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The National Association of Primary Care Educators (UK) ‘Vision 2000’ Managed CPD in the new NHS
The National Association of Primary Care Educators UK
FOREWORD It is with great pleasure to promote and publish this Vision 2000. I hope this publication addresses the various issues in education presented by the Government, as well as professional and educational bodies. The National Association of GP Tutors vision, role and suggested model of Continuing Professional Development and structure to deliver this CPD, will promote and provoke healthy debate for all “stakeholders” in Primary Care. The National Association of GP Tutors has started to deliver its promise of leading the learning and quality agenda in Primary Care. I would like to express my sincere thanks to Dr. Malcolm Valentine, Vice Chairman and Dr. John Howard, Honorary Treasurer for their momentous efforts they have been put in to create this publication. Yours sincerely Dr. Kumar Kotegaonkar Chairman SUMMARY
Reviews the current position of primary health care in the NHS
Reviews the influences on the Continuing Professional Development (CPD) of General Practitioners in a changing environment
Suggests systems and structures for ‘Managed CPD’
Explains the National Association of GP Tutors views and its evolving vision of the role of Postgraduate Primary Care Tutors
• Raises awareness of educational processes in a corporate culture
The document is written to help GP Tutors and others understand current influences on and changes in the Primary Care arena in which they work. It attempts to bring together some of the implications of these changes, focussing on continuing professional development as the vehicle for delivering future models of healthcare. This document is also a response to emerging proposals for developing CPD in primary care. By the production of this paper NAGPT seeks to stimulate debate and agreement, ensuring CPD is practical, helpful and deliverable. It is intended that the themes in this document be extended to the whole of the United Kingdom.
The National Association of Primary Care Educators (UK) ‘Vision 2000’ Managed CPD in the new NHS
(THIS DOCUMENT SUPERCEDES ‘NAGPT – A VISION, AIMS AND ROLE DEFINITION’ PUBLISHED FEBRUARY 1999 BY THE NAGPT IN MANCHESTER.) CONTENTS 1
The National Association of GP Tutors . 7
A Future Job Specification for Postgraduate Primary Care Tutors . 11
A Suggested Local Structure for managed CPD . 12
Roles of Educators in a Managed CPD Structure . 14
A Timetable for the Educational/Planning Cycle . 16
The relationship between Revalidation and Appraisal . 18
The National Association of General Practice Tutors (NAGPT) was established as a professional body for GP Tutors in 1993. It is a sub set of the United Kingdom Conference of Regional Advisers (UKCRA), which is the professional body of the Directors of Postgraduate General Practice Education.
In 1999, NAGPT published a booklet entitled ‘A Vision, Aims and Role Definition’ The aims of this paper were as follows: ‘This document has been produced to give an overview of current influences on the role of the GP Tutor and the NAGPT’s response to these influences. It highlights many of the variations in workload, function, training and support of GP Tutors. The Department of Health’s recent three white papers (‘A First Class Service’; ‘The New NHS – Modern and Dependable’; ‘A Review of Continuing Professional Development in General Practice’) and the similar Scottish and Welsh white papers, emphasise the need for skilled GP Tutors in the delivery of their health care vision. This document discusses the organisational, educational and information technology development necessary to enhance this vision for the future. The NAGPT, working with other organisations, has the potential and capacity to fulfil the vision of high quality Tutors supporting NICE, Primary Care Groups, General Practitioners and all members of the Primary Care Team in the drive for better health care. This document lays down a strategy for the development and enhancement of the GP Tutor Network, which the NAGPT seeks to promote.’
Since then, primary care has continued to evolve, with a number of new challenges and influences arising in the last year. The introduction of primary care groups (PCGs) heralded a corporate culture for primary care, which has been organised around small, autonomous clinical units for 50 years. The introduction of revalidation for doctors will necessitate the explicit demonstration of continuing professional self-appraisal and life long learning by every practitioner maintaining registration with the GMC.
At the same time, and partly because of these changes, the NHS is moving towards a system of managed CPD, replacing the outmoded methods of CME. This is described in the Joint Centre for Education in Medicine’s recent publication "The Good CPD Guide"1 This paper proposes structures, timetables and mechanisms for the implementation of the new systems.
