Quality improvement is a core aspect of general practice work amidst rising challenges and pressures in the sector. It offers benefits for practices, workforce, and patients, including gains in efficiency, satisfaction, and safety.

However, for practices and primary care organisations to perform and embed sustained improvement, effective leadership and management is required at that local level, along with the right resources and autonomy.

As NHS England identified in its 2022 report on next steps for primary care, ambitions to further integrate care and shift it to the community will also require local improvement cultures, supported by leadership and management.

Despite this, evidence the NHS Confederation has compiled suggests that the NHS, including primary care, is under-managed, with considerable variation as to the skills, autonomy, qualifications, and opportunities managers have. Managers also increasingly face hostile media and political discourses.

The Health Foundation and others have explored this area, yet much of the debate focuses on hospital management with little attention paid to primary care.

We decided to speak to several leaders and experts for a specific view from general practice.

Stakeholders consulted included academic experts as well as GPs and managers across a range of settings, from individual practices to large federations.

Capacity

Our stakeholders reported that management capacity (the ability of an organisation to respond effectively to the demands it faces at any given time) is often a challenge in general practice, with implications for improvement activity.

Given the time, autonomy, and training, both clinical and practice managers can be powerful drivers of change and improvement.

However, the pressures of other management activities (and clinical work in the case of clinicians) and lack of management staff/time significantly reduce the capacity for this.

This is particularly the case amidst the rising patient list sizes and dwindling resources, evidenced on The Health Foundation’s data dashboard (see link below).

Several stakeholders were also concerned that capacity lined up with the inverse care law, such that those areas with the greatest health and care needs had the least capacity.

Similarly, while many managers have prior experience and qualifications and are supported by their practice to further develop, this varies considerably across the UK, further undermining capacity for improvement.

For example, some practice managers will have progressed through administrative roles in a practice rather than a management career and GPs will often not receive specific management/leadership training during their specialty training programme, potentially limiting their capabilities.

This is also a wider economic issue with 82% of new managers in the UK having little or no management qualifications, according to the Chartered Management Institute.

There are some schemes in the UK to support management development, such as the FMLM clinical fellows schemes or the NHS graduate management scheme, but these remain relatively small and focused on secondary care.

Concerningly for our stakeholders, the GP fellowship scheme was also recently discontinued.

Of note, the Institute of General Practice Management offers managers support and maintains a large register with a robust accreditation process and comprehensive professional standards, but membership is voluntary. Learning resources remain limited in this area despite the valuable work of the Royal College of Practitioners, amongst other professional bodies.

Joanna Bircher, Clinical Director of the GP Excellence Programme at Greater Manchester Primary Care Provider Board Delivery Team commented:

‘There is no clearly defined career pathway for the non-clinical workforce in general practice to skill up the managers for the future. This could be such a positive development for professional bodies.’

Different models

Our stakeholders also extensively discussed the different organisational and governance models and structures seen in general practice and how this interacted with management.

Benefits and disbenefits are seen with every model and most stakeholders felt that a mixture of models across the country was inevitable and useful.

Smaller partnerships often feature high autonomy, agility, positive culture, lower staff turnover, and good understanding of local populations/geographies.

All of these lend themselves to improvement and we heard some great examples of this. The last independent GP partnership review asserted that partnership also fosters entrepreneurialism and creativity.

Meanwhile, the large scale of certain models, such as federations or chains, can release potential economies of scale and improve management capacity. They can facilitate effective networking and allow certain management functions to be done in-house.

They can also provide capacity for dedicated innovation roles, activities, and teams. For example, Tower Hamlets GP Care Group have specific transformation and innovation managers.

Regardless, of model type, the potential of Primary Care Networks (PCNs) for management was also cited by stakeholders. Despite a difficult start, PCNs can potentially provide additional management capacity and expertise.

They can also facilitate networking, primary-secondary care integration, and use of new technology and pathways. All of this is key to improvement, however, ongoing variation amongst PCNs is a significant hindrance.

Future work

Good management is key to improvement and there is growing recognition of the need to better support management capacity for this in general practice, with the Health Foundation also recently launching a research commission on NHS management capacity.

Labour’s manifesto commitment to a Royal College for Clinical Leadership and the regulation of non-clinical NHS managers, are also potential opportunities.

However, the issue cannot just be left to networks and professional bodies. Collaborative work and prioritisation by all relevant bodies is needed to improve the resources and development for managers in general practice.

Further reading

Read The Health Foundation’s research paper: Quality improvement in general practice: what do GPs and practice managers think?

Find out the latest monitoring data on general practice on the data dashboard.

See NHS England’s Next steps for integrating primary care: Fuller stocktake report