I’m a GP Practice Manager - AMA

[Menora]

My background - I am 40 and previously my whole NHS career has been in Community Services, so I am more of a fresh set of eyes in primary care. I started out as a receptionist many years ago.

I will and do answer telephones when the practice is busy, there is no job I won’t ask my staff to do that I wouldn’t do myself.

I deal with a lot of complaints, mostly about frustration with services and commutation. I can advise you how to make a good, effective complaint and how to get the answer you want from your practice.

There is a new contract change this year, with regard to access. I can answer how GMS operates

I can answer general questions people have about primary care, although I understand all practices are run differently so I might not be able to answer something very specific. I am also not a trained clinician so I can’t answer anything medical.

This isn’t something I am accustomed to. It’s hard to speculate it could be financial or workforce related. Small practices have struggled. Digital access is part of the GP contract

GP’s are independent contractors - they are a small business owner who has an agreement to hold a GMS contract with their local ICB. Each practice has to manage their own finances to stay solvent and they can go bankrupt. They have to provide certain services but they manage everything else internally their own way. If they are poor at managing money that’s their own internal issue. However the contract payments are very tight and it’s hard to make ends meet. There is a shortage of GP’s so practices may end up spending a lot on locums to provide basic services.

They are not involved with larger scale procurement this would be your local integrated care board or secondary care trusts who are not independent contractors. I don’t know exactly what they are doing to cut waste. Their managers in my experience are usually clinicians. I would struggle to get a job at a high level in the central NHS as I am not a qualified HCP. They pay a lot for management due to their clinical backgrounds. Suppliers probably do have a stranglehold on NHS services that’s down to the government, recession and the market.

GP practices largely can choose their own suppliers for consumables but nationally/local the prescribing formulary is set so this is why they are pushing some medicines OTC.

There ought to be a traditional route for those who cannot use digital means, each GP surgery now has to have cloud based telephony they are not getting rid of phones but expect those who can, to use digital means to free up lines for those who can’t.

I'm very sympathetic to GP practices and I know how hard they work. And I appreciate the staffing crisis issues. But I'm not liking this new trend of booking in patients with associates of various descriptions and blurring the boundaries with patients about who they actually are/the nature of their qualifications. You ring for an appointment and ask to see a doctor, and you just get "Mr x or Ms Y is available Tuesday, if that's possible ". My mother in law saw one, with suspected skin cancer, and yesterday, and was referred for that and a heart scan. When asking about something else, she was told "oh no, you'd need to see a doctor for that!". Shocking, I think. There needs to be much clearer guidelines about who they are and what they can and can't do.

Yes this is the ARR’s scheme NHE England have developed. You will see this in secondary care now too. It isn’t always clear however the concept is that they are supervised by a GP all the time so can essentially work under that doctor and it would only be a rare exception that needs to go to a doctor individually.

What was the something else? As they can prescribe, refer, plan, treat etc. I wasn’t there so wasn’t clear if they were politely ending your consultation after already addressing 2 big issues and then you asking about a 3rd. They don’t have time allocated to them for multiple issues

@Menora the point was, until the last sentence she was unaware that she wasn't in fact seeing a doctor. That is wrong, imo. Also, I dispute the level of skill/knowledge, after a two year course. And a recent one at that, given they are a new role.

I think practices appear not to be making clear to patients who they are seeing.

Whilst the name of the clinician should be given I do not agree that each patient has to be told someone is ‘not a doctor’ and ‘only had 2 years experience’ if they are perfectly able to complete all the tasks they were booked in to do. They did the two referrals as requested. Patients would immediately ask not to see that person due and clog up a GP with more admin that someone else is capable of doing.

I would certainly expect to be clearly told who I am seeing and what their role is.

I have grave concerns about the role of PAs and they way that these positions are often mis sold to patients who believe that they’re being seen by a Dr who has undergone full medical and GP training.

surgeries are very aware of the vast difference in training and skills and this should be clearly explained to patients.

