3 Practice management

‘If you have time to do something wrong; you have time to do it right’

W. Edwards Deming

GP partners in a practice have dual roles as both clinicians and managers of small businesses. As such, they must co-operate with their partners and practice manager to run the business side of the practice and with primary health care team members to cover all aspects of the clinical work.

Management is the process of designing and maintaining an environment in which individuals, working together, efficiently accomplish selected aims. The manager coordinates individual effort towards the group goal. To do this, he/she needs technical skill (knowledge specific to the business of the organization); human skill (ability to work with people); conceptual skill (ability to see the ‘big picture’); and design skill (ability to solve problems). There are 5 managerial functions:

Key features which contribute to successful teamwork are:

Essential to ensure necessary decisions are made; review policies and agree standards of care; review the financial position of the practice; educate and inform practice members; aid communication and improve morale of practice members.

Primary care is about risk and uncertainty, but sometimes unnecessary risks cause ourselves and our patients unnecessary harm. Defence organization records suggest ∼½ all successful negligence claims reflect poor clinical judgement on the doctor’s part; the other ½ represent avoidable mishaps which would be susceptible to risk management approaches—often failures in simple administrative systems, communication failures, inadequate records, or lack of training.

Risk management means taking steps to minimize risk and keep ourselves and others as safe as possible. All the major defence organizations run risk management programmes for their members. There are 4 stages:

Practices employ an array of staff. Staff costs are included in the Global Sum ( p. 22) paid to a practice.

Very complex field which changes rapidly. If in doubt, contact your local BMA office for advice. Major points:

Sample contracts are available from the BMA. Employees have a contract of employment from the day they accept their job—even if it is not written. All employees must be provided with a written statement of the main particulars of their employment <2mo after their start date. This must include: pay, hours, holidays, notice period, disciplinary and grievance procedures.

Workers must be paid ≥ the national minimum wage for every hour worked. Deductions can only be made if authorized by legislation, contract of employment, or in advance in writing by the employee. All employees must receive an itemized pay statement at, or before, the time they are paid, including all deductions.

After 1mo employment, an employee must give ≥1wk notice. An employer must give an employee ≥1wk notice after 1mo, 2wk after 2y, 3wk after 3y, and so on up to 12wk after ≥12y, unless other notice periods are specified in the contract of employment.

After 2y continuous employment, employers must make ‘redundancy payments’ related to employee’s age, length of continuous service with the employer (to a maximum of 20y), and weekly pay.

All employees must belong to a pension scheme. The NHS pension scheme is available to practice employees.

Parents of children <6y or disabled children <18y and carers may request flexible working patterns; employers have a duty to consider their requests. Working Time Regulations (1998) apply to agency workers and freelancers as well as employees and include:

Employees are entitled to time off for illness; antenatal care; emergencies involving a dependant; certain public duties (e.g. jury service); to look for another job; and approved trade union activities.

All pregnant employees are entitled to 52wk maternity leave (26wk ordinary maternity leave + 26wk additional maternity leave) regardless of length of service. Women are entitled to return to their own or an equivalent job after their leave. Similar arrangements exist for adoptive mothers.

Employees who have worked for their employer for ≥26wk by the 15th wk before the baby is due and up to the birth of the child are entitled to 1–2wk paternity leave which must be completed within 56d of the birth. Fathers may also claim additional paternity leave for up to 26wk from 20wk to 1y after birth/adoption to look after their child if the mother returns to work.

After 1y employment, employees are entitled to 13wk unpaid parental leave for each child born or adopted up to the child’s 5th birthday (or 5y after adopted). Parents of disabled children can take 18wk up to the child’s 18th birthday.

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Employers must not, either directly or indirectly, discriminate against their staff on the basis of age, race, gender, or disability.

Employees of >1y standing (or on maternity, paternity, or adoption leave) are entitled to a written statement of reasons for dismissal. Employers must not dismiss an employee unfairly.

GPs may either own or rent the property in which they practice:

New premises/refurbishments must meet national minimum standards.

The Equality Act (2010) gives disabled people rights of access to goods, facilities, and services. A disabled person is defined as ‘someone who has a physical or mental impairment that has a substantial and long-term adverse effect on his or her ability to carry out normal day-to-day activities’. Practices must:

The building regulations exist to ensure the health and safety of people in and around all types of buildings. Part M deals with access/facilities for disabled people. All new buildings/alterations to existing buildings must be accessible to and useable by anyone, including those with disabilities.

