Survival practice

south London fundholding practice a daily challenge

I arrived in primary care after completing the NHS general management training scheme, a hospital management post and three years as a contracts manager for a London health authority.

My interest in primary care came about as a result of developing a strategy for mental health services with the local authority, voluntary sector and primary care. During the implementation process I realised there was much I did not know about general practice, but met many practice managers whom I respected, and whose outlook and experience were refreshingly different from my own. They seemed to have their feet much more firmly on the ground than HA employees.

A year as a practice manager in a four-doctor fundholding practice, with a team which includes receptionists, nurses, a counsellor and a psychologist, has provoked several thoughts on the key contrasts between working for a HA and working for GPs. The pay and hours - about 50 a week - are roughly comparable, but the context is very different. You take more knocks in general practice because you are more visible. It is more practical and more immediate. I have been struck particularly by the extent of the pressure on receptionists and the amount of support they need.

The purpose of my HA contracting job was to secure the best services for the local population. But it was a real struggle to develop relationships with people who used the services, and I found it very easy to go for months without having any contact with them. When I did begin to develop relationships with user groups, their views became a powerful tool in making services more sensitive and humane. But I had to discipline myself to spend time approaching service users on their own terms, to avoid tokenism and to listen creatively. The time I spent doing this was never wasted.

In general practice, by contrast, I find there are almost too many patients willing to give their view on how we are going wrong. The hundreds of comments made during the week are difficult to distil into a list of things that one can actually do something about. I have realised that good GPs, practice nurses and receptionists have a huge store of knowledge of the user view, and do not always need HA-style models, meetings and focus groups. The challenge for me as a manager is to generate the political will to act on the knowledge that is already available.

My HA role was fundamentally about change. I felt a real failure if I went home at the end of a working day without having moved the change agenda forward in some way. A lot of time was spent keeping people on board the good ship Change, and reminding them of what they had already agreed to, and even letting them steer - at least for a while.

Now, when I go home, I am glad if I have managed to keep the practice afloat for another day. Getting through both morning and evening surgeries and visits without getting too behind time, with the computers still working and the receptionists still reasonably content constitutes a good day - especially at this time of year. Change is what we think about in the moments in between. On the one hand, I am very much enjoying the return to the immediacy of operational management and getting my hands dirty (very often, literally). On the other, it takes real discipline to carve out time for the practice to consider the future and to plan.

At the HA, my work involved large sums of money in a macro-framework. It could be extremely satisfying to see a whole multimillion-pound service area begin to turn round and meet client need in a way it never had before. But it takes huge amounts of time and energy to achieve meaningful change, and I learned that NHS contracts can be very blunt instruments, not always appropriate for the delicate surgery many situations require.

In practice management, I feel more like a fieldmouse darting around nibbling at lots of little bits of service. I cannot achieve on the scale of HAs - which has its frustrations - but I can derive satisfaction from being able to achieve meaningful (however small) change, quickly.

Line management was a very small component of my HA job, where I only managed two people, and my skills in this respect had become flabby. I had become more accustomed to managing joint service developments with the local authority's social services and housing departments, which involved having good relations with them and also a lot of diplomacy and politicking (plus keeping up-to-date with the latest policy developments from the centre).

Here, I am again becoming used to managing individuals in a team. I had forgotten how much I love it and hate it. I am so glad, though, to have the chance to get on with the business of managing a team of people again, rather than just encouraging a provider organisation to do it better.

Being in general practice has also brought home to me the gap between getting objectives down on paper and getting people to sign up to them on the ground. Being clear what motivates people is a vital element of successful management. Getting the best from limited resources is a key factor in HA work, and the skill is to blend the strong motivations in people such as public health consultants, finance staff, service users, voluntary organisations and local authority staff to achieve the maximum from the minimum.

The bottom line, however, is usually whether resources are available, and the debate is always circumscribed by this. This can be a real demotivator to provider units, which quite legitimately ask: 'What's in it for us to work harder?' The answers, in my experience, were varied, but rarely involved additional money, and staff salaries always stayed the same.

In primary care there is a very different feel. As a small business, the bottom line is practice profits. This can introduce a new flexibility, because doctors may be prepared to pay for certain things from their own pockets. (This can, incidentally, lead to financial indiscipline if, as manager, I always feel I can ask for more.) But the incentive to work hard for the GP is much more directly linked to their personal finances, and this has introduced a new issue for me as manager. Am I prepared to work hard to make these partners richer? Am I prepared to drive my reception team harder and reduce their overtime when the financial benefit may go to the doctors alone?

The answer, so far, has usually been yes, but with the proviso that there is good communication between the different parts of the practice and all staff have the opportunity to influence its development.

Just what this means in practical terms is not yet clear. But I do see the key to successful practice management lying somewhere in that nexus of motivating influences. I would not claim to know yet what makes a successful practice manager, but I do know that one will never get near it without peer support.

The main thing I miss about my HA job is having other managers around to bounce ideas off. In practice management, if I want to get information, feedback, support or ideas, I need to go out and find them. You can get isolated, particularly in terms of information: I am still trying to get hold of a copy of the white paper.

The more time managers in HAs and general practices can spend together through formal structures such as locality commissioning and fundholding negotiations, or informal ones such as learning sets and shadowing, the more they will learn, understand, and, one hopes, forgive, when people disagree.

The way I feel now I would not go back to an HA or a hospital. I do not know anyone else who has made the move I have. But on a good day, I like being on the front line.

Murray King is practice manager at the Manor Health Centre, part of a multifund in Clapham, south London.