There's a lot more to a practice manager's job than meets the eye. Jeremy Davies looks at research into this chameleon-like profession which found stark differences in pay, conditions and roles

We all know the stereotype of the practice manager - the senior receptionist of 25 years' standing who couldn't manage her way out of a chip bag but was promoted by her GP employers too stressed, too mean or too frightened to do any thing else.

Paid a pittance, Doris, as we shall call her, treats doctors as gods, is more inclined to read a knitting pattern than a Department of Health circular and thinks clinical governance is an antisocial disease.

In the old days, lots of GPs had a Doris. But practice management started to become a much more viable career during the late 1980s.And in the 1990s GP practice staff numbers doubled, as developments such as the new GP contract, GP fundholding and the increasing computerisation of practices brought with them a new emphasis on management skills transferable from outside the NHS.

So much so that Pauline Young, vice-chair of the Association of Medical Secretaries, Practice managers, Administrators and Receptionists (AMSPAR), who has met plenty of Dorises in her time, stresses that their days are now well and truly numbered.

'Practice management has come a long way in the last decade, and especially in the last three or four years, 'says Ms Young, who trains practice managers for the two year AMSPAR diploma. 'These days it's about a lot more than how to run a flu clinic. It's much more strategic and proactive.'

A Pay and Workforce Research survey showed the kinds of work practice managers currently do, highlighted the range of qualifications brought to the role, and illustrated the huge variety of remuneration packages on offer.

1On a similar note, a project commissioned by Newham primary care group in east London to map practice management roles and salaries is set to reveal enormous differences in what managers are expected to do - and not necessarily for corresponding pay differentials.

'Some managers working in non-computerised practices with practically no responsibility are very highly paid.

Others running big practices extremely well get very little, ' says practice manager Jenny Mazarelo (see case study, page 26), who sits on the project team.

Diversity is, it seems, the name of the game. Even practice managers working in practices of the same size can find themselves in completely different organisational structures, says former practice manager Carole Lawrence-Parr, now chief executive of West Dorset PCG.

'There's something about practices that went for fundholding or got heavily involved in commissioning, which pushed their organisational structures further on, for example, ' she says.

While GPs remain independent contractors, this lack of uniformity looks likely to continue. What GPs pay their managers, what they want them to do for the money and how - or if - they train them is up to the doctors themselves.

The Audit Commission's study on the early progress of PCGs suggests that groups have yet to get to grips with encouraging practice manager development, even though they could be crucial as footsoldiers of the clinical governance revolution.

2The commission found that less than a fifth of PCGs had even audited practice staff 's skills and training. Less than 5 per cent had produced training plans for them.

Ms Lawrence-Parr says PCGs' success will depend on ensuring that the interface with GP practices works:

'Practice managers will be key players. That's a challenge for us at PCG level, and professionally for them, too. It's a two-way thing - there's a good future for them if they're prepared to put their hands up and engage with us.'

The Audit Commission has called for 'agreed minimum acceptable standards for practice administration. . .

Where appropriate, the HA and PCG should consider developing plans for general practice accreditation.'

AMSPAR is lobbying for its diploma to become a minimum requirement for practice managers, and for health authorities to refuse GP staff reimbursements - they currently get 70 per cent of staff salaries repaid to them - without evidence that managers hold it.

So far, the NHS Executive's most tangible attempt to raise practice managers' game is the Phoenix (Primary Healthcare Organisations Exchanging New Ideas for Excellence) Agenda team's Development framework for general practice management.

3This document, published in February, offers a structured approach for establishing practice managers' personal development plans. It sets out the core competencies of practice managers as required by 'the new NHS', with a view to encouraging managers, their GP employers and their PCGs to initiate any necessary training to bring staff up to scratch (see table 4, above).

Away from the centre, other developments are chipping away at practice managers' splendid isolation in a piecemeal fashion.

Avon HA has for some years been raising their profile by organising secondments and 'buddy' schemes where they can shadow staff from trusts, HAs or PCGs. Interestingly, two of the HA's 12 PCG chief executives came from practice management, and a third was a fund manager.

Practice managers are even getting involved in research, thanks to a collaboration between the multidisciplinary East London and Essex Network of Researchers and East London University. Several practice managers and forums are working on research projects supported by NHS primary care research and development money.

ELENR director Dr Jonathan Graffy, a GP, identifies four types of research in which practice managers should get involved, for their own benefit and that of their practices and patients. These are: doing their own research into management in primary care; helping to manage practicebased clinical research; liaising with external bodies who want to conduct research on the practice population; and helping conduct internal clinical needs assessments and patient audit.

Most jobs in practice management are still too poorly paid for your typical NHS high flyer - the average practice manager in the Pay and Workforce Research survey earned£20,061 compared to£26,342 for the average trust administration manager,£28,582 for the average HA business manager and£29,614 for the average trust operations manager.

But confident practice managers can persuade GPs to invest good money in them, says Pauline Young. 'You have to be able to say : 'I know how much this job is worth, ' ' she explains. On the positive side, there are already signs among NHS managers of the future that the sands are shifting in favour of primary care.

Of the 54 NHS management trainees graduating this July,39 have already secured jobs. Of these,19 will be working in primary care. Few will work as practice managers, but Karen Lynas, associate director of the NHS management trainee scheme, says: 'It's about being able to gain a broad range of experience in what are often quite small organisations, rather than being one individual in a huge, faceless bureaucracy.'

Now even Doris could say amen to that.

REFERENCES 1 Pay and Workforce Research.

Pay, Terms and Conditions Survey of Managers in General Practice 2000: Report 1143. Available from PWR.