The basis of British health and safety law is the Health and Safety at Work Act 1974. The Act sets out the general duties employers have towards employees and members of the public, and employees have to themselves and to each other.

The Management of Health and Safety at Work Regulations 1999 (the Management Regulations) give clear guidance about employers’ duties towards their staff.

Under the GMS Contract, PCOs directly fund 100% of IT costs. PMS practices are similarly reimbursed.

Almost all practices now use computers on a daily basis. All specialist GP systems must be approved by the DH (termed ‘Systems of Choice’—see Table 3.1). The software covers all aspects of practice from appointment systems, through clinical care, to audit and reporting.

Most GPs maintain all records on computer, i.e. they are ‘paperless’.

Code all aspects of patient care in general practice in the UK. They code in a hierarchical way, e.g. all operations are quantified by 7 …; all appendix operations as 770; all emergency excisions of abnormal appendix as 77001. Characters in the code can be numerical or alphabetical. The huge number (58⁵) of possible combinations ensures there are enough unused Read codes to accommodate changes.

New coding system that will eventually replace Read coding. The aim is that all healthcare systems in the UK will use the same coding system, allowing a single unified patient record.

Electronic summary of patient medication list and drug allergies. Extracted from GP IT systems and can be viewed by healthcare staff in other settings.

Intranet connecting NHS organizations which are protected from the Internet by a firewall. This enables NHS users to access the internet but outside users cannot access protected NHSWeb sites. All GP practices in the UK are connected to the NHSnet enabling e-mail, internet access, electronic exchange of information (e.g. laboratory/X-ray results, discharge summaries, out-patient clinic letters), shared information portals, and many other benefits.

National service that combines electronic booking and choice of place, date and time for first outpatient appointments. Features:

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In England, all GPs must offer the facility for on-line appointment booking by patients and on-line prescription requests. Proposals to allow patients access to their own summary care record are underway.

Practices using this service can generate and transmit electronic prescriptions. The electronic prescription is transmitted to the Electronic Prescription Service (EPS). Patients ‘nominate’ a dispenser to receive their prescriptions who downloads the prescription to issue it. No paper prescription is required.

Under the Health and Social Care Act 2012, the Health and Social Care Information Centre (HSCIC) can extract personal confidential data (PCD) about patients from GP practice IT systems for planning services or secondary uses (e.g. commissioning, research). This can be done without seeking patient consent. If patients wish to opt out they must actively refuse; otherwise it is assumed that consent has been given.

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Is determined by whether a person is resident in the UK and not related to nationality or payment of National Insurance or taxes.

<60 countries worldwide have any sort of healthcare agreements with the UK. When travelling abroad, always have comprehensive medical insurance.

The EHIC entitles holders to reduced cost, or sometimes free, medical treatment that becomes necessary whilst in another European Economic Area (EEA) country or Switzerland. The EHIC can be obtained online from  www.ehic.org.uk or at any Post Office. Countries this applies to are listed in Table 3.2. Each country has its own rules—details for individual countries are available on the DH travel advice website. British citizens moving to another EEA country are not entitled to use an EHIC to obtain medical treatment.

The UK has reciprocal agreements with certain other countries for the provision of urgently needed medical treatment at ↓ cost or free. Countries and the services available are listed on the DH travel advice website. Only urgently needed treatment is provided on the same terms as for residents of that country. Proof of British nationality or UK residence is required.

Patients can apply to join a practice list by handing in their medical card at the practice or completing an application form. For children, a parent or a guardian can make the application.

Once the practice has accepted the application, it must then inform the PCO. The PCO confirms the application has been accepted to the practice and patient.

Practices wishing to close their lists to new registrations must inform the PCO in writing. The PCO must then enter into discussion with the practice to provide support to keep the list open. If that is not possible, the list will be closed for a specified period of time. Often, closure is requested due to high list size. In that instance, a list size can be set so that the list re-opens when it falls below that limit.

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When a patient has been accepted onto a practice list, or assigned to a practice list by a PCO, the practice must offer the patient a consultation for a routine health check (the ‘new patient check’) within 6mo of registration.

