I’m sure the majority of current practice managers weren’t around during the Fundholding days of the 1990s and didn’t experience a practice receiving a Management Allowance to spend on extra staff. I recall my practice at the time received an allowance of £36,000 and my salary at the time was enhanced as a result. We also employed at least three more staff – two data clerks and a medical secretary. We subsequently joined the brood of PMS practices that received Growth Funding Allowance to invest in the practice and staffing, which was used for a salaried GP and practice nurse. The lesson learnt was that these extra funds weren’t necessarily recurring and once the funding ceased, it wasn’t simply a question of making those specific staff redundant. I recall that fingers were burnt.

Practice budgets introduced

The original Ancillary Staff Scheme was designed to provide a level of reimbursement to partially fund a ‘core’ staff of administrative and nursing staff. Parameters were set in the terms of a maximum of two full-time staff per full-time GP. The primary care organisations I worked for at the time provided practices with information about NHS Whitley Council Pay Scales which practices followed so as to maximise their reimbursement. Not every practice maximised its income and following the introduction of the new GP Contract in 2004, inadequate practice staff budgets started to find a different level. There were both winners and losers. Those practices that had paid their staff well in the past had more budget to play with. Those that didn’t pay well are probably still feeling the ill effects today. It’s important to say that the Quality Outcomes Framework wasn’t guaranteed recurring income and it isn’t clear to me to what extent QOF was invested in staff costs. It was used to pay almost insulting bonuses here and there, but again without any consistency.

Trying to cut costs!

However, there was always a culture of trying to employ more staff hours for less money. Perhaps it started by employing more part-time staff on lower pay and less NI contributions. The irritation for GP employers was the requirement to allow staff to join the NHS Pension Scheme as the full costs weren’t reimbursed. I think this contributed to driving down staff expenditure, as did managing downwards-weighted lists and MPIG. Perhaps, too, this is where practices started to limit leave entitlement to the statutory 28-day requirement and to limit sick pay to statutory sick pay only. I cannot see that new staff joining a medical practice from a job elsewhere in the NHS wouldn’t be happy with that, particularly nurses.

Developing less expensive posts

Some practices, I’m sure, started looking at their most expensive staff, nurses, and applying the brakes. QOF brought with it the need for specialist practice nurses, concentrating on the likes of asthma and diabetes. The idea of saving money by having a Treatment Room Nurse developed, but so did the idea of a Healthcare Assistant. The latter may have developed out of the idea of having a clinical employee concentrating on phlebotomy. I recall receiving specific funding for a phlebotomist, although we were lucky that the Pathology Department provided a phlebotomist at their expense. But I also remember the funding being withdrawn and having to make a choice as to whether to absorb the expense.

More staff in a new model of providing care

Nevertheless, we’ve entered a new era of managing general practice, with more salaried GPs and the development of Advanced Nurse Practitioners who have the ability to prescribe. Practice management has seen the growth of Deputy or Assistant Managers. The number and type of clinical and non-clinical staff has in recent years changed quite dramatically. But the serious question remains as to whether the employment of staff beyond core staffing needs is both affordable and directly funded. Even more importantly, is the funding recurrent and guaranteed? I wonder whether the creation of Primary Care Networks has muddied the waters even more. Are they employing staff on NHS pay scales?

And then there are ever-increasing mergers!

In addition, the merging of practices is of course becoming more and more common. I’m beginning to wonder whether it’s wise to offer any new staff permanent contracts. Merging practices might have totally different pay rates and, again, totally different terms and conditions of service. While there’s any doubt remaining about the future of a practice, it does seem unwise to make a concrete commitment to employ new staff permanently. No wonder practices appear to constantly need personnel advice. So, all in all, do you have any concept of what your staff budget actually includes, and what steps do you need to take to keep within that budget? Are new posts funded and can you be sure that the funding will be consistent and recurring? If not, what steps are you taking to manage those contracts, and how do you avoid redundancy costs if funding ceases?

Setting your budget

In summary, your budget needs to reflect gross pay, along with employer’s pension and National Insurance contributions, plus training costs – but perhaps more importantly, the source of funding and whether it’s recurring. For instance, it may need to reflect any transfer of funding intended for the employment of GPs to the employment of members of the nursing team. Funding might only be guaranteed for one year or less. I recall that the loss of the Fundholding Management Allowance caused quite some consternation with threats of job losses and reduced salaries. Practices with slim budgets and unconfirmed extended funding need to look very carefully at the permanency of contracts they offer to new staff in new posts. Don’t forget, too, the impact of increases in the National Living Wage.

Author – Robert Campbell