John Howard

Cost and quality of education for general practice.

General practice constitutes the largest single specialty within medicine and its educational infrastructure needs to be equally large to provide community-orientated education for undergraduates, doctors on Foundation programmes, GP specialty trainees and established GPs and their teams. Over the last few years, service redesign in healthcare, the transfer of services into the community and, most recently, the role of GPs as commissioners of healthcare have all increased the prominence of general practice. The government have stated in the comprehensive spending review that all sectors of the NHS must reduce costs; all UK deaneries have already had to reduce costs by 15%, with 10% of this coming from reduced management costs and, further, it is suggested that this process will continue in the next few years. Despite these budgetary reductions general practice is still required to expand in terms of numbers of trainees being trained. If general practice education is going to play a major quality role, it must be fit for purpose in terms of delivering first-class training. So, how do we identify where we can reduce expenditure on GP specialty training and can GP training be delivered at a reduced cost without reducing quality or quantity? Little is known about what constitutes cost-effective training in general practice or indeed how current costs compare to other systems. This article describes current key quality markers and discusses the potential effects of cost reductions on the quality of specialty training for general practice.

General practice continuing professional development tutors: an appraisal of options for the future

This paper considers the potential future for general practice continuing professional development (CPD) tutors in the United Kingdom. It looks at their historical functions and the likely requirements of general practice in the future, their current and potential employers and funding arrangements. It is written from an English perspective and recognises the differences between the four home countries of the United Kingdom; the solutions it proposes may best apply in England. Indeed, the funding crisis that has provoked this review has mostly arisen in England, although the arguments set out below might apply in all countries. Some deaneries have been forced to re-grade or make redundant their tutors while others have continued with their current workforce. As a result, in England the number of CPD tutors deployed in each deanery now varies from none to one per 150 GPs. CPD tutors in England and Wales are employed by deaneries; some deaneries have shared these appointments with primary care organisations (PCOs) and in other instances tutors are solely employed by PCOs. In Scotland tutors are employed on behalf of deaneries by NHS Education for Scotland (NES). CPD tutors in Northern Ireland are employed by Northern Ireland Medical and Dental Training Agency (NIMDTA). In Wales, Northern Ireland and Scotland CPD tutors have been crucially involved in their national GP appraisal schemes and their position has seemed secure; in Scotland, NES, health boards and deaneries have all been involved in appraisal. The variations in policy and in function have clearly influenced the number of tutors employed by deaneries.

Assessing academic clinical fellows in general practice: square pegs in round holes?

BACKGROUND Academic clinical fellows (ACFs) training in general practice (GP) record competency progression in their Royal College of General Practitioners (RCGP) e-portfolio. The General Medical Council (GMC) recommend that current workplace-based assessments (WPBAs) should be used flexibly and formatively. GP ACFs find the e-portfolio inflexible and often only use the learning log and personal development plan to demonstrate academic progress. AIM This pragmatic pilot was undertaken to evaluate the utility of three assessment tools to trainees in the academic setting. METHODS ACFs in two deaneries were asked to pilot the use of an academic learning needs analysis (LNA), a new academic supervisor report (ASR) and current WPBAs. The use and value of these tools was assessed using an electronic questionnaire and a focus group of ACFs. RESULTS Twenty-two GP ACFs responded to the questionnaire and six participated in the focus group. Use of WBPA was 32% (n = 7), LNA was 55% (n = 12) and ASR was 82% (n = 18). GP ACFs valued discussions of academic progress, particularly the formal identification of areas for development. Use of the tools appeared to facilitate constructive feedback about an ACFs academic role. ACFs disliked tools containing elements that were not applicable to their needs and/or setting, undertaking mandatory academic assessments prior to commencement of their academic post and uncertainty about which WPBA to use. CONCLUSIONS ACFs appreciate formally addressing progress, learning needs and how to maximise the use of their posts. Formative academic feedback would be best accepted if delivered using specifically designed academic tools that are integrated into the e-portfolio. When designing academic tools, both research and education activities need to be considered. Academic experience is a pre-requisite for formal assessment of academic progress; commencing academic activity in ST1 would enhance demonstration of progress in later years.

