A Child in the 1950s
As a child in the 1950s, I was a regular attender at the sit and wait style of open surgery. There were no appointments. My mother and I sat waiting in the Doctor’s Lounge on upright chairs and we were seen in the Dining Room. The Doctor had a roll top desk, cluttered with paperwork. No computer screens. Probably no wash hand basin or screened couch. The receptionist sat in a cubbyhole under the stairs. My bulky record folder was handed to my mother. I was dying to peak; some did. We would wait at least an hour but I do not remember any complaints. The important thing was to be seen.
Purpose Built Surgeries
The home based style surgery was eventually replaced by a purpose built surgery in the mid to late 60’s around the time I started work in an Executive Council. I worked as a clerk in a Registration Department writing medical cards and the paper dust from records and index cards probably did not do me much good as an asthmatic. My boss at the time once told me that he would never have employed me if he had known I was asthmatic. That wouldn’t happen now would it?
Two whole time staff (equivalents)
I remember that GPs at the time, 1966, employed only a small compliment of staff, a receptionist, maybe a medical secretary and a part time nurse. There was no such being as a Practice Manager. It was probably well into the 70’s and 80’s that as a senior officer in a Family Practitioner Committee I started to meet and get to know the Practice Managers in my area – firstly in Dudley and then Wakefield. They were a good solid bunch of folk not put off by considerable change and hard work. We jelled at training events and during my visits to surgeries to discuss premises improvements. Information Technology was in its infancy. BBC Acorns were used for repeat prescriptions but into the 90’s there were in the region of some 60 clinical software systems on the market and today only around three have survived.
Being A Practice Manager
I became a Practice Manager myself in 1992, after the demise of FPCs and started to see the world quite differently. GPs were not used to managing their own affairs and those that I worked with in five different practices did not always understand their budgets and dare I say the rules of the game. Frustration abounded. The word independent often reared its ugly head and made for difficult relations between Practices and officials from variably named PCGs, PCTs, CCGs and so on. I often heard from my Partners ‘we don’t pay you to do that’ and ‘make em wait’!
Fundholding and Practice Budgets
In General Practice Partnerships merged and grew. My Practice reaches 10?doctors at one point. The number of staff required to run the show also grew. There were ‘funded’ fundholding managers along with data clerks and invoice clerks. But when fundholding ceased did all of these people leave? Probably No! Then there were new clinical staff entering the affray such as phlebotomists, salaried doctors and nurse prescribers who had been paid for out of fundholding monies. But the Personal Medical Services contracts brought another form of fundholding with it’s new so-called Growth money – enough to pay for new staff and more doctors. This is where innovation took hold and more new posts were created from salaried GPs to Advanced Nurse Practitioners who could prescribe. I think, however, it also created more richer and more poorer practices. It has to be said that these posts were all funded above and beyond the original Ancillary Staff Scheme and arguably still are or are they? There were also major issues about Practice Budgets as those Practices that were high earners continued to be so, yet you could argue that those Practices who were low earners and took on budgets lost out even more over the years. Added to that the Budgets fell short of reflecting the change of Practices to employer status and the new requirement to pay Employers Superannuation contributions for GPs. And then budgets and new funding started to be cut. My biggest question is whether the right proportion of funding in Practice Budgets ends up being spent on running the Practice or ends up in Drawings!
Understanding Funding
It is important for the owners of Practices and their Practice Managers fully understand the history and origins of the funding the Practice receives and are able to consider the consequences when these funds are reduced or withdrawn. The Minimum Practice Income Guarantee is no longer reliable. The Quality Framework has changed so much since 2004 and has become harder to achieve. So can you really afford a Health Care Assistant? If you think you can where did the money come from. I suspect the profits of the Practice. Are you actually replacing an expensive member of staff with a cheaper employee. Practices need to be so careful when introducing new ways of working with arguably cheaper staffing costs. One further point is that the Care Quality Commission has added to the pressures on general practice to prove that Practices are achievers and if not the threat of special measures and closure looms alarmingly. You may start to ask the question – is your Practice financially viable?
Can you really afford it?
I might argue that apart from an adequate quota of GPs, Practice Nurses, and general Practice Staff you cannot actually afford anyone else. You cannot afford a succession of long term Locum doctors. You could swap a doctor for a Nurse Practitioner and you could swap a Practice Nurse for a Health Care Assistant or Phlebotomist. But without guaranteed continuous funding you cannot afford a Practice Pharmacist or a Physicians Assistant. What would happen today without technology and instead we just sat and waited to be seen.
Is it all Acceptable?
I do wonder whether we have drifted away from the basic contractual requirements of providing treatment and care to patients within a reasonable time. Is it acceptable for patients not to be seen today or be spoken to by a clinician on the same day? Is it acceptable to wait for three weeks for a routine appointment? Has it become more important to please the CQC and the CCG rather than see patients on the same day. What will it take to get back to 1950’s standards. More money or less bureacracy?
Robert Campbell – June 2019
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