Professor of Nursing
Leslie Woods PhD BSc(Hons) Cert Ed RGN
Markella Boudioni MSc BSc(Hons)
Senior Research Fellow
Ferew Lemma MD MPH PhD DLSHTM
Senior Research Fellow
Shan Rees BA
Janet Broadbent MSc RGN
Centre for Leadership and Practice Innovation
Faculty of Health and Social Care, London South Bank University, London, UK
Received date: 6 October 2006; Accepted date: 8 December 2006
Introduction and aims This study sought to review the recent and future range of continuing professional development (CPD) activities undertakenby practice managers in the context of role expansion, to explore practice managers’perc eptions of the benefits of CPD and to identify practice managers’exp eriences of constraints and supports for engagement in CPD in the context of changing cultures for lifelong learning.Methods A formative, exploratory evaluation was conducted, utilising qualitative methods. Semistructured interviews were conducted with 16 randomly selected practice managers from general practices in the south east of England. Interviews were transcribed and content analysed using a structured framework.Results Practice managers’recent engagement in CPD covered a diverse range of educational topics. Future plans also reflected priority areas delineated in the new General Medical Services contract. Benefits of CPD were identified as enhancing skills, motivation, confidence, skill-mix, roles and improvement of patient services. Constraints to CPD engagement were negative attitudes, time pressures, lack of finance, and awareness of inclusivity in wider CPD policies. Role autonomy, a positive employer and trust attitudes to funding were supportive of CPD.Conclusions Insights into a transitional culture marked by resistance to lifelong learning alongside a drive for increased professionalism and engagement in CPD were present. Challenges still exist in overcoming constraints to CPD engagement and in ensuring that practice managers reach the potential for role expansion delineated in recent primary care policy changes.
lifelong learning, practice managers, role development
Engagement in CPD by the primary healthcare team is intrinsic to the delivery of quality services.[1,2] More recently the need for appraisal, education and training has been made explicit in the UK General Medical Services (GMS) contract, which has implications for the developing roles of all members of the primary healthcare team, including those of practice man-agers. A review of the role of the practice manager post-1990 recognised the potential for evolution from practice administration to innovation, for increasing professionalisation and the development of the role consistent with a primary care-led NHS. Since then the role has emerged as an occupational growth area in the UK.[5,6] More recently, as part of the GMS contrac-tual arrangements, a practice management compe-tency framework has been outlined to identify the broad range of skills that need to be in place to ensure that practices are e&ffciently managed, and these place emphasis on an expanded role for the practice man-ager. In relation to this, the scope of the role is envisaged to be a challenging combination of routine management skills with a strategic perspective, vari-ably encompassing personnel administration, finance, strategic planning and IT skills together with the facilitation of multiprofessional teamwork.
Comparatively little is known of practice managers’ experiences of CPD within primary healthcare teams and local practice cultures. A recent survey of general practices in Wessex found that practice managers had a pivotal role in leading the development and im-plementation of practice professional development plans; these linked the needs of the individual with those of the practice team and practice organisation. A need for adequate protected learning time to engage in professional development activities was an import-ant finding to emerge from this survey. In other exploratory studies, practice managers expressed as-sertive views about the expansion of their practice leadership roles and uniprofessional needs for devel-opment, in marked contrast to the ‘working together,learning together philosophy’. More recently, evalu-ation of a protected learning time scheme found that practice managers benefited from the information and networking opportunities offered, but that cultural changes were needed to acknowledge the fact that development and training opportunities applied to non-clinical staff.
The aim of this study was to explore the experiences of general practice managers in developing their role through engagement in CPD. Specific objectives were:
(1) to review the recent and future range of CPD activities undertaken by practice managers in the context of role expansion; (2) to explore practice managers’ perceptions of the benefits of CPD; (3) to identify practice managers’ experiences of constraints and supports for engagement in CPD in the context of changing cultures for lifelong learning.
