1 Introduction

Life before the NHS

The concept of the National Health Service stretches way back before its formal creation in 1948. Prior to 1948, our healthcare system is described as a disorganised and complex mixture of private and public services (Baggott, 1994), with local government being responsible for community health services, which tied into their other areas of responsibility, such as environmental health and housing, and with the private sector, which consisted of voluntary hospitals, private practitioners and a series of other ‘interested’ parties, both voluntary and commercial.

Some of the voluntary hospitals were founded as far back as the middle ages and were generally established by public subscription or charitable patronage. Originally seen as prestigious establishments, doctors would often waive their fees as they were so keen to be associated with these hospitals. They would make up for any shortfall in earnings by payments received by treating the rich benefactors of the hospitals. These people were generally treated at home, leaving the hospitals to cater for those that could not afford to pay for their treatment.

At this time general practitioners (GPs) were private practitioners and would charge a fee for their service. In Victorian times a system of friendly societies were developed where the better off of the working classes would make subscriptions in order that they could hire in the services of a GP for their members when they became ill, ensuring that those less well off also had access to healthcare. These societies however, didn’t extend to everyone, and were generally limited to those in employment, and would therefore by default exclude married women and children.

Although the exclusivity of these clubs gave cause for concern, they continued to evolve and in 1911 the then Liberal Government introduced the National Insurance Act. This Act entitled the employed working classes to free sickness benefits, drugs and GP services, and as today, contributions to fund the compulsory scheme were taken from the employee, employers and the government. The scheme was administered by local insurance companies.

GPs were not entirely happy with this scheme, and it was within the same year that LMCs were legally established to represent the doctors who worked for the panels set up under the National Insurance Act. Furthermore, another representative body, the British Medial Association (BMA) felt that the GPs pay for the scheme was inadequate. Concessions went on to be made and by the outbreak of war in 1939, 90% of GPs were involved in the scheme, but only 43% of the population were covered. The unemployed, married woman and children still had to pay for GP services directly.

In 1939, the Second World War arrived and the healthcare system was required to react to this and did so with the provision of an emergency healthcare structure. The experiences of the war and lessons learned from the emergency structure and from Lord Dawson’s report as far back as 1920, which described how a health service might be organised, the Labour Government of the time, led by Health Minister, Aneurin Bevan proposed their vision of the NHS. This vision favoured the nationalisation of all hospitals and a comprehensive state health care system – the National Health Service (NHS). Compromises regarding the vision had to be made however, as negotiations did not run entirely to plan. Consultants for example, secured an agreement that enabled them to offer private work alongside their employment with the NHS.

Birth of the NHS

The NHS was born on 5 July 1948. There were no immediate changes to the facade of the NHS during those early days following inception. It was very much business as usual in terms of the services on offer and the buildings and teams that delivered those services. The major difference though, which can be difficult for those of us having grown up with an accessible health care system is that the services were provided free of charge. Health care would no longer be a luxury that only the wealthy could afford, and as such the new NHS became inundated with people who had been suffering remediable conditions, which at one point they could not afford to address.

Although not entirely unique to Britain, The principles upon which the NHS was based were very much ground breaking. Most countries were reliant upon insurance-based schemes, but although founded at a time where there was massive innovation in a country that was struggling to rebuild itself from the war, the building of the healthcare system was not deemed a priority. The building of new hospitals came way down the list behind the country’s housing and educational needs.

Key principles of the new NHS:

Role of the GP in the new NHS

Now known as family doctors and along with dentists, pharmacists and opticians, general practitioners who, as many still are now, were self employed, and provided a service to the NHS under a contract from an Executive Council. Again, as in modern day primary care the GP acted as a gate-keeper to the NHS, referring patients on for specialist care. GPs were supported by community teams who offered immunisations and maternity services amongst others under the jurisdiction of the ‘Municipal Officer of Health’.

It is noted that during this period, just after the war, that the status of GPs and as such their pay and morale was low, but funds were made available during the mid 1950’s to support GPs to develop group practices – a significant development for Primary Care. The NHS continued to develop and settled down during the 1950s and early 1960s. However, there were still problems and discontentment amongst doctors, with pay continuing to be an issue and to such an extent that mass resignations were submitted. Consequently, a Royal Commission established a review body to consider the many issues, which subsequently led to the introduction of a Family Doctors Charter in 1965, which was the original ‘new’ contract. This contract provided incentives for doctors to develop and from that came improvements to premises and better staffed facilities.

General practice very much stabilised following the introduction of the family doctors charter. However, with the rapid expansion in technology opening new opportunities for the NHS during the 1970s and 1980s the NHS found itself struggling to fulfil expectation and demand, and subsequently suggestions were made that some services offered within the hospital setting could be offered out in the community. A review followed of general practice and of community nursing teams. A further white paper laid out by the then Conservative Government in 1987 paved the way for the new contract of 1990 and numerous, subsequent white papers that provided a pathway for the evolution of general practice, primary care and the wider NHS.

With this came the ‘internal market’ and GPs were offered opportunities to become GP fundholders, where they were given budgets to purchase services from the NHS. Many GPs jumped at this opportunity, wishing to have more control over the provision of healthcare to their patients. The government provided incentives for them to do so. Those GPs that became fundholders generally saw their patients access secondary services more rapidly than those that did not, which as suggested by some, created a two-tier healthcare system. Almost as quickly as it came, fundholding went, when ‘new Labour’ took power in May 1997 and once more the NHS was the subject of a review. ‘The New NHS Modern and Dependable’ (1997) was the result of this review, which was the start of a ‘drip-fed’ series of change that formed the foundations of the structure of where we are at today, including the introduction of the opportunity to work under different styles of contracts, where again GPs were incentivised to do so (see below).