1 “The Good CPD Guide” Joint Centre for Education in Medicine, Reed Business Information, 1999
CURRENT INFLUENCES Primary Care Groups Practices have grouped together into Primary Care Groups (PCGs). There are now 471 primary care groups in England (figures from NHSE, Leeds). Similar groupings have occurred in Wales, Scotland and Northern Ireland. Some primary care groups are in an accelerated phase of development and are applying to become Primary Care Trusts (PCTs) in their own right. The first Trusts are likely to appear in April 2000, but there is an expectation that over the next three years all PCGs will eventually become Trusts. A Trust has much greater autonomy to shape primary care services than any other past organisation. Uniquely in primary care, a Trust will no longer be a committee of the health authority but will report directly to Parliament2. It becomes responsible for determining all of its activities, including policy and strategy, service provision and commissioning, human resource management and financial probity. Primary Care groups remain strategically accountable to Health Authorities, who can assess performance and if necessary insist on change within the PCG Management Board.
These organisations must be "learning organisations" with a full supporting infrastructure for each function described above. The task for the educationalist as a manager of change in these organisations is clear, and will of necessity be multi-professional. Not only must we develop and implement educational policies that facilitate individual clinicians professional development for each discipline, but must also ensure that the organisation’s structure and culture are sympathetic to this aim. The Primary Care Educational Hierarchy Re organisation of post graduate educational structures continues in primary care, so that structures match more closely the system in secondary care. The Medical and Dental Educational Levy (MADEL) has now been fully identified and is being progressively devolved to a proposed structure of 7 Regional Directors of Education and Training. These civil servants will also hold the budget for Non Medical Education and Training (NMET) funds and Service Increment for Teaching (SIFT) and so will have increasing influence over how these funding streams are integrated and used. There are 26 Directors of Postgraduate General Practice Education in England, with responsibility for education for General Practice. The whole deanery structure is hierarchically placed below these Regional Directors, with the budget being passed to Postgraduate Deans and then to Directors of General Practice Education.
2 “The New NHS – Modern and Dependable” Department of Health, London 1997
Clinical Governance The nature of Clinical Governance means there are still varying interpretations of this concept in different parts of the UK. Inevitably it will be based on the principles of good medical practice and will be applicable to the whole Primary Care Team. It will take into account: •
www.doh.gov.uk/pricare/clingov.htm . This describes the principles of clinical governance as:
clear lines of responsibility and accountability for the overall quality of clinical care
a comprehensive programme of quality improvement systems (including clinical audit, supporting and applying evidence based practice, implementing clinical standards and guidelines, workforce planning and development)
integrated procedures for all professional groups to identify and remedy poor performance
www.doh.nhsweb.nhs.uk/nhs/clingov.htm This takes the form of a bulletin board. To facilitate clinical governance, one Deanery has recently changed its arrangements to try and create generic Primary Care Tutors. North Thames East has re-appointed all its GP Tutors to be roughly co-terminus with Primary Care Groups (32 out of 35 PCGs have tutors). However, the Tutor is not in themselves responsible for clinical governance, and is not expected to implement educational policies to support individual, practice-based and primary care group wide learning and development on their own. They will work with a network of primary care team-based educational leads to fulfil educational strategies required to implement clinical governance and other professional development activities. This group includes at least 5 non-GP tutors. Most PCGs will have by now appointed a Clinical Governance Lead who holds responsibility for the implementation of clinical governance procedures by the whole team. This person does not necessarily need to be a doctor and is a member of the PCG board. Currently, 697 clinical governance leads have been identified. Many PCGs have appointed more than one CG lead. Because of the complex interaction between clinical governance and the educational activity that will be needed to fulfil its requirements, many PCGs have appointed Educational Leads. The NAGPT has identified over 118 educational leads, but this number is rapidly increasing. There is considerable variation in the educational expertise of these educational leads, but both the clinical governance and education leads have an interest in ensuring their PCG policies for individual and organisational development are soundly based on relevant educational principles. The GP Tutor should be the source of that advice, in most areas collaborating with Course Organiser colleagues who have expertise in managing small group learning. External Quality Assurance There are a number of external Quality Assurance and Standards bodies: The National Institute for Clinical Excellence has been established to evaluate new treatments and set national standards