The value of reflection

The UK General Medical Council (GMC) requires a doctor to be able to demonstrate reflection on their own practice ‘You should regularly reflect on your own performance, your professional values and your contribution to any teams in which you work’ as a fundamental part of Good Medical Practice [1]. Irrespective of what doctors are required to do, engaging in reflective practice is associated with improvement in the quality of care, stimulating personal and professional growth and closing the gap between theory and practice [2]. Records of reflection vary between journalistic descriptive accounts to deep reflection eloquently describing the broad impact of cognitive dissonance on the learner, often leading to subsequent behaviour change. Reflections in learning log entries are ‘assessments for learning’ rather than ‘assessments of learning’. The paper by Curtis et al. suggests that the quantity of reflections required for work place based assessment (WPBA) is ‘having an adverse effect on trainees learning’. There is no mandatory number of reflections required as part of WPBA; only the trainee chooses when to record their reflections. As entries are made, the accumulated evidence provides an overview of the trainee’s ability to reflect. In terms of contributing to assessment, the quality of reflection demonstrated therefore determines the number of entries necessary, accepting that at any one time it is necessary to demonstrate current rather than historical competence, just as with appraisal after completing specialty training. Reflection can occur in many contexts; over coffee in discussion with a peer, within tutorials, or while undertaking other life tasks. The nature of thought and memory means that not all parts of the reflective sequence will be given equal weight; rather the emotional impact for the learner may colour a subsequently recorded account. The reflective questions that general practice (GP) trainees are asked to complete in log entries are based on Gibb’s reflective cycle, used as a prompt to help facilitate the reflective process [3]. They are by no means rigid. There is wide agreement that such prompts structuring reflection within written records increase the quality of reflection and the record of the process by learners. The WPBA group is responsible for the content and strategic development of workplace assessments during GP training in the UK [4]. They entirely recognise the limitations of the written record. It is unlikely to be contemporaneous, is necessarily formulaic and does not capture the richness of experience communicated face to face through both verbal and non-verbal communication. It prevents current interaction; the reader is not able to explore nuances and inferences which are so important in normal human communication. It is interesting to speculate given the varying contexts and mechanisms how reflection might be captured as technology evolves. Real time video logs may provide some of this information and allow more engagement from the learner’s perspective; better still might be embedded CGI reconstructions in developing technologies such as Microsoft’s Sway. We also agree with Curtis et al.’s statement: ‘it is possible those least satisfied with the process of written reflection were most motivated to complete the survey and make their views known.’ These views fall into different domains, for example perceptions, beliefs, peer norms, behaviours, effects etc. The purpose and content of reflection will be different for GPs and trainees because of their career stage. GP trainees themselves are not a homogenous group of individuals with the same educational and cultural backgrounds. Reflective practice does not come naturally to each individual [5]; however we reiterate the importance of developing this skill in all. Shaughnessy and colleagues’ key argument seems to be that ‘simple reporting’ and ‘goal setting’ are more common

Consistency and reliability of judgements by assessors of case based discussions in general practice specialty training programmes in the United Kingdom

Abstract Case based discussions (CbDs) are a mandatory workplace assessment used throughout general practitioner (GP) specialty training; they contribute to the annual review of competence progression (ARCP) for each trainee. This study examined the judgements arising from CbDs made by different groups of assessors and whether or not these assessments supported ARCP decisions. The trainees selected were at the end of their first year of GP training and had been identified during their ARCPs to need extra training time. CbDs were specifically chosen as they are completed by both hospital and GP supervisors, enabling comparison between these two groups. The results raise concern with regard to the consistency of judgements made by different groups of assessors, with significant variance between assessors of different status and seniority. Further work needs to be done on whether the CbD in its current format is fit for purpose as one of the mandatory WPBAs for GP trainees, particularly during their hospital placements. There is a need to increase the inter-rater reliability of CbDs to ensure a consistent contribution to subsequent decisions about a trainee’s overall progress.

Commentary (on Ragg et al.).

