropriate indemnity cover. All the major legal defence bodies offer cover for practice managers as well as non-medical partners.
Consideration needs to be given to comparative workload in working out partnership shares. Some practices have opted to use formulas which recognise that GPs have greater responsibility than non-GPs and profit shares reflect this. Others give equal terms and conditions to all partners irrespective of roles.
The extent to which a non-medical partner can influence clinical decision making will also need to be teased out. One clause the authors came across stated that the non-medical partner ‘‘shall not vote on purely clinical decisions, which shall be interpreted as decisions, which do not have an effect on the operating business and/or finance and/or earnings of the Practice’’. As time goes by this rather ambiguous clause will need to be refined. Practice-based commissioning will inevitably further blur the boundaries between clinical and non-clinical decision making.
Most practice managers who have become partners say that a great deal depends on trust. There are no known cases of people recruited straight into partnership; instead relationships have evolved to make this possible. It is very important that practices seek professional guidance before proceeding. Solicitors are now getting used to drafting clauses for non-medical partners, and accountants who specialise in general practice should be able to assist with financial issues.
Workforce planning
It is vitally important to the quality of the service and the financial health of the practice to think about the future roles of the practice and who will discharge them. Workforce planning sometimes seems to be an exercise in reading a rather cloudy crystal ball, but a little thought will put the practice in a better position to meet ever-changing demands.
Responsibilities for workforce planning in primary care are currently (as of 2002) being allocated between PCOs and Strategic Health Authorities, and more information will be included in future Handbook Updates. Until then, the following provides an approach to workforce planning at the practice level.
Like it or not, tomorrow will be different from today. Practice managers may appreciate this more readily than many GPs.
What services might you be expected to be delivering in 5 years’ time? Think about developments in your practice area, about government policies (not just in health) and about local policies, looking especially at your local “Joint Strategic Needs Assessment”.
Estimate the number and type of appointments you may need, and what time of day they may be required.
Do you have the right staff (right numbers, right skills) to do this year’s job? Nextyear’s? In 5 years’ time? Start with the skills needed and match them up with staff. Do existing staff members foresee changing their commitment?
If you have the right staff but at the wrong times, can you change the timetable? What is the best match between convenience for patients and family-friendly working practices?
Can work be delegated to less highly trained, and hence less costly, staff? Can nurses take on work previously done by doctors, and can health care assistants or reception staff do work historically done by nurses?
Assess whether your current staff have the skills they need or are going to need. Consider job specifications and performance assessment (see Section 4, Recruitment and employment).
Assess whether staff have the will to change their role. Some staff may legitimately not wish to do so. It is much easier to change skills than to influence wills.
Having done the above surveys, consider training and development (see ‘Training’ in Section 4, Recruitment and Employment, and Section 5, Education).
Where will new staff come from? Consider recruitment and retention issues, returnees, and cooperation with other practices to share staff. Investigate opportunities for flexibility in GMS. Consider PMS.
Short of doctor time?
One-off crisis: if it cannot be covered from within, you need a
Repeated crises: use
Part-time or full-time help for up to 3 months (e.g. to cover a sabbatical or sick leave): a
Part-time or full-time help for a finite period of longer than 3 months (e.g. for maternity cover, sick leave, sabbatical): you need an
Frequent odd sessions to cover partners’ outside commitments or holiday, etc.: employ an
Isolated single-handers: may qualify for an associate.
Many factors will influence decisions on workforce planning. NHS policy, local council decisions on housing development, professional developments in nursing and medicine, and changes in health technology all bear on workforce planning. The availability of doctors looking for partnerships and for contracts and locum work, and the cost / benefits of taking on a new partner versus employing a doctor can change surprisingly rapidly. Practices also need to bear in mind employment law, see section 4.
Bullying and harassment in the workplace
Bullying and harassment are abuses of power in which individuals are singled out, demeaned and devalued. Victims feel isolated and are likely to lose confidence at work and home. Their mental and physical health is likely to suffer.
Bullying is defined as persistent and is intimidating, degrading, offensive or malicious and undermines the confidence and self-esteem of the recipient. Harassment involves similar behaviour, but is specifically related to discrimination on the basis of age, sex, religion, race, disability, sexual orientation or some other personal characteristic. It may be persistent or an isolated event, but in all cases the actions or comments are viewed as demeaning and are unacceptable to the victim. Generally advice on management of bullying also goes for harassment, unless otherwise stated below.