for current interventions. Its role is defined in "A First Class Service" and subsequent guidance3. It is intended to collate all the work assessing health care interventions funded by the Department of Health, so that there is a single source of authoritative, evidence based clinical guidance for practitioners in the UK. It is a Special Health Authority and includes the National Prescribing Centre, the National Centre for Clinical Audit, Prescriber’s Journal and involvement in the new National Service Frameworks. So far NICE has provided guidance on the prescribing of ‘Relenza’, the anti flu drug, and produced a framework for Mental Health Services. Current expected recommendations (Guidance on the management of Coronary Heart Disease) were the subject of delay, because of more detailed cost analysis, but are expected to be available imminently. These early problems could cast doubt on the effectiveness of NICE; implementation in practice will inevitably depend on the educational programmes within PCGs/PCTs. Major strategic health issues will be addressed through National Service Frameworks (NSFs). The purpose and implementation of NSFs is defined in The New NHS: Modern and Dependable (1997) and in A First Class Service: Quality in the NHS (1998). Current NSFs under construction or being implemented include: Mental Health Managing Diabetes Coronary Heart Disease Care of the Elderly The best way to monitor progress with these NSFs and other Department of Health activity is to visit their website, using www.open.gov.uk as a jump to do this. The Commission for Health Improvement was established to regulate health care delivery. It was established to ensure equity of implementation and delivery of healthcare. Its role is defined in A First Class Service: Quality in the NHS (1998). CHI has responsibility for developing local systems to monitor the outcomes of healthcare delivery. The nature and constitution of the commission is now well established, but at the time of writing, the authors are unaware of any practical examples yet appearing regarding its output.
3 “A First Class Service: Quality in the NHS” Department of Health, London 1998
This quality framework has been previously described3:
National Institute for Clinical Excellence
Additionally the NHS Executive and Department of Health have sought to develop quality assurance further through their recent publication4 ‘ Supporting Doctors, Protecting Patients’ which seeks to introduce annual performance appraisals for all doctors. At the time of writing this document is still under discussion. NAGPT strongly supports developmental appraisal for all doctors. We reject the concept of an annual managerial performance review since evidence suggests this would be less productive5, further demoralising the medical workforce. The concept of Regional Assessment Centres has yet to be fully developed. General Practitioner individual performance is difficult to assess reliably and objectively; such critical assessments have great potential for legal challenge. Better, perhaps, to focus the Assessment Centre concept on assisting doctors who have failed to be revalidated to recover acceptable professional standards. Such work is likely to be specialised; it is neither appropriate or practical for educationalists working in primary care groups to take on this complex and challenging task. There continues to exist a working party on the Chief Medical Officers review of Continuing Professional Development and it is expected to report by March 2000. It is expected to give guidance on the implementation of practice professional development plans. Professional Initiatives There are professional bodies with responsibility for quality development and regulation in general practice:
4 “Supporting Doctors, Protecting Patients” Department of Health, London 1999
5 “Motivation and continuation of professional development” Miller et al, British Journal of General Practice, 1998, 48, 1429-1432
The Royal College of General Practitioners is the academic organisation in the UK for General Practitioners. It has progressively developed its voice on issues of education, training and standards. The RCGP was the body who primarily established vocational training for general practice. It has now introduced performance standards and guidelines encompassing all who work in the Primary Care Team. About 18 000 doctors are members of the college – virtually all by examination. Extensive information about current policies, and the College’s history, is available on their web site www.rcgp.org.uk More recent developments from the college include the Quality Practice Award scheme, by which practices can be recognised as having achieved a set of agreed quality standards. There are personal accreditation systems including Membership by Assessment of Performance (MAP) and Fellowship By Assessment (FBA). MAP consists of a rigorous personal assessment programme, culminating in membership of the RCGP, and is designed as an effective way for established GPs to be able to gain membership. The MRCGP exam is now perceived as an endpoint assessment for qualification from vocational training. FBA is even more rigorous and seeks evidence of the highest standards of primary clinical care in order that applicants can be awarded fellowship of the RCGP. The RCGP is currently working on systems for implementation of Accredited Professional Development. APD will be a selection of educational tools with which all members and fellows can prepare to be revalidated for continuing membership of the College. The methodology of this is not yet clear, but is expected to be