@Menora I don't think we should con the patient population. It's patronising and sneaky. Patients are entitled to know the job titles of those they consult, whether you agree or not.

I was commenting on the way this was worded above. The HCP who saw the patient was able to complete all of the tasks requested in the appt (apart from item no 3 that was added on during the appt). However if you assume that only a doctor can do things for you and all other HCP are lesser, and maybe even dangerous this isn’t something that’s going to be phrased in this way to you.

All patients should be told the name of the person they are seeing for their appt, although this doesn’t happen in a hospital - you don’t often see the consultant you see a registrar or a nurse. The consultant is overseeing their team. In primary care, the GP is overseeing that team in the background. In the NHS is it is not common for people’s qualifications to be explained to you at each appointment. It’s not a con. It’s a big team of various HCP who are supervised by GP’s. They are an extension of the GP, the same as a registrar is an extension of the consultant whose clinic you might attend in an outpatient appointment. At my practice you are told the name of the person but it is not phrased “sorry they aren’t a doctor you have to see someone else”. It is phrased that X person is seeing you. You may see a pharmacist who is even better at meds management than a GP, but people assume that a GP is the best and they want that only. There isn’t enough GP to go around, it’s sad but true.

The responsibility of managing people’s skills is the GP and the clinical supervisor of the PA’s… not patients. They are responsible for managing that persons competencies. If you are worrying about an incompetent PA or HCP then you need to report it to the senior clinician at the practice/hospital and they will address that. We have got what we have got and have to make the best of it. You will also see a lot more PA’s in A&E now too.

I unfortunately had cause to make a complaint about a GP recently who incidentally owns the surgery. I emailed the PM however I wasn't entirely confident they would be neutral given the GP's ownership. I was also forced to email the generic address so no privacy as it will have been read by reception. Is this standard practice?

@Oohmontydon this is challenging as the PM is usually an employee. If you want a more independent view point you can contact your local integrated care board.

Yes, no PM is going to allow reception staff to give out their named email address, that way lies madness . I’ve never emailed a patient directly from my own account it would be very dangerous. Patients do email about serious and urgent health issues that need attention, if I was on leave or in a meeting I wouldn’t read it. Nearly every practice will have a generic account for this reason but you can write a handwritten letter. I would not assume reception would read complaints and gossip - mine wouldn’t and they don’t all have access, it’s just the more senior ones. They would just forward it to me.

Gosh @Menora do practice managers not know how to turn on their out of office and direct urgent matters to the main in-box? The rest of society manages that.

It would be inappropriate for a patient to have my direct email address. I’ve worked in the NHS for over 20 years. Rarely ever met anyone who gave out their email or personal mobile number to a patient. It’s unsafe for a multitude of reasons. Almost all departments in all trusts and practices use generic mailboxes. I know you assume everyone would use it sensibly, but that’s not at all true and I’ve had to report various things to the police about my own personal safety, and have colleagues who don’t always feel safe around certain patients contact either. People often have no boundaries online or email saying things they wouldn’t say to your face. The local Facebook groups can be brutal I’ve seen peoples personal info shared on them before. If me having a boundary in my own workplace bothers you then I am sorry that you feel entitled to challenge that.

Thank you for the reply.

Fascinating and informative thread. Thank you @Menora for taking the time and for the work you do.

Our practice manager's named email address is freely available and given out by her online.

I don't really understand your answer about physician associates and why you defend hiding that the patient isn't seeing a doctor. Surely you could just have some information saying PAs do list of things so if the patient's need is on that list they might be seen by the PA if a GP isn't available. Then everyone is clear.

@HappyHolidai I had a death threat last year and police involved. This is why I never would. This person had hold of my email and harassed me for some time. I don’t really want to answer more questions about it, my boundary is my boundary for a reason I’ve explained now 3 times. I have PM’s as friends and colleagues and none of us give out our email address. Your PM is obviously happy with the risk. I’m not. It doesn’t affect the patients they can still send an email and I will still respond.