It is now recognised that organisations may have a culture in which bullying is a norm. The fine dividing line between an effectively managed organisation and a bullying culture is more likely to be crossed in a hierarchical, highly competitive, organisation. General practice does not tend to attract aggressive doctors or staff, and few practices will feel that they are unacceptably hierarchical or target driven. Nevertheless surveys show that bullying of GPs and their staff is on the increase, from people within as well as outside the organisation.
Bullying and harassment depend on the perpetrator knowing that the victim is unlikely to complain and the organisation is unlikely to take action. Written policies alone will not prevent bullying. It is incumbent on practices to be watchful for bullying and to have a culture that gives victims the confidence to confide their experiences, since victims tend to retreat into their shell and look for another job. Many will tell no-one and very few will bring even an informal complaint.
Researchers have described five categories of bullying behaviour. Awareness of them can make identification of bullying easier:
Threat to professional status (belittling opinion, public professional humiliation, accusation of lack of effort)
Threat to personal standing (name calling, insults, teasing)
Isolation (preventing access to opportunities such as training, withholding information)
Overwork (undue pressure to produce work, impossible deadlines, unnecessary disruptions)
Destabilisation (failure to give credit when due, meaningless tasks, removal of responsibility, shifting of goal posts).
Note that bullying is in the eye of the beholder. If it feels like bullying, it is, even if it is not done with malicious intent.
It is also helpful to recognise the potential sources of bullying:
patients and their relatives (probably the most common)
PCO staff
colleagues from outside the practice
colleagues within the organisation.
How practices can manage bullying
The best protection against bullying is an organisational culture that is open and supportive. The practice manager has a key role in facilitating this, by personal example and by tackling bullying behaviour whether it be deliberate or an unfortunate response to stress. The practice manager needs to be aware of the informal power structures and relationships within the organisation. Brainstorming team members’ perception of the practice structure can be enlightening and provide material for further study and review.
Example
A practice with a culture of equality and teamwork was aware that staff were unhappy and decreasingly willing to take on new tasks. At the annual away day the outside facilitator asked everyone to write down or draw their view of the practice structure and their place in it. It turned out that many felt demeaned by a new young partner whose informal and teasing manner came over to employees as patronising. The nurses particularly felt that his approach to them over QOF targets amounted to accusations of professional incompetence and laziness. It took some time and outside help before the young partner could accept that his behaviour, which had served him well when he was the underdog in his family and on ward rounds, felt like bullying to his employees, and was enabled to adopt a more mature and appropriate persona.
The practice should have policies relating to bullying and harassment. A whistleblowing policy (see page 2-26z) is an essential element of these policies. Staff contracts, induction and training should include information on the practice’s policies and how they work in practice, and staff should be encouraged to seek help earlier rather than later.
Complaints of bullying and harassment must be addressed promptly or the victim could potentially make a claim of constructive dismissal. Legal processes exist for most forms of harassment. See HoPM Section 4 for more information on discrimination and the relevant legislation.
Appraisal is an opportunity to find out whether staff members feel bullied and to instigate personal support and development to help the thin-skinned and vulnerable to acquire life skills.
If the perpetrator belongs to another organisation, e.g. the PCO, the practice manager should address the problem with the organisation.
Doctors who feel they are being bullied, whether they are partners or employed, and whoever the perpetrator is, should contact their LMC. If that is difficult (for instance, the bully is an LMC member) the BMA or the GPC may offer help.
Practice managers may be bullied by their employers. Given that the job is already isolating – few practice managers have a peer within the organisation – finding the support necessary to deal with the problem can be difficult. Practice manager groups and the LMC are sources of advice and support.
Further information
Ⓦ www.acas.org.uk – ACAS has guidance for managers and employers and also for employees, and a free e-learning package on policies and management of bullying and harassment.
Ⓦ www.rcn.org.uk – See the RCN’s 2005 ‘Working Well’ initiative on bullying and harassment, which includes model policies and advice for organisations.
Ⓦ www.bma.org.uk – See the BMA’s 2006 report on bullying of doctors
Whistleblowing in general practice
In recent years a number of well reported and high profile cases involving some tragic incidents within the NHS have risen. NHS Employers was established in 2004 to take over responsibility from the Department of Health for much of the NHS workforce agenda. NHS Employers works in partnership with Public Concern at Work, which is an independent charity promoting whistleblowing accountability and good governance in the workplace.