realistic and attainable. The process will provide evidence of performance above the minimum level anticipated in the GMC revalidation procedures, so that College revalidation should provide acceptable evidence for revalidation by the GMC. The General Medical Council is the registration body for all doctors. There are about 180 000 doctors registered with the GMC. Although more information is now recorded about the status of doctors on the register, if asked about the safety or competence of any doctor, the only comment the GMC can make is "there is nothing extremely bad that we know of about this doctor" (or the contrary, of course). It was against this background that the GMC has initiated the development of its own Revalidation Procedures for all doctors. The NAGPT is represented on its GP consultative group. The GMC is setting minimum performance criteria for all doctors and anticipates having its proposals ready in May 2001. These will be set before parliament and if supported and funded, will be implemented thereafter. The evolution of this process can be tracked on www.gmc.org.uk. THE NATIONAL ASSOCIATION OF GP TUTORS UK
The NAGPT has continued to develop its role as these new influences have started to affect the tasks of GP Tutors. A number of guidance documents have been produced over the past year: NAGPT – A Vision, Aims and Role Definition (1999) NAGPT – The Professional Development of GP Tutors NAGPT – The Role of Postgraduate Structures and Individual Educators in Managed CPD. (A report to the Department of Health) Supporting Doctors, Protecting Patients – A Response from the NAGPT The NAGPT Handbook
These documents have covered issues such as:
The Professional Development of GP Tutors
-Information Management & Technology
Establishing distribution of a quarterly newsletter to all GP Tutor members
Developing a GP Tutors handbook, which will be capable of being updated by electronic distribution of updated material
Establishing regular contributions to ‘Education in General Practice’
Establishing a website, www.nagpt.org.uk, hosted by the educational site for General Practice, www.ukpractice.net
Establishing important links with the RCGP, contributing towards its Revalidation Group, Accredited Professional Development activities and advising on the functions of medical appraisals
Establishing important links with the GMC, with involvement in its Revalidation General Practice Consultative Group, providing reviews on this issue
Maintaining regular representation at and contributions to meetings of the United Kingdom Conference of Regional Advisers (the UK DPGPE’s professional group)
Establishing important direct contact with the Department of Health to explore the future role of the GP Tutor in Primary Care Education.
NAGPT considers the GP Tutors role to be that of a ‘manager of change’ in a multi-professional learning environment in primary care. As organisational changes have occurred, we have responded by developing our concepts as outlined in the paragraphs that follow. The NAGPT has sought to develop links with:
United Kingdom Conference of Postgraduate Directors of General Practice (UKCRA) Royal College of Nursing (RCN) General Medical Council (GMC) British Association of Medical Managers (BAMM) Royal College of General Practitioners (RCGP) General Practioners Committee (GPC)
‘VISION 2000 – TOWARDS MANAGED CPD’
Continuing Professional Development is defined as6:
"A process of life long learning for all individuals and teams which enables professionals to expand and fulfil their potential and which also meets the needs of patients and delivers the health care priorities of the NHS"
GP tutors were originally responsible for CME provision at their inception. The tasks encompassed within the role of the GP Tutor have been listed7 and cover the full range of CME and CPD activities. It is clearly not possible for a single educator to undertake all of these tasks within the available resources.
In other disciplines the organisation of educational activity has been split for some time. Multi-professional CME provision, and the administration of Deanery resources, such as study leave, have always been the domain of the Clinical Tutor. The maintenance and dissemination of clinical professional standards has been the role of the College Tutor in each District. Each Royal College has been operating a system of assessment for continuing professional development. It is likely that the College Tutor will play an increasing role in these systems, resourcing CPD for career grade colleagues.
Evidence about the most appropriate facilitator of CPD is strong. There is agreement that a wise peer who can be non-judgemental is most effective in motivating and achieving change in the learner1,5. GP Tutors experience make them an appropriate group to manage the CPD process. A general practitioners individual facilitation need not be undertaken by the GP Tutor, or indeed by a doctor, so long as the process is managed by a peer commanding the respect of the learner, such as the GP Tutor.
In a national survey, in 1997, it was found that seventy percent of Tutors wish to continue to work with individual colleagues or small groups8. NAGPT have stated that it is unrealistic for a single Tutor, contracted for two sessions a week, to undertake personal mentoring for more than 50 Principals at once6. With other facilitators, Tutors may potentially manage the process for a larger number of Principals. To undertake this, NAGPT has suggested that GP Tutors should be assisted to take appropriate higher educational qualifications, preparing them for the role of managers of CPD.