An exploratory, qualitative, formative evaluation of the perceptions and experiences of practice managers was conducted in the preceding two-year period following the implementation of a regional workforce development strategy. This had as its focus the devel-opment and implementation of appraisal linked to personal development planning and CPD, in which lifelong learning advisors, primary care workforce tutors, GP tutors, patch associate deans and chairs of primary care trust education committees played key roles. This study formed part of a wider exploratory survey conducted over a one-year period, designed to evalu-ate the impact of the regional primary care workforce development strategy in Kent, Surrey and Sussex.
Twenty-two of the total 24 primary care trusts (PCTs) in the region agreed to take part following multicentre research ethics committee (MREC) and local governance approval. Potential participants were randomly selected from website listings within the public domain. Recruitment packs were distributed by post, comprising project information and an informed consent proforma consistent with ethical approval. Following return of the signed consent form, partici-pants were contacted by telephone to take part in semi-structured interviews. Sixteen practice managers agreed to take part.
Participants were offered the option of either a face-to-face or telephone interview of 30–60 minutes’ duration, at a time and location convenient to them. Interviews were tape recorded, transcribed and inde-pendently checked for accuracy prior to analysis. Following preliminary pilot work, interview topic guides were developed, encompassing diverse areas of CPD experience related to the study aims and objectives.
Qualitative interview data were transcribed and checked for accuracy. Transcripts were intensively and repeatedly read to identify key themes, codes and categories which were then developed into a coding framework. This was subsequently used to code the interview data by hand. The final thematic frame-work was agreed by the researchers. Six major themes emerged, some of which encompassed a number of subthemes; these comprised recent CPD engagement; future areas of learning demand; supports for CPD engagement; constraints for CPD engagement; per-ceived benefits of CPD and cultural changes in lifelong learning.
Recent engagement in CPD
Participants reported attending a diverse array of CPD events in the preceding 18 months, which encompassed both formal courses and national and local conferences. Content covered different aspects of operational management and information technology (IT) skills, together with some clinical topics.
‘Appointed person first aid thing... . Employment law update... . Understanding health and safety parts one and two. A bridge event on complementary medicine. Sup-porting the quality and framework outcomes... . Resus’ evening. Health and Safety Foundation Certificate, I’ve done all those in the last year.’ (Interview 46, p. 3)
‘Well I stay abreast of current legislation so I attend employment law lectures, I also attend pension lectures. We’re very fortunate that we can access good training and I also, personally I’m doing ECDL [European Computer Driving Licence] just to give me a little bit more with my computer.’ (Interview 49, p. 1)
Learning demand: future areas of CPD engagement
Participants emphasised the need to keep up to date, and were able to identify very clearly areas of future learning demand which included areas within the GMS contracts, for example, chronic disease manage-ment and aspects of operational management.
‘I’ve become involved to a relatively high degree in comparison with my peer group here in one of the clinical collaboratives around chronic obstructed pulmonary dis-ease and diabetes, which has been developed in terms of me being asked both locally within the southeast and across the southern part of England to be involved in facilitating break-out sessions at workshops, so that has come out of it as well.’ (Interview 27, p. 2)
‘I would say the financial side ... and employment law because it’s changing all the time and you’ve just got to keep up with it, that’s a very hard aspect that we need to continue with. I’ve done personnel training in the past so I feel quite confident with that, but again things are changing all the time, so it’s a matter of keeping up to date with everything.’ (Interview 48, p. 2)
Benefits of continuing professional development
Four subthemes were distinguished here.
Maintaining skills, motivation, confidence
Benefits of CPD linked to personal development planning (PDP) accrued by linking individual needs and targets with those of the practice. An emphasis was placed on the benefits of maintaining up-to-date management systems, and professional skills and learning were envisaged as a continual process, con-sistent with the philosophy underpinning lifelong learning. The development of confidence and enhanced motivation were also seen as enhancing working life.
‘Well I personally feel it’s extremely important because you never stop learning, we shouldn’t stop learning, there’s always something that someone can teach you somewhere, keeps you, as being part of the management structure and looking after lots of staff as well, you need to ensure that your systems are in place and that everything’s current and up to date.’ (Interview 46, p. 3)
‘Yes, I think it keeps you interested, it keeps you motivated, keeps you up to date and think, you know, all those things make for a much better working life.’ (Interview 51, p. 3)
Other benefits of undertaking CPD were opportunities to extend professional development to enhance the role, a factor which appeared to be influential in retention of one manager in the same practice for a number of years. In contrast, another participant noted the disincentives created by lack of CPD opportunities in recruitment and retention within the current role and its potentially negative consequences.