Up until recently, the issue of whistleblowing in the NHS has focused on secondary care. Following the Shipman enquiry, the emphasis has now shifted to primary care and NHS Employers has recently issued guidance for GPs regarding whistleblowing.
Public Interest Disclosure Act (PIDA)
This act of 1998 protects individuals from workplace reprisals for raising a genuine concern, whether a risk to patients or other wrongdoing. The act promotes internal and regulatory disclosures. In practice, under PIDA, practice staff are given protection for raising a concern at a senior level. Protection is also available for disclosures to prescribed regulators and in some cases, even to wider disclosures (e.g. the media!).
Implementing a whistleblowing policy
Practices of all sizes are encouraged to adopt a whistleblowing policy. A team meeting should consider what the advantages of such a policy might be to the practice. Hopefully the need to implement the whistleblowing policy would be rare but staff should feel comfortable that if they feel the need to do so they will be supported. You might want to look at some case studies together. Examples are available from public concern at work, contact details at the end of this section.
Draft policy
This draft policy has been agreed between NHS Employers and Public Concern at Work and should be customised for each practice.
Draft Whistleblowing Policy for General Practice Introduction
All of us at one time or another have concerns about what is happening at work. Usually these concerns are easily resolved. However, when you are troubled about something that involves a danger (to patients, public or colleagues), professional misconduct or financial malpractice, it can be difficult to know what to do.
You may be worried about raising such an issue, perhaps feeling it’s none of your business or that it’s only a suspicion. You may feel that raising the matter would be disloyal to colleagues, to managers or to the practice. You may have said something but found that you have spoken to the wrong person or raised the issue in the wrong way and are not sure what, if anything, to do next.
We have introduced this policy to enable everyone to blow the whistle safely so that such issues are raised early and in the right way. This practice welcomes your genuine concerns and is committed to dealing responsibly, openly and professionally with them. We know that to provide the best local health care we must all try to deal with issues on their merits. Without your help, we cannot deliver a safe service and protect the interests of patients, staff and the practice. If you are worried, please raise it when it is just a concern rather than waiting for proof.
If something is troubling you, which you think we should know about or look into, please read and use this policy. If, however, you are aggrieved about your personal position, please use the Grievance Procedure or speak to the practice manager about what to do. This Whistleblowing Policy is primarily for concerns where the interests of others or of this practice are at risk.
This applies to you whether you are a permanent employee, an agency or temporary staff member, or a volunteer.
Your safety
We are committed to this policy. You will not be at risk of losing your job or suffering any form of retribution for raising a genuine concern under this policy. Provided you are acting honestly, it does not matter if you are mistaken or if there is an innocent explanation for your concern. So please do not think we will ask you to prove it. Of course we do not extend this assurance to someone who maliciously raises a matter they know is untrue.
Your confidence
If you want to discuss your concern in private with someone first, please say so when you approach them. While we hope this policy and these assurances will give you the confidence to raise your concern openly, we recognise that you may nonetheless be anxious. If you ask us not to disclose your identity, we will do our utmost to respect your request. However, in any organisation people may well deduce who has raised a concern and for this reason we think it is in everyone’s interest if concerns are raised openly.
Anonymous concerns
Clearly it is in the interests of the practice that concerns can be raised openly and dealt with fairly and professionally. Remember that if you do not tell us who you are, it will be much more difficult for your concern to be investigated and for us to protect your position or give you feedback. Accordingly, while we will consider anonymous reports, this policy is not well suited to concerns raised anonymously.
Once you have told us of your concern, we will look into it to assess initially what action, if any, should be taken. This may involve an informal review or a more detailed investigation. We will tell you who will handle the matter, how to contact them and whether your further assistance may be needed. At your request, we will write to you summarising your concern and setting out how we propose to handle it.
When you raise the concern we may ask you how you think the matter might best be resolved. If you do have any personal interest in the matter, we ask that you tell us at the outset. If your concern falls more properly within the grievance or other procedures we will tell you.
The purpose of this policy is to enable us to investigate and deal with possible malpractice. To reassure you, we will give you as much feedback as we properly can. Please note, however, that we may not be able to tell you the precise action we take where this would infringe a duty of confidence owed by us to someone else.
If you have a concern, we hope you will feel able to raise it with your line manager so it can be resolved quickly and effectively.