The activity of the local GP Tutor will vary depending on the capability and functions of educators at board level within the PCG. Where suitable systems for the facilitation of CPD have been implemented by the PCG, the GP Tutor could adopt the role of educational manager detailed below. Where such systems have not been implemented, the GP Tutor may need to be involved directly in personal and practice mentoring, reducing the total number of GPs the Tutor could resource. Whichever method is adopted, a close relationship with the clinical governance lead will be necessary.
6 “A Review of Continuing Professional Development in General Practice”; Chief Medical Officer, Department of Health, London; 1998
7 “The Professional development of GP Tutors” J C Howard, NAGPT Manchester 1999
8 “The Introduction of Personal Learning Plans for General Practitioners in North East Scotland”; Report to SCPMDE; M Valentine and F French; 1998
A new local structure for education is needed for primary care. A strategic lead should be given to primary care educators, allowing them to function within suggested role definitions. Although, in practice, there will be local solutions to the problem of designing an appropriate structure for managing CPD, NAGPT suggests the following model, which is already developing in some deaneries9 .
9 Personal Communication; Dr S Field; DPGPE, West Midlands; 2000
A FUTURE JOB SPECIFICATION FOR POSTGRADUATE PRIMARY CARE TUTORS
GP Tutors job description should be amended to recognise their altered role. In future Postgraduate Primary Care Tutors will need to offer:
The management of postgraduate learning, and the management of developmental change for practitioners and the local PCG/PCT(s) on behalf of the Director of General Practice Education
A mentoring system, either for practices or individuals, promoting life long learning
Educational support to individuals and practices, including the implementation of assessment and appraisal tools
The assessment, licensing and certification on behalf of the Director of uni- or multi-professional educational activities provided for general practice in the locality
CME – ensuring provision of learning activities (courses and schemes; not necessarily provided directly by the Tutor)
The promotion of multi- professional audit and clinical guidelines with other involved agencies
An involvement in the locality educational strategic development with secondary care
Networking with stakeholders in primary care and higher education
Resource location to support learning in Primary Care
Advising on the organisation and culture in PCGs
The promotion of PGMCs as a resource for learning
Postgraduate Primary Care Tutors, building on the foundations laid by the GP Tutors, are uniquely placed to ensure the coherent and integrated implementation of all these activities, contributing substantially to the continuing enhancement of quality in the primary care arena.
These functions will produce learning needs for most Tutors; the necessary learning points may frequently be best assimilated experientially, but some topics (e.g. the use of appraisal tools) may necessitate additional learning modalities. NAGPT would like to establish a dialogue with stakeholders such as COGPED, RCGP, and the Department of Health about the most appropriate tools for some of these tasks, and programmes for addressing the learning needs of Tutors.
A SUGGESTED LOCAL STRUCTURE FOR MANAGED CPD
NAGPT suggests that the model for managed CPD should be regionally determined. It is likely there will be different local resources in Regions and Districts and it is essential that all resources are seen to be maximally used and valued by the NHS.
The model we propose includes the components that NAGPT feel are essential for the future delivery of revalidation, clinical governance and continuing professional development. We also outline some suggestions for methods, which could be used to assess and deliver educational needs for these purposes.
Primary care groups and Trusts will inevitably be involved with education, research and audit needs within their boundary. However, formal links between the PCG/PCTs, community and secondary care and established and continuing District resources such as Postgraduate Medical Centres have not been developed. We suggest a Combined Clinical Governance Group – the NAGPT proposes that these are titled Quality Assurance Development Group (QuAD Group) - will be vital in each District. This group would allow strategic development and liaison between stakeholders in the CPD process.
Such a group should be multi-professional and may incorporate:
The clinical governance leads of the local primary care groups,
The clinical governance leads of the acute and community Trusts
The Postgraduate Clinical Tutor and Postgraduate Primary Care Tutor,
The Public Health lead and/or Health Authority Medical Adviser
The local MAAG (or successor organisation) representative
Representation from Professions Allied to Medicine
The exact numbers and composition will vary according to local needs.
The establishment of this group will link in each District the educational provision for life long learning and resources and support for audit and research and development. Without such links, there is potential for duplication of activity in these areas between neighbouring PCG/PCTs served by the same acute Trusts and acute Trusts themselves. The proposed group provides a mechanism for co-ordinating bids for national or regional funding within the District. Such a combined bid is more likely to be successful in obtaining additional monies, such as funding for primary care research and development.
