Jeremy Syree, practising chartered accountant and Chairman of the ICAEW Healthcare Committee, outlines key areas of focus for practice managers

As an accountant specialising in providing accountancy and taxation services to the healthcare professions, my workload varies with the time of year. The majority of the doctors for whom I act have a March year end, but fortunately not all the accounts are sent in for preparation at the same time. My team in the office has been preparing accounts for the early providers since mid-April, but we have had to put finalising these accounts on hold as details of final amounts required to complete the accounts have not been available. We have now started to receive details primarily relating to balances owing on the achievement aspects of quality networks and quality and outcomes framework figures.

A harassed practice manager phoned me recently to announce that all of the outstanding information was available and this would be emailed to me within the following few days. However, he commented, ‘Goodness only knows when we will be able to see you to discuss the accounts though, as we are spending so much time attending meetings with our new consortium that we really do not know whether we are coming or going.’ After a little prompting the manager then said, ‘Yes, we are going along to all of the meetings because we are worried that we are going to lose out financially if we are not there. Really we just want to get on with looking after our patients.’ It was a worrying and sad comment in almost equal measures, but the reason for my story lies in his next comment: ‘We are not half as bad as some of the others in the consortium though. They have practice managers who are new to the NHS and they REALLY do not know whether they are coming or going!

Following this conversation, I rang a few other practice managers, the majority of whom backed the comments about the reasons for joining the consortium, but with some exceptions who were eagerly embracing the challenge and business opportunities that they saw in the new arrangements. The managers also commented that they too knew of a number of practice managers who were new to the NHS and struggling to cope. This article is addressed to new managers in doctors’ surgeries, but will also, it is hoped, act as a reminder and challenge to those who are more established in their role.

NHS reforms

It was only recently announced that the Government had agreed to a series of changes to the NHS reforms,1 as recommended by an independent panel, the ‘NHS Future Forum’.2 While matters are still unsettled, this at least gives healthcare professionals a better idea of how the NHS system is to operate in the future. For practice managers this means there is now time to make strategic plans and better-informed decisions, and help to ensure their practice thrives in the ‘brave new world’ of clinical commissioning groups.

The White Paper Equity and excellence: liberating the NHS, published in 2010, set out the creation of the ‘ideal’ NHS by:3

  • putting patients and the public first
  • improving healthcare outcomes
  • cutting bureaucracy and improving efficiency (among other objectives).

While most healthcare professionals agree that the NHS could be improved in many areas, it was not the concept of change that they doubted, but the radical shake-up proposed by the Secretary of State for Health, Andrew Lansley. The widespread criticism of the perceived ‘capitalisation’ of the healthcare sector led to a raft of changes to the proposed bill and, following the recommendations from the NHS Future Forum,2 the bill is now being returned to the committee stage in the House of Commons to be scrutinised again by MPs.

Much more dissection of the reforms is probably unwise at this stage, given the current state of flux, but suffice it to say that there will be a dilution of competition between health service providers, and hospital doctors and nurses will be afforded more decision-making powers. However, GPs are still expected to be in charge of 80% of the NHS budget, which, in turn, presents a new wave of opportunities for practitioners and practice managers alike.

Manage your practice effectively

It seems that there are two things to weigh up when considering how to be an effective practice manager; there is what your GP partners and fellow employees expect you to do, and what you are capable of doing, often leading to an ‘expectation gap’ in the middle. There are a number of areas that you should focus on in order to give yourself the best chance of running an efficient and profitable practice. Try, if you can, to step back and view the practice as a business and this approach will sit more effectively under GP commissioning.

Budgeting
Budgets are an important planning tool and are used to set revenue, expenditure, and profit targets. You should come up with targets in all these areas, with positive and negative tolerances (such as plus and minus 10%), and then review your actual results compared with budget results on a monthly basis. Any significant variations from budget should be considered, as there may be underlying issues such as cost-control failures.

Cashflow
You may have heard the phrase, ‘Cash is king’ applied to businesses. It is also an essential mantra for practice managers to bear in mind in the day-to-day running of a medical practice. It is vital that adequate funds are left in the practice to pay for major items of expenditure and to ensure that tax payments on account can be met when they are due in January and July.

Effective use of technology
Use of technology to your best advantage is an area that is often overlooked, yet it can vastly improve patient services as well as saving human resources. Text messaging services are used by some practices to remind patients of appointments and communicate information on issues such as the recent swine flu epidemic. This type of use of technology can help reduce bottlenecks at the reception desk and ensure that GPs’ time is not wasted through missed appointments.

Networking
Networking is a powerful tool, which, if employed effectively, can:

  • lead to increased revenues and profits for the practice
  • be a source of invaluable support
  • assist with learning of ‘best practice’ methods
  • cut out waste and inefficiencies.

Discussion forums involve practice managers taking it in turns to make a presentation to the group on something they may specialise in, or on an initiative they have successfully implemented. If you are not already part of such a forum, consider joining one or starting a group from scratch. Attending these meetings gives practice managers the chance to compare informally the performance of their practice with other similarly structured ones, and also provides a support network in what can, at times, seem like a lonely role.