If you don’t feel raising it with your line manager is appropriate or it hasn’t worked, please raise the matter with the practice manager or [insert name of the lead or designated GP and direct contact details]. Please say if you want to speak privately so that they can make appropriate arrangements.
NHS—"PCO"
If you are unable to raise the matter internally, or it has not been dealt with properly, we would rather you raise it with the “PCO” than say nothing at all. The contact at the “PCO” is [insert name and direct contact details].
If you are unsure whether or how to raise a concern or you want free independent advice at any stage, you may contact:
your trade union or professional association
the charity Public Concern at Work (http://www.pcaw.org.uk/). Their lawyers can give you
free, independent, confidential advice at any stage about whistleblowing.
While we hope that this policy gives you the confidence and reassurance you need to raise your concern with us, we recognise that there may be circumstances where you can properly report matters to outside bodies. This may be to a specific regulator, such as the Health & Safety Executive. Where you believe our response has been inadequate or there is an ongoing risk, you may also contact a body like the National Patient Safety Agency, National Clinical Assessment Service or the Healthcare Commission. Public Concern at Work and your union will be able to advise you which route is appropriate in your circumstances.
While we cannot guarantee that we will always respond in the manner you might wish, we will do our best to handle the matter fairly and properly. By using this policy, you will help us to achieve this. If there is ongoing malpractice, please remember you can raise your concern with the other bodies listed in this policy.
Contact details
Public Concern at Work, Suite 301, 16 Baldwins Gardens, London, EC1N 7RJ. Ⓣ 020 7404 6609, Ⓕ 020 7404 6576, Ⓦhttp://www.pcaw.org.uk/
NHS Employers, 29 Bressenden Place, London, SW1E 5DD. Ⓣ 020 7070 43200, Ⓕ 020 7074 3201, Ⓦ wwww.nhsemployers.org
Teamwork
It is vitally important to knit all the members of the PHCT into a cohesive team. It is also important to realise the importance of the smaller teams within the larger PHCT – the uniprofessional teams, small multidisciplinary project teams and the teams of different professionals that need to work together for specific groups of patients or even an individual patient. The practice manager has an important role in facilitating team building, based on mutual respect for the roles and expertise each member of the team brings (see Section 7, Basic management techniques, ‘Teambuilding’).
Appraisal systems for the primary health care team
Introduction
It is good practice for every person who works in the practice to have an appraisal and the practice manager has a key role in setting up systems. There is an expectation that everyone who works in the NHS will have a personal development plan (PDP). An appraisal is an opportunity for an individual to review what they are expected to do in their job, reflect on how well they do the job currently and identify any training or additional practice support or resources which would enable them to do their job better. It is also an opportunity to consider their aspirations and career development, both within and outside the practice. Appraisals should be a motivating experience for every individual, giving clarity to the role of each person in delivering the practice strategic plan while encouraging the growth and professional development of every member of the PHCT.
The general principles and purpose of appraisal are the same for each member of the team but different models and styles can be used for different members of the team to reflect the needs of different groups of people.
Appraisal for doctors has become compulsory as of 2002. Doctors will need to be appraised by another GMC-registered doctor each year, and this has become a requirement for doctors who will also need to be revalidated every 5 years in order to remain on the medical register. Nurses too must demonstrate ongoing nursing practice and comply with educational standards to maintain their registration with the NMC.
Nurses working in a practice are likely to be either employed by the practice (practice nurses, nurse practitioners) or by the community provider (district nurses, health visitors). In the past community nurses working for a community trust have had regular ‘peer reviews’ with a nursing peer and traditionally the practice has had little input into their appraisal or indeed job description. Employed practice nurses and nurse practitioners have traditionally had appraisals with the practice manager and a partner, but many practice nurses have never been appraised.
Practice managers have reported a number of different models of appraisal. Initially, this is for principals only until it is decided how NPs can be appraised. However, it is likely that NPs employed by one practice will be expected to be part of that practice’s doctor appraisal system. Most practices have adopted a model that is objective based and takes into account the practice business plan and the practice manager’s own personal development plan. Some practice managers are appraised by all the partners and others have one partner conducting the appraisal on behalf of the others. Satisfactory objective setting and appraisal of practice managers depends on a robust, negotiated business plan. The business plan must be agreed beforehand as the appraisal should not be hijacked by further discussion about priorities within the business plan. The appraisal should focus on a review of last year’s objectives, reflections on current performance and prioritised objectives for the practice manager for the following year. Opportunities for career development, professional education and increased job satisfaction should be discussed.