Additionally, a subgroup of this group could be responsible for reviewing the quality of study leave requests, Practice Professional Development Plans, Revalidation, and appraisal or mentoring systems. This would provide co-ordinated, quality assured best educational practice between neighbouring PCGs and local Trusts.
A typical remit for such a group might therefore include:
To ensure a continuing improvement in the quality of patient care
To promote clinical governance in all areas
To offer mutual support and problem solving for all PCG/Trust members, and to share common solutions
To co-ordinate educational activity of relevance to clinical governance
To encourage a consistent approach across the local PCGs/Trusts with regard to practice/clinical unit development
To develop standards and guidelines across primary and secondary care, where relevant
To promote a virtual Local Health Information Strategy
To co-ordinate bids for development money in education, research and clinical governance
To plan new educational ventures across the District, e.g. planning for students, PRHOs or NMET initiatives in the community
ROLES OF EDUCATORS IN A MANAGED CPD STRUCTURE Postgraduate Primary Care Tutor:
Generally strategic as a manager of learning in a District, as set out in 5.1. As suggested in 4.6, the role of the Tutor will vary depending on the educational resources in the primary care group. The Tutor will license learning, and advise education leads on PCG’s, and other providers and individuals about the educational content of their CME programme. They will advise about assessment and appraisal tools.
The Tutor will no longer solely provide CME, but will administer the resources for learning under the supervision and authority of the Director of General Practice Education. These may include prolonged study leave, research and educational bursaries. The Tutor will also assist doctors who have educational difficulties, either because they are less competent than the average or very much more competent than the average.
The Tutor will be a channel for information about development opportunities for practices and individuals through their network with other stakeholders in primary care education. The Tutor will have dual accountability to PCGs/PCTs and the Director of General Practice Education.
PCG Educational lead:
Organises and evaluates CME for the PCG’s Health Improvement Plan (HIMP), or other issues arising from PPDPs, liasing with the RCGP as necessary for craft advice about general practice. Facilitates, under the direction of the Primary Care Tutor, practice peer appraisal, personal development plans and mentoring. Supports practices in the production of their multi-professional practice professional development plan, offering resources from the PCG, such as locum time allowing away days, or colleagues from other disciplines in the PCG as resources/facilitators.
May be assisted by other staff in the PCG such as nurse tutors, managers or other health professionals; refers to the GP Tutor as necessary.
Clinical governance lead:
Responsible for devising, implementing and assessing PCG quality assurance programme. May assist with CME activities, but is more likely to be involved in audit and consequent resource allocation to practices. Liases with RCGP and Primary Care Tutor, management and stakeholders, including secondary care, to devise measurable outcomes related to HIMP for audit. Will also audit professional standards and other process and structural issues. Involved in assessing the relevance of PPDPs/re-validation material and giving feedback.
Ideally would have the advice of a College Tutor to each PCG. Responsible for promulgation of professional standards derived from the science and literature of general practice. Advises PCG Board of College initiatives and resources; may be involved in mentoring and supporting outlying practices with Primary Care Tutor. Will undertake assessment of PPDPs/re-validation with Clinical Governance lead. LMC Educational Representative:
Deals with workforce/terms and conditions issues. Involved in assessment of PPDPs/re-validation of practices/individuals.
A TIMETABLE FOR THE EDUCATION/PLANNING CYCLE
It is clearly essential that all systems aimed at developing the primary care team are contiguous, so that effort is targeted solely at productive education rather than bureaucracy. Only one event is fixed by statute in the planning cycle for PCGs; the production of the primary care investment plan. Logically the production of practice development plans needs to immediately precede this plan. This need, along with the requirement for practices to take in to account the primary care investment plan and annual health improvement programmes when developing practice professional development plans, will in practice mean that most PPDPs will operate from January or April.
A suggested NAGPT timetable for Practice and PCG/LHCC/LHG activity is therefore as follows: PCG Activity Practice Response
If the audits for outcomes of the educational activities are conducted in practices in January-March, alongside the personal or peer appraisals, there will be practice based evidence around which to create the PPDP in June. The practices will by then have had time to assimilate the information from the PCG’s HIMP, and have the financial information they need to implement changes in their structure.
This proposal will harmonise the academic, educational and business planning cycles.
