Associate Advisor in Continuing Professional Development
Carole Stoddart BSc MSc
Advisor in Continuing Professional Development
Diane Kelly MD FRCGP
Assistant Director in GP Education (CPD)
NHS Education for Scotland, Glasgow, Scotland, UK
Received date: 31 July 2006; Accepted date: 18 September 2006
Introduction Government recommendations have encouraged the primary care team to learn together in order to improve both teamworking and the quality of care for patients. Protected learning time (PLT) has become an established method of learningfor many primary care teams. PLT offers teams the potential of learning together by providing time that is protected from service delivery. Practice managers are often tasked with the organisation of practice-based PLT events for the primary care team.Aims The aim of this research was to elicit the perceptions of practice managers about their role in this task.Methods A 16-statement questionnaire was devised and emailed to the practice managers of 56 general medical practices that take part in PLT within NHS Ayrshire and Arran.Results A response rate of 90% was achieved. The results showed that managers considered that it was their role to plan and prepare practice-based events. However, only 11% of managers felt it was their responsibility to arrange educational events that included the attached team of health visitors and district nurses. They also reported that the attached team only attended a minority of practice-based PLT events.Conclusion Practice managers need more support fromwithin the team when planning and preparing PLT, and need help to overcome the exisiting barriers that prevent learning together with the attached team. Primary care teams and primary care organisations who fund and commission PLT need to work differently if they are to improve practicebased PLT.
continuing professional development, medical education, practice-based learning, pri-mary care team
The Scottish Executive’s plan for health care involves a shift in emphasis from acute secondary care to pri-mary care with the expectation that more complex care will be provided by the primary care team rather than just by general practitioners (GPs). Some of these challenges include increasing levels of health pro-motion, anticipatory care and chronic disease man-agement within communities. It is clear that much change in healthcare delivery is anticipated, and it is likely that teams, who learn together and from each other, may be better equipped to meet the challenges set by this plan.
Government recommendations encourage team-based learning within primary care as a way of improv-ing the quality of care and range of services offered to patients.[2,3] These recommendations are also supported by established educational theory, which emphasises the need to develop the whole team rather than just single professional groups.
Protected learning time (PLT) has become an estab-lished method of learning for primary care teams in many parts of the UK. It was introduced to primary care by schemes such as TARGET (Time for Audit, Reflection, Guidelines, Education and Training) from Doncaster and Portsmouth, and CREATE (Clackman-nanshire Resource for Education, Audit and Team working) from central Scotland.[5,6] Many primary care organisations have used PLT to allow teams to have time dedicated to learning.
Evaluations of PLT schemes are few but generally positive.[6,10–12] PLT has also allowed teams to focus on improving the quality of the services they provide and enabling team members to learn from each other. It has been shown that some practitioners in primary care are ready to learn from each other by engaging in interprofessional learning within PLT.
None of the published PLT evaluations has focused on the role and responsibilities of practice managers with regard to the planning and preparation of practice-based PLT educational events.[6,10–12] Practice managers are often tasked with arranging practice-based educational events, and these make up the majority of sessions within PLT. Practice managers’ perception of their role in planning and preparing for practice-based PLT educational events is not known.
PLT commenced in NHS Ayrshire and Arran in 2001 and now involves almost all of the 58 general medical practices in the area. NHS Ayrshire and Arran serves a mixed population of rural areas and small towns, and has a degree of deprivation. Practices usually have six or seven practice-based educational events per year, and are invited to attend one or two large educational events which are centrally organised by the community health partnership (CHP). NHS Education for Scotland (NES) is a special health board and advises other health boards within NHS Scotland on educational matters. Two NES associate advisors in continuing professional development have given ad-vice to the three CHPs within NHS Ayrshire and Arran on the development of PLT.
An unpublished evaluation (2003) of two PLT schemes managed by North and East Ayrshire CHPs was undertaken by the first author. This evaluation showed that GPs and practice nurses valued PLT highly, but that attached staff (health visiting and district nursing teams) valued it less. Similarly admin-istrative and clerical staff (A&C) and practice man-agers did not share the enthusiasm of the GPs and practice nurses within the team.
Free-text comments submitted by practice man-agers as part of the evaluation alluded to their per-ceived difficulties in planning and preparing for practice-based PLT educational events. A qualitative focus group study involving practice managers cor-roborated these findings, and emphasised the diffi-culties faced by practice managers. The extent to which other practice managers within NHS Ayrshire and Arran agreed with some of the issues raised was not known.
Thus a questionnaire study was commissioned to elicit the perceptions of practice managers in NHS Ayrshire and Arran towards practice-based PLT events.
The aims of the study were to:
• quantify practice managers’ perceptions of their responsibilities in organising PLT practice-based events for different members of the primary care team
• gauge whether practice managers felt they had enough time to organise for practice-based PLT events
• elicit practice managers’ estimates of how many of the primary care team were regularly attending practice-based PLT events
• establish whether evaluations of PLT practice-based events were being performed, and whether they influenced further educational activities
• quantify how many practice managers felt PLT should continue.
respondents were asked to indicate whether they strongly agreed, agreed, disagreed or strongly dis-agreed to the statements. A ‘don’t know’ option was also given. It was decided not to use a neutral option in the scale so as to encourage participants to give an opinion. Free-text comments were also encouraged for the last two statements, so that managers could provide more detailed replies.