‘I’ve been here for nearly 26 years. It has improved over the years, and with changes there have been opportunities to expand and extend your own professional develop-ment; certainly had general practice remained as it was 15, 20 years ago I would not be in this role, but because there have been extra opportunities and extra possibilities then yes, one has been able to extend.’ (Interview 26, p. 5)
‘Sorry, I think I’m at the stage where I may look some-where else because I think the challenges are waning because I don’t have the opportunity ... I’m beginning to think that I’ve gone as far as I can go now, without investment or more staff ...’ (Interview 46, p. 5)
Benefits within the workplace were identified to result from increased skill-mix through engagement in CPD linked to PDP. The acquisition of a range of generic skills provided a more effective cover for sick leave and other absences.
‘I personally think that you can’t run an o&ffce without everyone’s skill-mix, appreciating and value. In other words when I came here there were people that would just do that, I can try and make sure they can do a range of things, which benefits everyone... . You know it keeps them having something new to learn and it also means that if people are off sick we have more people that can cover.’ (Interview 46, p. 4)
Quality of service provision
Finally, other managers emphasised the importance of CPD in enhancing service provision to patients.
•.. And at the end of the day it’s the patients that benefit, which is the whole reason behind it hopefully ... I think if there wasn’t that support then I would be finding it very di&ffcult.’ (Interview 39, p. 7)
Constraints to CPD engagement
Three subthemes were distinguished here (see Box 1).
Unhelpful attitudes occasionally emanated from other professionals within their practice setting, which did not foster a culture of lifelong learning. Most practice managers were responsible for the appraisal, PDP and CPD engagement of their o&ffce staff; not all of whom were career motivated.
Some managers were under the impression that train-ing opportunities and access to educators working in primary care related more to general practitioners (GPs) and that those opportunities were not being targeted at them as managers specifically.
Time and funding
Constraints could arise from pressures created by the need to have protected learning time to engage in CPD and the financial cost of employing a locum. Other managers recognised that things had changed in the local cultures over time, and although improvements had occurred, taking time out to pursue development still raised issues about covering workloads
Supports for CPD engagement
Three subthemes were distinguished here (see Box 2).
Organisations and networks
The presence of close working relationships with PCTs, the existence of local networks for managers and a regional training alliance were seen to be important supports for CPD.
Positive employer attitudes
Receiving support from employers in relation to time and funding was seen to be crucial in accessing CPD. Local practice manager networks and GP colleagues could provide valuable advice on CPD. The need for appropriate, relevant, practice management-related courses was a common reiteration.
Role autonomy and flexibility
Other important supports for CPD were the degree of role autonomy and flexibility in decision making that managers had acquired, linked to financial resources. Several reported positively on their facilitation of practice staff access to CPD.