THE RELATIONSHIP BETWEEN ANNUAL APPRAISAL AND REVALIDATION
NAGPT’s view is that appraisal should be a formative process which should assist the doctor to prepare for the five yearly revalidation procedure. We believe the purpose of revalidation is fundamentally different from the purpose of an appraisal. Revalidation is a fail-safe procedure to ensure minimum standards, while an appraisal should improve performance by the mutual setting of goals and objectives.
NAGPT has frequently argued for personal appraisal following evidence based human resource procedures for GP Tutors. There are sound reasons for instituting appraisal for all doctors, but the objectives and methodology of the appraisal must be clear. Industry demonstrates two objectives for appraisals. It can be a management tool for enforcing minimum standards. Alternatively, it can be a formative, participatory process that is the cornerstone of professional development i.e. an essential component of an individual’s Personal Learning Plan. The link on to Practice Professional Development Plans and hence revalidation places appraisal at the centre of the continuum of an individuals life long learning.
The GP Tutor network already has wide experience in devising Personal Learning plans and aiding colleagues to assess their learning needs. Facilitating the appraisal/learning process for colleagues in primary care should be one of the key roles of Primary Care Tutors in the future.
One of the fundamental issues to be considered in any proposed model of appraisal is the frequency of this process. Annual appraisal may be too frequent for many established general practitioners. However, educational planning at a personal level needs to co-ordinate with the development plan of the organisation. A solution may be to alternate self appraisal, utilising the increasing number of self assessment tools available, with an appraisal utilising a peer or external resource.
Government, NHS and Educational organisations should rapidly reach agreement about appraisals. The current uncertainty is causing confusion amongst GPs and educators which in turn leads to resistance to change. Clarity is needed to gain the support of the profession.
These processes represent different stages in already established learning cycles. GPs in particular, are intuitive, effective learners. The processes should not be seen in isolation but should be seen as identifying stages in the spiral of supported enhancement of individual professional development – all contributing to improved quality of care. In turn this individual development contributes to the development of the organisation. To date, too many of these processes have been addressed in isolation. Future activity must incorporate strong evidence of more ‘joined up thinking’.
EDUCATIONAL NEEDS ASSESSMENT
‘Needs assessment’ should be utilised at all levels in the cycle of individual and organisational development. Although currently single methods of needs assessment are adequate, it will become common practice to “triangulate” the information produced by using several different techniques. These should preferably involve techniques from each of the groups below. This will ensure greater validity and reliability of the derived needs.
The different elements of needs assessment include:
Audit – of individual and collective performance
Critical case analysis Objective self assessment e.g. MCQs or other material Peer comparison – e.g. on training and other practice visits
Academic activities, e.g. writing, teaching
Participation in peer groups and other clinical meetings
Training related visits to other practices or units
Team audit 360 degree initiatives (Pendleton; SCPMDE 1999)
The NAGPT has gathered together templates for some of these activities and is publishing them in its Handbook for GP Tutors. This is in print and is being distributed to all member GP Tutors. It is intended that this Handbook will be updated regularly. Future templates will be distributed electronically for local incorporation into the handbook, or for further modification by individuals to fulfil local requirements. See www.ukpractice.net and then go to the NAGPT site. METHODS OF LEARNING
Because causal processes in behavioural change cannot be predicted for each individual, a range of learning styles must be available for each educational intervention to ensure optimal learning.10 This concept applies to organisations as well as individuals. Thus, to fulfil the needs of the individual and the needs of the organisation in which the individual works, a large range of different learning opportunities may be required for the same topic.
Individuals are most likely to learn using the method which is most meaningful to them. The practical experience of both authors confirms this. One of us (MJV), in a large regional project studying general practitioners, described a broad spectrum of learning activity, ranging from those who predominantly learn as individuals in personal study, through those that predominantly learn in groups. Individuals used different methods for different subjects or learning challenges.
Careful management of the needs assessment process and adherence to the principles of adult learning are required to select the best mix of learning styles. Learning styles are however less important than the context of learning7; practice based activities are more successful learning experiences because they more completely embody Brookfield’s (summarised) principles of adult learning. Utilising these principles ensures higher levels of motivation in the learner.