The NHS Plan (1998), the next major development to be introduced by new Labour, established a ten-year plan of reform for the NHS. In addition, 1998 saw the first break from the national universal contract when PMS was introduced and actively encouraged as a method of offering flexibility to enable patients access to services in areas where it was deemed that GMS was not working. The PMS contract generally worked well (and still does) in under-doctored areas, particularly because at that point incentives were offered to practices in the form of funding to recruit additional doctors to support practices that were situated in under-doctored areas.

Today, we have an NHS and primary care system that finds itself continually under scrutiny. Never before have we seen such interest from central government and such regular review. Following a period of drawn out negotiation during the early days of the NHS Plan, a further new, GP contract emerged – nGMS (2003), again offering incentives to GPs to hit specific performance targets. Alongside this, and within the broader NHS, there are new systems of financial flow. Payment by results and a tariff system have brought instability to the finances of the NHS. Health service computing, although well behind schedule, is rapidly improving communications between the primary and secondary care sectors; hospital waiting lists are down as we all struggle to work in a target-driven arena just awaiting the next change, which we know will be just around the corner.

New beginnings

The role of the practice manager has probably been somewhat evolutionary, primarily due to the growing administrative demands placed upon general practitioners.

The RCGP suggest that the role was first created during the 1970s and would have more than likely been offered to experienced reception staff as an acknowledgment of the requirement to formalise the link between the clinical and administrative duties of the practice and to determine a formal framework for the associated responsibilities. The role grew during the 1980s and 1990s as target-driven general practice became ‘the norm’. There are now approximately 8000 general practice managers working in the UK.

Today’s practice manager

Today’s practice manager looks very different from the manager of the 1970s with many practice managers now having a stake in the business as partners. This is recognition of the pivotal role of the practice manager.

The importance of the role was recognised when negotiations were taking place regarding the nGMS contract, resulting in the provision of a competency framework relating to practice management (annex C). Indeed the contract itself has tools to measure the standard of the management of the practice and practices are now rewarded for providing high standards of managerial support and initiatives via the Quality and Outcomes Framework.

Qualifications

There are no specific qualifications for a practice manager. The role very much varies from practice to practice and as such the qualities and qualifications required will differ as will the level of responsibility and input from the partners.

A growing number of today’s practice managers have a business background and will be educated to degree level, although a degree is by no means a necessary quality to be able to perform the role effectively. Conversely, many practice manager’s have started their careers as practice receptionists or administrators and may have many years of experience of working in general practice.

Typical aspects of the role

A practice manager’s primary function is to support and at times lead the doctors in running the practice. This will include managing the accounts and payroll, managing the staff, including recruitment, performance, training and attendance, etc., the accurate up keep of medical records, whether that be electronically or in the traditional paper format, as well as a business strategy for the healthcare facility that links in with national direction. In a small practice the manager may take the entire responsibility for managing the practice. They may take a more ‘hands on approach’. However, in larger practices it is becoming more popular to have a management team. This could involve one or more of the partners, the practice manager, and a deputy or even team managers dependent upon the organisational structure of the practice. The day to day running of the practice would be delegated down to members of that team with the practice manager possibly having a more strategic and ‘back room’ role.

The role of the practice manager can at times be somewhat isolated, falling between the partners as the employers and the staff. It is vital, therefore to develop networking links to enable dialogue with other managers.

A huge advantage of the role is the diversity and breadth of the remit and whilst this in itself may be challenging it is also very rewarding. The traditional practice manager is a generalist in its broadest sense, being required to call upon a whole host of management skills in order to perform their day to day duties, for example:

A strong practice manager is essential if the practice is to grow and be successful in what has become a difficult and challenging economic climate. We have reached a time when general practice is being steered through very choppy waters. Only practices with strong managers and a cohesive management style will survive and continue to see growth. The practice manager will be the hub of that successful practice, in leading, negotiating and generally motivating that team to pull through. He or she will be required to draw upon all of their resources to manage their teams who will be a very diverse bunch and will include partners, nurses and administrative staff. Each of these areas of staff will want something different from their practice manager. It is essential that the manager can respond and build a rapport with each individual that makes up the workforce as well at the patients. Patients are the reason for the existence of general practice – they are our reason for being. Many practice managers may find themselves more and more removed from day to day patient contact as the business side of the practice becomes more challenging. The patient however, will not understand the business side and will only be concerned with his/her own well being. A talented practice manager will ensure that he/she does not lose their flair for negotiating with patients and will ensure that they maintain awareness of operational issues within the practice so that they are able to deliver an appropriate response when required to patients, as whatever your internal structure the patient will anticipate that the practice manager is best placed to address their needs and will expect to talk to them in their time of need.

Professional status

Although practice management is indeed a profession, there is no formal professional body at the moment for practice managers, and as such managers have to rely on informal networking opportunities, such as local practice manager groups, where individuals working within a certain PCT area for example will meet on a regular basis to discuss issues that affect them all. This may be led by the managers or possibly by the local PCT seeing the managers as the point of contact with the practice and the partners, relying upon them to impart information.