Similar models have been used for the administrative staff and training in appraisal skills should be given to middle managers as practice managers are unlikely to be able to do everyone’s appraisal if the practice is large. Staff appraisal is carried out by their line manager and is fully discussed in Section 4.
Increasingly, reflection on performance at appraisals is informed by feedback from others. This can be done by simple questionnaire; when those requested to give feedback include bosses, peers, subordinates and customers it is known as 360-degree feedback.
GP appraisal
Appraisal is part of the NHS clinical governance process. It is described as ‘a professional process of constructive dialogue, designed to give GPs feedback on past performance, chart continuing progress and identify development needs’.
Annual appraisal was introduced following high profile concerns about doctors’ performance. It was set up as a formative process to help doctors reflect on what they do in their work, identify what they would like to do and give them new thoughts about further development. It should encourage all doctors continually to improve their performance while providing patients and health care organisations with reassurance.
Satisfactory annual appraisal is a requirement for revalidation. Revalidation, i.e. the demonstration of satisfactory performance, will take place every five years and be required for doctors to remain on the GMC register (http://www.gmc-uk.org/). GPs are appraised by a peer, i.e. another GP registered with the GMC. Appraisees complete documentation, which is then formally reviewed by their appraiser. They then create a Personal Development Plan (PDP, see page 5-06b) in which the appraisee identifies areas to be worked on in the coming year.
Evidence for appraisal
Ongoing PDP
Form 4 from last appraisal
One audit or data collection exercise
A patient survey
One significant event analysis
Structured reflection on two cases
Reflection on last year’s learning
The completed appraisal statement and supporting documentation can then be seen by the appraiser before the appraisal. The appraisal generally lasts about two hours, perhaps longer if there is a major problem such as possible career change or serious illness or personal event impinging on work. The appraiser and appraisee will review the appraisal statement and supporting documents including the previous year’s PDP.
The appraiser will celebrate achievement, but is expected to challenge vague statements (‘I am good with patients’; ‘I read the BMJ every week’) and to stretch the appraisee. The appraisee’s work and CPD (included impact of learning) should be reviewed in the light of his or her practice or portfolio, personal life where relevant and ambitions, and set against the local and national context. Appraisee and appraiser then complete the online appraisal toolkit, which is an agreed summary of the appraisal; an assessment of the extent to which the previous year’s PDP has been fulfilled, and if the appraisee is struggling for any reason a plan for dealing with the problem. A PDP for the forthcoming year is also produced, with the appraiser helping the appraisee identify appropriate goals, together with specific plans for learning and a date by which the objectives should be achieved and how to meet them. The finalised and completed appraisal is then submitted to the Responsible Officer (RO). The RO would have complete access to the online toolkit, and would then make any neccessary recommendations to the GMC.
Note: If appraisers have any concerns that they cannot complete the appraisal, they would contact the RO and discuss the case. It is the appraisee’s obligation to seek appraisal each year. If for some reason appraisal is not possible, the appraisee should explain the situation to the relevant PCO and seek an extension of the timetable.
Payment for appraisal
When appraisal was introduced, an appraisal premium of 26p was added to their global sum for payment of all providers and salaried GPs working in the practice to compensate for the time taken by appraisal, based on a DoH estimate that the process would take 4.5 to 6.5 hours. (This is substantially less than the GPC’s estimate of 9.25 hours.)
Since then the sources of funding have become less clear and money tighter, and the original intentions to fund the costs of appraisal for all GPs are not always honoured.
In England, the money for all GPs, partners and employed, was included in nGMS practices’ global sum and generally put into PMS budgets. Now, some practices will pay a special sum to their GPs for appraisal, some GPs take study leave, some have time off in lieu, and some do appraisal in their own time. Whatever a practice decides, all GPs whether partners or salaried must be treated equitably and the practice’s policy should be made clear to salaried GPs at the time of engagement.
Note that appraisal takes up the same amount of time whether you work ten sessions a week or one.
Locums: Payments to primary care locums undergoing appraisal have previously been made in some areas. These facilitated the engagement of these doctors when appraisal was a new process. NHS England is committed to providing appraisal to all doctors with a prescribed connection free of charge. However it is NHS England’s view that direct payment to any doctor undergoing appraisal can no longer be supported. It is now every doctors’ professional responsibility to undergo appraisal as part of revalidation. In exceptional cases, Area Teams may support individual doctors where particular hardship is demonstrated.