Although they are well known, it is worth re-stating Brookfields principles:
Participation in learning must be voluntary
Respect for participants self worth must be maintained
Facilitators and learners are engaged in a collaborative exercise
They are involved in a process of activity and reflection on that activity
Facilitation aims to foster a spirit of critical reflection and
The nurturing of self directed, empowered adults
Since Brookfield discussed these principles in his book ‘Understanding and Facilitating Adult Learning’11, opinion about their worth has fluctuated. There is no doubt however, that when they have been incorporated in GP educational projects, the projects have met with a high level of participant satisfaction. In their literature review, Grant and Stanton7 conclude:
“Learning is a function of the process and context in which it occurs.”
Educational facilitators should ensure that individuals are encouraged to learn by their most effective method, whilst also being challenged to explore less familiar learning methodology. Since there is no reliable tool for matching methodology to an individuals learning need, the advice of experienced educators such as GP Tutors is necessary at every level of organisations to offer all available learning methods. All members of the primary health care team must be aware of differing methodologies if practices and PCG/PCTs are truly to become learning organisations.
10 “The effectiveness of CPD – a literature review” J Grant and F Stanton, Joint Centre for Medical Education, London 1998
11 “Understanding and facilitating Adult Learning”, S Brookfield, OUP 1986
The emphasis on practice based planning of learning which informs PCG plans and fulfils national strategic priorities has been emerging as a response to the NHS environment of the past 3 years. There is a danger that the professional cultural emphasis on individual practitioners as autonomous learners will be lost in the new corporate learning system, without evidence of such a change being beneficial. Primary care educators must carefully balance the individual and corporate dimensions. Educational context and process should be used to ensure the motivation of individuals within organisations as well as the fulfilment of the organisations strategic aims. Addressing the process and context of learning in this way will enhance the worth of team based learning and help lead to meaningful and evolving Practice Professional Development Plans.
Personal Learning Plans (includes agreed personal learning methodology and agreed team based learning)
Portfolio Learning Professional development activities (includes non medical activity)
Topic learning QPA activities MAP/FBA related activity Action learning sets
These are all well tried and established activities. To make them more meaningful means sharing best practice. NAGPT will disseminate templates for these activities in its handbook and will seek to rapidly update these to disseminate good practice in life long learning.
Review the NHS context for primary health care
Review the influences on General Practitioner CPD in a changing environment
Suggest systems and structures for ‘Managed CPD’
Explain the National Association of GP Tutors views and its evolving vision of the role of Postgraduate Primary Care Tutors
Raise awareness of educational processes in a corporate culture; these will be further supported in the NAGPT handbook
The Primary Care arena has recently witnessed the production of many theories about how healthcare might be delivered. Very few of these theories have been constructed as part of a comprehensive overview of current activity in primary care. This paper provides such a comprehensive review of the issues regarding CPD in primary care.
To increase the efficiency of any health care organisation requires the optimal development of the staff in the organisation. NAGPT contends that the implementation of managed continuing professional development for primary and community care in the next few years is the major challenge facing the primary care service. For the Government, Health Departments and all those involved in Primary Care education, pragmatic delivery of life-long learning within reflective learning organisations at the ‘coal face’ must be the aim for this decade. We believe that this document contributes to that aim.
Dr Malcolm J Valentine, Vice Chairman Dr John C Howard, Treasurer The National Association of GP Tutors UK 17 Spring Lane RADCLIFFE Manchester M26 2TQ February 2000
SUMMARY OF REFERENCES AND WEBSITES References
1”The Good CPD Guide” Joint Centre for Education in Medicine,
2”The New NHS- Modern and Dependable” Department of Health, London 1997
3”A First Class Service: Quality in the NHS” Department of Health, London 1998
4”Supporting Doctors, Protecting Patients” Department of Health, London 1999
5”Motivation and Continuation of Professional Development” Miller et al, British Journal of General Practice, 1998, 48, 1429-1432
6”A Review of Continuing Professional Development in General Practice”; Chief Medical Officer, Department of Health, London; 1998
7”The Professional Development of GP Tutors” J C Howard, NAGPT Manchester 1999
8”The Introduction of Personal Learning Plans for General Practitioners in North East Scotland”, Report to SCPMDE; M Valentine and F French; 1998
9”Personal Communication; Dr S Field; DPGPE, West Midlands; 2000
10”The effectiveness of CPD – a literature review” J Grant and F Stanton, Joint Centre for Medical Education, London 1998
11”Understanding and Facilitating Adult Learning”, S Brookfield, OUP 1986
Royal College of General Practitioners www.rcgp.org.uk
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