Changing lifelong learning environments
Responses of some managers suggested changes had occurred in the local lifelong learning environment, including cascading learning to peers, greater awareness of access to training opportunities and the need to be proactive in taking them up. ‘... When I’ve said I’m going to do something I am given the time to do it. And if necessary it’s funded. But it’s never suggested and that very much depends on myself, and I think that’s true of a lot of practice managers.’ (Interview 51, p. 3)
‘I’ve seen more opportunities since the new contract, I think you know, the PCT have realised that practice managers have sort of been left out on a limb for a long time and they do need far more support than they have been getting, so I mean it’s getting better.’ (Interview 48, p. 3)
‘I have an assistant practice manager, she was a receptionist beforehand and obviously with her and I, we support one another, it’s really great, and we’re both learning. I’ve learnt things that I can now pass on to her and likewise.’(Interview 55, p. 5)
Recent developments in the UK emanating from the GMS contracts for primary care, have recognised a pivotal and expanded role for the practice manager which are intrinsic to the quality of service delivery. Little empirical research has evaluated the develop-ment of practice managers’ roles in the light of recent policy relating to service contracts and CPD frame-works. This exploratory, qualitative investigation of-fers some insights in these areas, key findings of which are summarised in Box 3. An important finding was the diversity of current areas of recent CPD engage-ment reported by practice managers, encompassing law, health and safety, financial management, IT, complementary medicine and more clinically focused topics. Future areas of learning demand also included chronic disease management, reflecting the priorities identified in the GMS contracts and the need for managers who are involved in quality improvement through redesign and development of services to have some understanding of the evidence relating to prob-lems and needs of patients and carers.[7,8] Benefits of engagement in CPD were envisaged as development of skills, confidence and motivation, enhancing role development and skill-mix and improving patient services, all of which are consistent with the vision for achieving quality through CPD in primary care. Overall, these findings suggest that for many, engage-ment in CPD linked to expansion of the managerial role is consistent with the drive for professionalism, marked by role autonomy and a developing career structure consistent with the NHS Knowledge and Skills Framework. Management competencies outlined in the GMS contract were seen as contributing to innovation demanded by a primary care-led NHS.[1,3,7]
However, findings also suggested that not all man-agers’ attitudes to role development and expansion were positive; some were not career motivated and viewed their role as ‘just a job’. Length of service in the post was not established in our interviews, but it is possible that this may reflect the views of individuals who had been in post for some time and were recruited prior to recent policy changes. Historically, the inde-pendent contractor nature of GP practices has been a factor which has been linked with resistance to CPD engagement, and negative responses may illustrate the persistence of this culture. In the light of recent policy and contractual arrangements, commitment to devel-oping both role and contributions to quality of ser-vices is an issue for future recruitment, appraisal and PDP for practice managers.
Variable constraints for engagement in CPD had been experienced; these included time pressures, workloads, the need to provide locum cover which could be costly, or where this was not possible in-creasing workloads for other practice staff. Negative attitudes encountered within general practices were also occasionally cited as constraints. Some practice managers were not aware that the national, regional and local initiatives relating to CPD were intended to be inclusive for clinical and non-clinical staff within the primary healthcare team – an issue for further awareness-raising by primary care organisations.[7,13] Other investigations have also confirmed that adequate protected learning time is necessary to support CPD engagement in general practice and that changes are needed to acknowledge the fact that CPD oppor-tunities also apply to non-clinical staff. [9,10] How are these barriers to be overcome? In part, the inception of the PMS and GMS contracts, which encompass financial incentives for quality of services, have impli-cations for role development of practice managers who will for example, require the knowledge and skills to innovate and manage new systems for patient access and electronic care records. However, a sustainable culture for change also needs a support system in which transparent, equitable financial resources for CPD linked to protected time are more clearly ident-ified within contractual arrangements – a continuing challenge for policy. Beyond this, enhanced partner-ship working between GP practices and PCTs, furthered by leadership in which ‘change agent’ skills of com-munication, negotiation and facilitation are used to embed changes in lifelong learning cultures can be helpful.
Other supports for cultural change identified by managers encompassed role autonomy, supportive PCTs, training alliances and positive attitudes from practice partners. Employer support relating to time and finance was seen to be crucial in supporting CPD, linked to structured training plans based on realistic budgets which facilitated the development of admin-istrative staff in the practice. It had been recognised that changing the culture for CPD within primary care organisations would not be easy, illustrated by the variable experiences reported by practice managers in this study. However, these exploratory findings provide some insights into a transitional culture, of change for lifelong learning which is marked by the persistence of some resistant attitudes, but also by developments characteristic of learning organisations which were evident in the drive for professionalism and CPD engagement of some practice managers. However, considerable challenges remain in ensuring all practice managers reach the potential scope and level of role expansion envisioned in recent policy development.
We acknowledge the patience, co-operation and time of the study participants across the KSS health econ-omies. The chair of the project steering group, Mr D Selling and Professor A Tavabie, provided helpful advice at different stages of the project.
The research team gratefully acknowledge the financial support of the commissioners, Kent Surrey and Sussex Postgraduate GP Deanery on behalf of the Deanery, Workforce Development Confederation and Strategic Health Authority for Kent Surrey and Sussex.
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