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Many practice managers are being driven away by the stress of implementing GMS2 ­ Rachel Stark suggests how to ease the burden so you don't lose yours

Statistics show that many practice managers have left primary care since the introduction of the new GP contract. A key factor was the increased pressure

for practices and practice managers under GMS2.

Although there are a multitude of reasons why pressure has increased, there are four main areas. These are:

·unclear and frequently changing guidance

·more work and a tight timescale

·clinical tasks outside the remit of practice management

·partnership issues.

Each of these challenges can be overcome with effective planning, knowledge and communication.

Unclear and changing guidance

The new contract was released behind schedule and many areas needed further clarification. Changes occurred throughout its first year and meant some practice time and effort went to waste. This caused apathy and disenchantment until a final version was available. Local negotiations and different ways of working added to this uncertainty.

But practices can avoid further confusion.

·Build a good two-way responsive relationship with their PCT. Most PCTs have a manager responsible for GMS2 and the practice should ensure they keep this person up to date with any practice issues and also request regular updates from the PCT.

A strong relationship will also enable the practice to influence PCT policy and also increase PCT understanding of practice issues. This helps to reduce the anxiety around the annual review and also likelihood of any disputes at the end of the year.

·Regularly refer to the BMA and Department of Health websites for new contract updates.

·Read all updates from the LMC and feeding any problems to the LMC to inform their discussions with the PCT.

·Use reliable external resources. This could be the NatPACT training or the NAPC helpline and their expert practices.

·Keep clear records of services, budgets, targets and standards to ensure the practice can easily identify what is required and the remuneration due.

More work and a tight timescale

Although some practices started work on the new contract when it was initially released, many waited until it was implemented. The first year of any new contract or quality framework always generates significant work ­ for example, cleaning registers and writing policies from scratch. The second year will be easier as the bulk of the preparation work is done and the work becomes routine. In April, though, we face a revised version of the QOF and this may generate similar swells in workload. This can be controlled.

·Ensure you understand what is required and therefore avoid any unnecessary work. The new contract should reward practices fully for all the work they do and anything outside this should be resisted without adequate resources.

·Review each task and evaluate whether it is cost-effective. Although the practice must bear in mind that QOF performance may be in the public domain and good scores are therefore useful to safeguard list sizes, it may be inappropriate to use more resources hitting the target than the remuneration it generates.

·Plan effectively by creating an annual timetable with all required tasks. This should reflect the one-off activity such as the annual review and signing off the final report. It should also build in the regular work and time to monitor performance.

·Assign each task to someone responsible for overseeing it. This could be a GP, member of staff or manager and this person must report regularly on progress.

·Have a key team tackling the wider contract issues and managing performance. This should be an IT-literate and QOF-aware GP and the practice manager and other key personnel. This creates a more dynamic approach but also shares responsibility.

·Review your staffing structure to ensure everyone's time is being used effectively (many tasks under GMS1 no longer need to be done ­ such as new patient checks). Any shortfalls needs to be addressed and you should consider additional staffing.

·Exploit all opportunities for data collection. For example, the flu season brings about 40 per cent of patients into practices for jabs. Increasing staffing during clinics allows you to do more outstanding blood pressure checks, blood tests and data collection.

·Work jointly with other practices. Instead of each practice writing its own policies from scratch, share the workload. The policies can be more comprehensive as more time can be spent on each one if each practice manager has to only write one or two, although they may have to be tailored.

Clinical tasks that are outside of practice management

While practice managers can develop services to meet standards and manage performance it is the clinicians that actually perform the service and collect the data. However, clinicians' time is often already stretched in the consultation and QOF should not be the focus of patient contact. Instead it should derive from usual treatment and management.

·Ensure staffing levels reflect the workload required but that this relates to the remuneration the work attracts.

·Look at the skill mix in the practice and find innovative ways to release time for this extra work. For example, you can train receptionists to undertake routine blood pressure checks so that nursing staff can focus on hypertensive patients. You could also train and support nurse practitioners and practice nurses to take on full responsibility for certain chronic diseases, such as diabetes and hypertension.

·Make sure clinical staff fully understand the standards in QOF and how the practice is reaching them. This will mean training sessions, distribution of the standards and regular updates and feedback on performance.

·Have clear, simple policies and procedures for clinical indicators and enhanced services.

·Set up templates on clinical software and refine them to ensure they are quick and easy to use but also cover all relevant aspects of the indicators.

·Make sure all people inputting data are aware of correct coding. Also ensure data is entered correctly. Input clerks need to identify and code relevant clinical and diagnostic information in hospital correspondence.

·Make sure clinical staff delivering services have adequate time to address any outstanding data. However, this should not detract from their clinical tasks. Where possible use administration staff to collect data.

·Look at how to exploit data collection opportunities. Create adequate additional resources at peak times ­ such as the flu season ­ to boost data collection so that you don't have to ask the patient to return for this at a later date.

Partnership issues and disputes

So much has changed under the new contract that partnership agreements are out of date. Now, when a GP retires or a dispute arises about workload and income relating to GMS2 the partnership agreement does not cover it and often a long legal process begins. Managing any dispute in the partnership is stressful so practices must prevent these situations arising.

Practices need to revise their partnership agreement to reflect these changes.

·Pensions

GPs will not know for sure what their pension payment for the first year of GMS2 will be until after February 2006. The agreement needs to consider how the practice manages any shortfall and also how the practice will manage this position when a GP retires. You need a mechanism to hold a balance in the practice in case there is a shortfall in payment but also assurance for the retiring GP that any overpayment will be remedied.

·Seniority

The new formula for seniority is based on average earnings ­ which is calculated using the pension forms submitted in February of the subsequent year. Again there will be a delay in establishing the actual seniority due and this may mean the practice has been over- or underpaid throughout the previous year and a balancing payment may be due. Again, this poses a problem for retiring GPs as the risk of over- or under-payment has to be managed.

·The partnership needs to consider the additional income from the QOF ­ and also the additional workload to ensure that workload and income are fair.

Keeping morale and enthusiasm

Practice managers may also lack enthusiasm for certain standards in the framework. They can be encouraged to counter despondency by looking at the extra funding as a way to address areas that aren't yet part of the QOF. Although the practice should not feel obliged to go further than the QOF this is an option for practices if they want to make an impact in an area that matters to them.

Adopting these points will enable the practice to manage the new contract in bite-size chunks. Trying to tackle the whole contract at once is a huge challenge, so setting up a timetable, delegating responsibilities, adopting clear procedures and communicating on performance effectively will reduce pressure on the practice ­ especially the practice manager.

Rachel Stark

is practice manager at

the New East Quay Medical Centre, Bridgwater, Somerset

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