There is a list of what PA’s and nurses do but it isn’t read out to patients on the phone every time someone calls to book an appt with the staff credentials. It will be on the website and reception have a crib sheet. What I have tried to explain is that there isn’t a huge difference in what they can/can’t see as they are supervised by a GP so if something is outside of their remit they ought to have a GP they can call on for assistance. Nurses have been doing this for a long time. From the description of the PA consult it was appropriately booked because the PA made the two referrals the patient was booked into see. It as the 3rd added item during the consult they said they could not help with but that’s not clear what it was or whether they were fobbed off because the appt was getting longer.

GPs do not “oversee” nurses. Nurses are independent practitioners and are legally, professionally, and personally accountable for their own practice.

@MrsDrudge surely they do in a GP practice where the GP's own and runs the business that employs the nurses. In that sense the GPs are accountable for their staff.

@MrsDrudge Doctor accountability for some health care groups is a hotly contested area, as you may have noticed from the recent debates over Associate Physicians.

Nope, nurses are independent practitioners with a professional registration and PIN number. The buck stops with them. We are responsible for our own clinics, our own patients and our own practice.

The GP practice will hold indemnity insurance which covers us, and are “responsible” for us in HR terms as any other employee would be. But clinically we are not accountable to the GPs like PAs are (who do not hold any PIN number or, as far as I know, have a professional registration.

I think @Menora meant that nurses are more aware of their professional limitations and will have a GP to call upon for guidance if something seems beyond their remit, rather than having to be directly supervised by a GP or accountable to one.

@sidge but surely if the GP practice sub contracts it's obligations, for example, for smear tests to practice nurses, whom they also pay and employ, the GP is responsible for their conduct and performance. If not, no wonder the buck never stops anywhere in our health service.

@SpringNotSprung well no, no more than any employer is responsible for their staff in terms of behaviour, or performance. The buck stops with the nurse.

For example I take smears. Lots and lots of smears. The GPs have absolutely nothing to do with the smears I take. They do not supervise me. (Not a great example as I actually train the new GPs lol).

I have a code which is my identifier at the lab and results will come back to be filed, and my name will be in the medical records as having taken that smear, and the lab records will show that I took that smear.

If I balls up my smears it would become apparent in my audit process (which is my responsibility, not the GPs) and the lab may highlight my lack of adequate smears. It would be between me and my manager to address the issue. Do I need more training? Am I needing supervision from a more experienced member of staff?

I have regular clinical supervision for my team and I myself will have appraisals. But my day to day clinical practice is not overseen by a GP. I do not have to report to them per se. I am responsible for my own practice and prescribing.

Not all HCP can prescribe so yes I meant that they will call on GP’s for assistance if it is outside of their limitation, this was not about getting a smear it was about seeing a HCP for something patients expect a GP to be doing and getting a different HCP altogether. As partners are the business owners with liability they obviously support their staff and are the clinical ‘supervisor’ on site for what of a better word, they will attend HCP appts to assist them if there is something unusual or urgent outside of the HCP remit.

We have a system where all of the GP’s are on hand for advice and guidance, support, second or further opinion. This is usually when it comes to prescribing or if someone becomes very unwell during an appointment and needs to have an ambulance called, or perhaps someone has been booked in for X but they need Y and it’s not in the HCP skill set or something they are unsure about.

This is true of even district nurses they may see a patient and then refer back to GP for further assessment of anything that is outside of their remit.

It was not intended to make it sound like nurses have GP supervisors as they aren’t independent, they are. However medicine can be complex and now that there are less GP’s, other HCP are seeing more complicated cases nowadays and sometimes they will need to pass a case to a GP or ask for support.

I have tried to help and explain but I am going to step away from the thread now. Thanks

I hope your specialist nurses also supervise and support your GPS in the same way. Often GPs in my surgery refer patients to the diabetes specialist nurse, the respiratory specialist nurse, the cardiovascular specialist nurse, the family planning nurse etc. Specialist nurses have training and education which is far more focussed and specialised than your average GP.