In Scotland money is available for partners and employed GPs but not for locums, although this is under discussion with the Scottish Executive.
In Wales a fee of £300 is paid by the Department of Post Graduate Studies to all GPs, including freelance GPs, who participate in appraisal.
In Northern Ireland all GPs can claim £300 for appraisal from their PCO.
GP appraisers
GP appraisers are appointed by the PCO and generally paid per appraisal. They receive training and ongoing support. PCOs generally limit the number of appraisals that an appraiser can carry out each year. GPs usually keep the same appraiser for two or more years, depending on the PCO’s policy. The appraisals they conduct are confidential unless there is a serious performance concern. Most GP appraisers find the work enjoyable and rewarding.
Role of the practice manager in GP appraisal
It is to be hoped that few practice managers now find themselves with GPs who reject the appraisal process, but some doctors may need encouragement that appraisal is potentially valuable, or even persuasion that it is a contractual requirement. The primary health care team . 2-69. Practice Management (Update 85) August 2012. Downloaded from hpm.sagepub.com at SAGE Publications on June 24, 2014
GP revalidation
Appraisal is the doctor’s responsibility and the degree to which the practice manager is involved will depend on the practice. Practice managers may wish to keep a note of the appraisal dates of all doctors working in the practice.
It is convenient if appraisals take place in the workplace and practice managers may need to ensure that a suitable room is available for doctors who do not have their own consulting room.
Practice managers should look at the appraisals website and study the guidance to understand what is required. Much of the supporting documentation is practice based, i.e. QOF and prescribing data, patient surveys, significant event analyses, practice protocols, minutes of practice, clinical governance and prescribing meetings, details of complaints, and can be submitted by all doctors working in the practice. The practice manager can help by collecting such data in an electronic or paper folder. Any patient data should be anonymised. It is up to the doctors to make sure that they have read and thought about the documents they submit for appraisal.
Sessional GPs, especially locums who are working in many practices, can have difficulties producing support for their appraisal statements, and practice managers may become involved in helping them generate evidence, e.g. supporting a doctor wishing to hand out feedback questionnaires to patients consulting with him or her, or in providing a letter of assessment on clinical and teamworking that the doctor can present at appraisal.
GPs who struggle to get their data together may be helped by suggestions such as keeping a drawer or folder for paper documents they might wish to scan in and submit. As appraisal becomes more rigorous doctors need to provide evidence to back up their claims. Claiming to read the BMJ every week, providing course certificates, and mentioning ongoing learning from patient contacts will not suffice. Doctors can be encouraged to record their learning as they do it, e.g. using a logbook or spreadsheet recording ‘PUNs and DENs’ (Patient’s Unmet Needs, Doctor’s Educational Needs) and describing what they learned as a result. The same methods can be used for recording learning from journals, books, meetings and courses.
Appraisal involves the appraisee considering how their personal objectives fit with those of the organisation in which they work. Ideally the two should be congruent, and an annual review of practice aims and objectives and discussion of the contribution to these of each doctor, partner or employed, and other staff can help practices maximize the potential of their team, and can help appraisees see where they can best contribute and what they need to achieve that.
The appraisal process challenges appraisees to identify barriers to achieving their objectives. Often these are time and money, but bureaucracy can also be an obstacle. Practices need to be prepared to support doctors in finding resources and in bringing problems to the notice of the PCO where appropriate.
Further information
— The GMC: W http://www.gmc-uk.org/
— England: http://www.england.nhs.uk/
— Scotland: http://www.scottishappraisal.scot.nhs.uk/
— Wales: https://gp.marswales.org/
— Northern Ireland: http://www.nimdta.gov.uk/general-practice/gp-appraisal/
— General resource: http://www.patient.co.uk/doctor/gp-appraisals
— See Handbook of Practice Management p 5-06 for a general discussion of appraisal for all staff
Summary
This section looks at the primary health care team (PHCT) and explores the roles of the doctors, nurses, managers and administrative staff that make it up. It includes issues about teamwork and workforce planning as well as the recruitment and induction of locums. It covers in some depth the development of PHCT members through professional development and appraisal, and includes the special requirements for the appraisal and revalidation of doctors.