Practices must offer a consultation for a routine health check to all:

In England, patients aged 40–74y are eligible for a free NHS health check and personalized assessment of risk under a scheme launched in 2009. Mechanisms for delivery of the check vary across England, but GP surgeries may provide checks as a Local Enhanced Service.

Patients may register with a practice on a short-term basis for treatment or advice if they are living temporarily (for >24h but <3mo) in the practice area.

A practice must provide services required in core hours for the immediately necessary treatment of:

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PCOs may assign patients to any open practice list if the patient has problems registering with a practice. PCOs can only assign patients to closed lists if all other local practice lists are also closed and an assessment panel has approved the placement.

Each practice is required to produce a practice leaflet to distribute to patients. In Wales, the practice leaflet must be in Welsh and English. The practice leaflet aims to inform patients about the practice, the services provided, and how to access them. In addition it informs patients of their rights and responsibilities. Most practices also take the opportunity to include general health information and information about self-management of minor illness.

Practice leaflets must be updated annually and include details of:

The GP does not function alone. Doctors within general practice are an integral part of a team of professionals that care for patients in the community—the primary healthcare team (PHCT). Precise composition of PHCTs depends on the overall aims of the team, needs of the practice population, and practice characteristics. Team members include GPs and:

General manager of the practice in liaison with the partners. Roles include: staff appointments, supervision, training, and dismissals; duty rotas; liaison with outside organizations (e.g. PCO) and other primary healthcare team members (e.g. community nurses and health visitors); maintenance of premises and equipment and financial planning. Most practice managers have management qualifications.

Duties can vary but include ‘traditional’ nursing tasks; health promotion; immunizations; new registration checks; specialist clinics (e.g. asthma, DM, etc.); administration and audit.

Specially trained nurse who takes on clinical responsibility for specific aspects of care she has been trained for either within the GP surgery or in patients’ own homes, e.g. filtering out-of-hours calls or managing heart failure. Seen as a way to alleviate pressure on GPs. Nurse practitioners are at least as effective as GPs in the roles they perform.

Qualified nurse who has a community nursing qualification recognized by the Nursing and Midwifery Council. Most work is conducted in patients’ homes, particularly in looking after the chronically ill or those recently discharged from hospital. District nurses are usually employed by local community trusts or PCOs and coordinate their own team of community nurses.

Highly experienced, senior nurse who works closely with a limited number of patients who are high-intensity users of health and social services (usually with serious, long-term conditions or a complex range of conditions). The community matron acts as a ‘case manager’ and single point of access to provide, plan, and organize care.

Works with individuals, families, and groups in preventive medicine, health promotion, and education. Health visitors visit all babies after the midwife ceases to attend, carry out developmental assessment checks, and advise on general care and immunization. Some health visitors have a role exclusively for the elderly. Health visitors must be trained nurses and registered as health visitors with the Nursing and Midwifery Council.

Important link between hospitals, GPs, and other members of the primary healthcare team in obstetric care. May practise independently when dealing with uncomplicated pregnancies but are obliged to refer to a doctor in the event of complications. Midwives must be registered with the Nursing and Midwifery Council.

Perform all the non-clinical tasks necessary to keep the practice running. Training varies.

Perform an essential role as the interface between the general public and the GPs and nursing staff. Good interpersonal skills are essential. Training varies.

Increasing role within practices—managing repeat prescribing, monitoring prescribing practices, and advising on prescribing policy.

Helps people live more successfully within the local community by helping them find solutions to their problems. Social workers tend to specialize in either adult or children’s services:

Might include dieticians, occupational therapists, physiotherapists, and/or complementary therapists (such as psychological therapists).

Community-based service working closely with the PHCT. Provided by multidisciplinary teams. Provision and team composition varies across the UK but may include specialist doctors and/or GPs, nurses, physiotherapists and occupational therapists, home carers, and social workers. Usually provided in patients’ own homes but can also involve community hospitals and/or short-term nursing/residential care placements. Common service features:

Respect for confidentiality is also an essential requirement for the preservation of trust between patient and doctor. Failure to comply with standards can lead to disciplinary proceedings and even restriction/cessation of practice.

Disclosure can be authorized by a person with parental responsibility. Young people, mature enough to understand the implications, can make their own decisions and have a right to refuse parental access to their health record.