2 Audit Commission. The PCG Agenda: early progress of primary care groups in 'The New NHS'. February, 2000.

3 NHS Executive Phoenix Agenda Project. A Development Framework for General Practice Management. February, 2000.

The perfect practice manager?

These are the core tasks of general practice management as set out by the Phoenix Agenda:

Establish a strategic vision for the practice Agree shared long-term business objectives for the practice, linked to the primary care investment plan of the PCG and health improvement programme;

Plan how the practice will achieve its objectives;

Obtain the resources necessary for the practice to achieve its objectives;

Measure the performance of the practice against its objectives;

Establish and communicate the organisational values of the practice.

Manage and improve patient services Support clinical governance by managing the quality of patient services through standard-setting and audit;

Monitor patient satisfaction and respond to complaints;

Market the practice's services;

Encourage patient-focused practices;

Encourage integration of health and social care.

Manage practice staff Recruit practice staff and issue employment contracts;

Plan and allocate practice staff 's work;

Manage practice staff 's performance (including appraisals);

Manage disciplinary and grievance procedures;

Encourage and support staff induction, training and development using personal development plans;

Encourage team working and team development;

Manage change and contribute to the change process;

Undertake workforce planning;

Set individual and team objectives.

Manage the practice premises and physical resources Draft a health and safety policy for the practice and ensure compliance;

Ensure practice premises and equipment are maintained and secure;

Ensure premises are conducive to productive working;

Undertake stock control and ordering of supplies.

Manage the practice finances Agree budgets for the practice;

Monitor income and expenditure and undertake cashflow forecasting;

Monitor fees and allowances;

Monitor private income;

Gather and present financial information to support decision-making;

Maximise practice income;

Calculate partners' drawings;

Manage salaries/PAYE/pensions etc;

Manage petty cash;

Liaise with bank manager/accountant/HA.

Manage information and communication Identify the practice's clinical and business information needs;

Maximise use of existing information needs, and if necessary plan procurement of additional technology to meet identified needs;

Develop an information management policy for the practice, including confidentiality and data protection;

Chair and/or participate in effective practice meetings;

Gather and present information to support decision-making;

Liaise with key stakeholders;

Provide information required by PCG/HA;

Network with colleagues from other practices;

Draft efficient policies and procedures;

Draft practice's annual report.

Source: Phoenix Agenda 'Development framework for general practice management'.

Case studies

Reach for the sky Jenny Mazarelo is practice manager at the Graham Practice in Manor Park, east London. Her role at the four-partner practice, which is in a highly deprived, multi-ethnic area, encompasses everything from estates management to finance, personnel and health and safety.

Ms Mazarelo started her NHS career in 1984 as a medical receptionist.

From 1986 to 1988 she worked in public health and administration at a district health authority, but found she missed the patient contact involved in surgery life and has worked in practice management ever since.

She has also clocked up an impressive range of qualifications relevant to her work, starting with a diploma in management studies, followed by an Open University MBA. She is currently studying for an MSc in health and social policy at City University.

But despite all this dynamism, Ms Mazarelo envisages sticking with practice management for the foreseeable future, rather than moving into a less isolated seam of NHS management.

'I suppose ideally I should make the move to a primary care group or trust, but from my experience locally, they're too bureaucratic, ' she says.

And she points out the appealing diversity of her current role, which includes sitting as chair on the local practice managers' forum, training other managers, and helping run a PCG-led project to map the skills and situations of all the practice managers across east London, to work out whether they have been graded accurately.

Big is beautiful Jim Bishop runs the biggest GP practice in Britain - the Latham House Surgery in Melton Mowbray, Leicestershire.

The practice has 17 partners and three GP retainers, managing a list size of just under 34,000 patients. Mr Bishop oversees 61 staff, including 12 nurses. He has a deputy practice manager and is about to appoint a supervisor for the reception area so that he and his deputy can develop a more strategic role within the organisation.

The practice is hoping to join up with another practice and become a primary care trust next April. It is also considering applying to become a personal medical services pilot, and is a prototype for New Labour's vision of 'one-stop shop' healthcare.

Many of the GPs have developed mini-specialisms and cross-refer to each other within the practice. There is a casualty department, and four nurses triage all patients before they see the doctors. Six nurses also run their own specialist clinics - for example, on asthma and family planning.

Mr Bishop has been practice manager at Latham House for 23 years, during which time the practice has grown from 10 partners to the current 17.

During the 1990s it became a fundholding practice and a total purchasing pilot. Around this time the practice employed management consultants Pannell Kerr Forster to establish and formalise a clear management structure.

This system stuck, and Mr Bishop says it works well. There is an executive committee made up of four GPs, Mr Bishop and his deputy.

Each GP does a four-year stint on the committee, there is a practice chair instead of a senior partner and there are clear rules on voting - major decisions need an 80 per cent majority to go through, but less complex ones need a simple majority.

Take your partners

Sandra Gower trained in banking but became a practice manager in the mid-1980s.She was headhunted by her current practice, Bennetts End Surgery in Hemel Hempstead, in 1990 and has worked there ever since.

She became managing partner of the practice in 1997, which means she has a financial stake in the practice and is on an equal footing with the 10 GP partners, both in terms of votes on practice decisions and legally speaking - for example, as an employer.

'It was incredibly flattering to be asked to become a partner, but it's a big commitment and took some considerable thought, ' she says.

In the end Ms Gower decided the financial investment and extra work required to buy in to the partnership was worth it to reap the rewards of greater job satisfaction and development opportunities.

'It's hard to explain what a difference being a partner makes, but it's a big motivator, ' she says.

Since becoming a partner she has taken on joint responsibility with the doctors for developing a£500,000 suite for extra services, including physiotherapy and a range of clinics for NHS patients. The practice was recently awarded NHS beacon status.