‘Buddying’
Consider shadowing other practice managers for a day or two to pick up key operational differences and cherry pick their best work habits. There is a good chance that you will learn something which will help you operate more efficiently in your role. Of course, you should also reciprocate the offer, as your ‘buddy’ will not only value the experience of learning about your management style, but might also point out some areas for improvement. This type of opportunity could easily be explored via a practice manager’s forum or networking group (see above).

Marketing
Marketing sounds like something for commercial organisations, but it also applies to today’s healthcare sector. Your patients are your market and they will have needs that extend beyond the range of services offered by the GPs. They will need referrals to specialists and what better way than to offer those services in your practice. The key is to market this offering, via in-house posters, the practice website, take-home leaflets, and reception-area televisions. While patients are waiting to be seen, they are an almost captive audience and this is an ideal time to advertise other services the practice can offer.

Importance of benchmarking

The healthcare sector of today is generally striving to become more corporate, accountable, transparent, and competitive, and to achieve that, a system of checks and balances needs to be in place. Benchmarking is a useful tool that allows practices to compare performance with that of their competitors, and also gain a better understanding of their patients’ needs.4 Benchmarking gathers all sorts of numerical data from across a number of practices and allows practice managers to understand how their practice is performing on a number of levels.

There are several key objectives that practice managers should be looking to achieve when undertaking a benchmarking exercise. Benchmarking:

  • promotes the need for change, to deliver improvements in terms of efficiency and high levels of patient care
  • helps to improve motivation and individual employee performance
  • can help form the basis of a business plan strategy that can be reviewed continually
  • highlights what level of performance is possible under similar circumstances
  • can help you to identify and establish what your patients’ needs are.

As accountants, we have carried out many benchmarking exercises across medical practices. Each one of them differed in structure, culture, size, and location, and therefore delivered contrasting outcomes. Most usefully, we were able to determine outstanding levels of performance and key areas for improvement. Taking part in a benchmarking survey gives you access to a wealth of information that you could use to improve your practice’s performance. Knowing why a similar practice is more profitable in a particular field, or that it performs better at certain operations, gives you the opportunity to be proactive and make useful suggestions to your GPs. This not only improves the performance of the practice, but enables you to exceed expectations of your own performance and marks you out as an invaluable resource within the practice.

In our recent benchmarking survey, we found that the number of specialist clinics on offer varied dramatically across the practices, with some reaping the financial rewards of offering immunisation clinics, and others generating a healthy income from renting out rooms to medical consultants, such as dermatologists. You may determine that there is more potential in the private patient sector and change your marketing strategy accordingly. On thorough analysis it is possible to identify areas of weakness and strengths throughout the practice. Benchmarking results are an excellent topic for discussion at practice forums, where more light can be shed on the numbers, and the reasons behind the findings can be analysed by people at the ‘coalface’.

For practice managers on the journey of continuous improvement, taking part in a benchmarking survey will steer you in the right direction.

Mergers and acquisitions

As a practice manager, you will be relied on to have an understanding of the local market and also of what other practices are doing. Be aware of any other practices with GPs looking to retire; there may be practices comprising sole practitioners who are looking for an exit route and a smooth path to retirement. If there is a good fit between your practice and theirs, begin discussions with a view to taking over new contracts and merging the two practices. A merger with another practice of similar size will tend to offer greater rewards. However, the radical changes brought about by a merger are probably the most challenging and difficult that any practice manager will encounter in the workplace. You will need to consider issues such as:

  • potential staff redundancies
  • reorganisation of employees
  • who will have autonomy for managing the new practice
  • how the cultural differences will be overcome
  • whether the new practice will operate from one of the previous premises or both, or from a new location.

The benefits of merging practices can be huge, but ensure you undertake thorough due diligence before proceeding.

Superannuation and pensions

As an employee of the NHS, you will be entitled to the benefits of being in the NHS pension scheme, which is considered more competitive than private sector equivalents. General practices manage the contributions to the pension scheme for their employees and for doctors’ superannuation schemes, which entails understanding of additional rules.

Practice managers must ensure that superannuation certificates for the previous year ending 31 March are completed and submitted by 28 February of the following year. The certificates must be completed by salaried GPs as well as by GP providers, and all practices need to complete a form outlining the GPs’ (and non-GP providers’) estimated pensionable income for the forthcoming year.

Calculating superannuation is a complex task and one that we recommend you ask an experienced accountant to help with. Contributions need to be paid based on the pensionable pay and there are associated tax consequences reliant on the timing of these payments.

Summary

You will already be aware of many of the points covered in this article and will be incorporating beneficial actions into the daily running of your practice. Your role as a practice manager will be changing in the near future and you should now put new strategies into place for your practice, and gain a clear understanding of the role you will be expected to deliver as a practice manager under the new system. With the current pause in NHS reforms, you now have some breathing space to consider how best to position your practice under the new clinical-commissioning group system and how to ensure that you offer a good service for all stakeholders.

  1. Department of Health. Government response to the NHS Future Forum report. London: The Stationery Office, 2011. Available at:
    www.tsoshop.co.uk
  2. NHS Future Forum. Summary report on proposed changes to the NHS. Available at: www.dh.gov.uk/nhsfutureforum
  3. Department of Health. Equity and excellence: liberating the NHS. London: DH, 2010. Available at: www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsPolicyAndGuidance/DH_117353
  4. NHS Benchmarking website. www.nhsbenchmarking.nhs.uk G