There has been much interest and discussion within the medical education community about the differential rates of achievement in postgraduate medical assessments between UK qualified trainees and those who have qualified overseas. This differential resulted in a judicial review of the Clinical Skills Assessment (CSA) after a highly publicised legal challenge from the British Association of Physicians of Indian Origin (BAPIO) in 2013 against the RCGP and GMC. In the judgement, Mr Justice Mitting exhorted the GMC and RCGP to review the situation and take action to support doctors from other cultures who may be disadvantaged by the present situation.[1] One response has been to consider how best to support those whose performance has given cause for concern and to set in place an analysis of communication issues within the exam itself. The paper from Eleanor Ragg and colleagues [2] in this issue takes a different approach, considering which general factors associated with the candidates training appear to relate to success in the exam. The work builds on a short report published in 2013 considering the characteristics of trainees who pass the MRCGP on their first attempt.[3] There is considerable concordance between the two studies; both described strong benefits from supportive relationships allowing honest constructive feedback to trainees. The early identification of the challenges allowing trainees to take responsibility and plan their study within an organised educational framework was perhaps not a surprising outcome. Insight into the trainees’ own learning needs, the ability to maintain self-discipline, be organised, positive and proactive and the need to formally learn communication skills might all have been expected. But the strong emphasis on supportive, trusting relationships and methods such as joint teaching surgeries is an interesting finding common to both studies. As Eleanor Ragg and colleagues state, barriers to ‘an impressive level of openness and trust’ allowing a ‘willingness to share perceived personal weaknesses and deficiencies’, need to be researched further. We need to consider not just the way that trainees relate to their patients, but also the way that supervisors work with trainees to develop their communication skills and knowledge about General Practice and the consultation. We have always recognised that when it works well the apprenticeship model in ST3 is capable of producing highly effective change and educational benefit, but perhaps we have not previously analysed why this model of teaching is fit for purpose in the modern context. What is it about this key supportive relationship that allows the efficient transfer of the complex skills exhibited in every successful consultation? The management literature has long considered the factors which allow the maximisation of the communication of knowledge and skills within organisations. McAllister writing in 1995 [4] set out a framework which developed the concepts of cognition-based and affect-based trust between colleagues. These concepts have been refined and developed subsequently in many different areas, with similar results. Broadly, it appears that while respect for professional abilities and problem solving (cognition-based trust) allows professional association and the transfer of explicit knowledge, it is affect-based trust that allows emotional openness without vulnerability and the sharing of tacit knowledge, that is the subjective, deep knowledge we use for key strategic decisions. This type of communication is usually face to face and corresponds to the ‘know it when I see it’ recognition that is required for the CSA.[5] What then is the impact of culture on the development of affect-based trust within a professional educational relationship? An interesting perspective on this is the impact on creativity in professional relationships demonstrated in some novel work from Harvard.[6] Experiments with groups of managers in multinational

The United Kingdom Conference of Educational Advisers (UKCEA) workforce surveys.

Like most areas of primary care, the activities included under the term education have increased significantly over the last 40 years. That period covers the development of vocational training, the recognition and fostering of continuing professional development (CPD) and the introduction of National Health Service (NHS) appraisals. In response, the primary care medical educator workforce has grown in both size and complexity, yet there has been little published information available to practitioners, employers and regulators about the nature and numbers of educators employed in deaneries in the UK. Change continues to happen; the introduction of revalidation in 2011 will bring new demands. In a devolved UK with increasingly complex professional regulation, information about the capacity and composition of the educational workforce will assist directors of primary care education, the medical profession, regulators and the government to manage change. Since 2005 the UKCEA has undertaken regular surveys of primary care educators employed in deaneries in the UK. The surveys were introduced after the development of the NHS primary care medical educator pay scale in 2003. The surveys report on trends in numbers and types of educators employed within deaneries and include confidential feedback from new employees and those who have recently left deanery employment. It is timely to review the origins and purpose of the workforce surveys and outline the most recent survey findings.

Significant event reporting in a postgraduate deanery

The article focuses on the responsibility of postgraduate deaneries to ensure the high quality of postgraduate medical and dental education in Great Britain. It states that postgraduate deaneries develop an event reporting form to monitor the occurrences of events including near-miss and adverse significant event. It also notes that the form was used by school staff to determine and give out learning experiences in the deanery.

South Cheshire Local Multi-disciplinary Evidence Centre: an evaluation

The South Cheshire Local Multidisciplinary Evidence Centre (LMEC) was a two-year project commenced in March 1998 and completed in April 2000. The project aimed to develop an information service to enable all primary and community care staff in South Cheshire to access high-quality evidence and thus to improve patient care. The LMEC gave access from the workplace to both physical and electronic resources to support clinical governance and lifelong learning, with a strong emphasis on evidence-based material. Automation of the library catalogue enabled its inclusion on the website. The project developed enquiry and document delivery services and provided training on using the LMEC and on critical appraisal. An evaluation carried out at the end of the project showed that over 120 primary and community care staff had used the LMEC and were positive about the service. As Clinical Governance, the NHSnet, and plans for continuing professional development are implemented, the LMEC is one model for a Local Health Information Service outlined in the NHS IT strategy.