Assessment of capacity to consent to information disclosure is time- and decision-specific. A mentally incapacitated adult can consent to information disclosure if the person is able to:

Otherwise, decisions must be based on an evaluation of the person’s best interests, taking into account the views of the patient’s representative(s) and reflecting the individual’s expressed wishes and values.

Except in Scotland, parents are able to consent for mentally incapacitated 16–17y olds.

Legislation covering records made since 1st November 1991 permits limited disclosure in order to satisfy a claim arising from death. Where there is no claim, there is no legal right of access to information.

Only breach confidentiality in exceptional cases and with appropriate justification. This includes discussing a patient with another health professional not involved currently with that patient’s care. Wider disclosure to people loosely associated with care (e.g. support staff in residential care settings) requires patient consent.

Implies willingness of a patient to undergo examination, investigation, or treatment (collectively termed ‘procedure’ on this page). It may be expressed (i.e. specifically says yes or no/signs a consent form) or implied (i.e. complies with the procedure without ever specifically agreeing to it—use with care). For consent to be valid, patients:

If you are the doctor carrying out a procedure, it is your responsibility to discuss it with the patient and seek consent. The task may be delegated, but the responsibility remains yours.

Document if a patient does not want to be fully informed before consenting.

It is good practice to seek written consent if:

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The Mental Capacity Act (2005), and equivalents in Scotland and NI, enables patients’ advocates (usually friends, relatives, or carers) or suitable professionals (e.g. doctors, social workers) to act in patients’ best interests on their behalf. This includes provision of medical care. Before acting:

In situations in which there is disagreement about the patient’s best interests, the decision can be referred to the Court of Protection.

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A competent child is able to understand the nature, purpose, and possible consequences of a proposed procedure as well as the consequences of not undergoing that procedure. This is termed ‘Gillick competence’ after the court case in which the principle was established (Gillick v West Norfolk and Wisbech AHA [1986] AC 122).

A competent child may consent to treatment. However, if treatment is refused, a parent or court may authorize procedures in the child’s best interests*. Where a child is not judged competent, only a person with parental responsibility may authorize/refuse investigations or treatment. If in doubt, seek legal advice.

Sadly, complaints are a fact of life for most GPs (see Figure 3.1). The most constructive and least stressful approach is to view them as a learning experience and a chance to improve practice risk management strategy. Always contact your local LMC ± defence organization if you are directly implicated in a complaint. Patients who complain generally want:

NHS complaints can only be accepted:

After that time, complaints can only be accepted if there is good reason for delay and it is possible to effectively investigate.

A 3y time limit after the incident (or after the date upon which the claimant became aware that the incident might have caused harm) is placed on civil clinical negligence cases, except for children who may claim until their 21st birthday.

Is a way of dealing with complaints that helps to avoid adversarial situations. Either party can ask the local PCO for conciliation, but both parties must agree to it taking place. By bringing the two sides together with a neutral conciliator, it aims to:

A file on the complaint, including a copy of all correspondence, should be kept separate from clinical records of the patient and, if the patient leaves the practice, should not be sent on with the clinical notes.

Most private sector healthcare providers have their own complaints resolution procedures. Patients should contact the organization concerned for details.

There is no direct connection between complaints procedures and disciplinary action. If a complaints procedure reveals information indicating the need for disciplinary action, it is the responsibility of the PCO to act. If they decide there has been a breach of the terms of service, the PCO can fix a penalty, if appropriate.

Removal of a patient from a practice list can be distressing for both patient and GP. In England and Wales ∼53,000 patients/y are transferred by PCOs at the request of the GP; ∼1,000/y because of an act or threat of violence.

Practice policies for removing patients and dealing with threats/violence should be stated in practice leaflets.

Patients also have a right to change their doctor. They are not required to give reasons or any period of notice, and there is no requirement for the GP to be notified.

Removal of other family members should not automatically follow removal of a patient from a practice list unless removal of that patient makes ongoing care of the rest of the household impossible.

The most contentious reason for removal from a practice list. Causes the most problems. As a good doctor–patient relationship is fundamental to successful care, it is in the interest of both patient and GP that the patient moves to another practice list if that relationship breaks down. Difficulty arises when the patient sees matters differently.

Includes actual or threatened physical violence or verbal abuse leading to fear for a person’s safety.