Statements in the questionnaire were grouped into five themes. Practice managers were asked to:
• give their opinion on whether they considered that they had enough time to organise for practice-based PLT educational events
• give their opinion on whether they thought it was their responsibility to organise practice-based PLT events for different members of the primary care team. The team was considered to be made up of A&C staff, attached staff (of district nurses and health visitors), GPs, practice managers and prac-tice nurses
flestimate the level of attendance of the different members of the primary care team at practice-based PLT educational events (it was clear from informal communications with practice managers and CHP managers that registers of attendance were not always kept for practice-based PLT edu-cational events)
flestimate the percentage of practice-based edu-cational events that they had evaluated and whether these evaluations had resulted in change to future educational events
flexpress an opinion as to the overall value of PLT, their opinion on which members of the primary care team benefited from PLT and their opinion concerning whether PLT should continue.
A copy of the questionnaire is shown in the appendix. The questionnaire was piloted with six practice managers (approximately 10% of Ayrshire and Arran practice managers) who completed it, and gave their comments on ease of completion and clarity of the questions. The six practice managers in the pilot were well known to the first author as they worked in his locality, and it was hoped that they would give frank feedback. As a result of the practice managers’ com-ments, minor amendments to the wording of the statements were made to increase their clarity. The questionnaire was then converted to a web-based
questionnaire and linked to the NES website. Practice managers from practices who took part in PLT were sent an introductory email from the authors in April 2006, explaining the nature of the research and containing a hyperlink that took them directly to the web-based questionnaire. They were asked to enter their unique NHS practice-identifying number as a way of preventing duplication of entries and to iden-tify practice managers who had not responded to the first invitation. This identifying number was not used for any other purpose, and a guarantee was given of confidentiality and anonymity. Two reminders were sent at weekly intervals. The web-based questionnaire was closed three weeks after the initial introductory email.
Data were collated from the website and converted into an Excel spreadsheet and tables constructed. Free-text comments were collated and interpreted using thematic analysis. The comments were read and reread, and sorted into themes.
There were 58 general medical practices in NHS Ayrshire and Arran at the time of the study. Two practices did not take part in PLT and two practices learned together as they were about to merge to become one larger practice. Four small practices, located on an island, pool resources and learn together and replied as one unit. Forty-seven practice managers completed the questionnaire out of a potential 52 practice managers who are involved in PLT, giving a response rate of 90%.
The proportions of practice managers who agreed with 14 of 16 statements are outlined in Table 1. The results of the remaining two statements are incorpor-ated into the text below.
The practice managers’ estimates of attendance at practice-based PLT educational events for various groups showed a wide variation. Their estimates for those members of the team who attended 76% or more of the events were: health visitor 9%, district nurse 15%, GP 70%, practice nurse 73%, A&C staff 87% and practice manager 90%.
Practice managers’ estimates of the proportion of practice-based educational events that had been evaluated were:
• 0–25% of meetings: 8%
• 26–50% of meetings: 30%
• 51–75% of meetings: 39%
• 76–100% of meetings: 17%
• no answer: 6%.
Analysis of the questionnaire results showed that 59% of practice managers considered that they had enough time to organise educational events. The majority of respondents perceived that the organisation of edu-cational events was their responsibility, for practice nurses (79%) and GPs (76%). In particular 96% of respondents agreed or highly agreed with the state-ment about their responsibilities for organising edu-cation for A&C staff. In contrast, only 11% of practice managers thought it was their responsibility to do this task for the attached staff.
There were clear differences in the practice man-agers’ opinions of who they thought benefited from practice-based PLT educational events. Eighty-one percent of practice managers agreed or strongly agreed that practice-based clinical staff (GPs and practice nurses) benefited from these events; 96% thought that non-clinical staff (A&C staff and practice man-agers) benefited; but only 37% felt there was a benefit for attached staff. In general, practice managers con-sidered that PLT was worthwhile (86%), and they also thought PLT should continue (84%).
Free-text responses were invited to give further details about whether PLT should continue, and for further feedback generally. Twenty-five out of 47 practice managers entered free-text comments into the online questionnaire. It was decided to analyse the data from both responses together. Eighty percent of comments were essentially positive about PLT. The main themes of the responses are considered under the headings that follow.
Practice-based events provide an opportunity for the entire team to learn together
Some practice managers felt that practice-based PLT events were the only time when the whole team could come together to discuss their work and plan changes for the future. A dominant theme in the free-text comments was that this time was valuable and would be missed should PLT end.
‘It is the one time we can all come together without constant interruption. Dedicated time without the worry of visits, telephone calls or having to be somewhere else has to be a bonus for all of us taking part.’
‘This is the only time that all the GPs, practice staff and attached staff get the opportunity for networking and learning.’
‘PLT educational meetings provide valuable training and updates from clerical staff through to the GPs. The fact that a complete afternoon is dedicated to this certainly makes a difference.’
‘They should continue as long as topics are both edu-cational and informative for those in attendance. We generally try to stay in-house due to mishaps in the larger events. Thus we are able to arrange meetings to suit the needs of the practice.’
‘I am not convinced that for A&C staff there are enough subjects which can be planned for group learning/training at specific PLT meetings. I prefer to see individuals given time to develop their own training and learning needs.’
‘I think the whole concept of PLT is essential in a general practice setting. I do however have difficulty in organising training for the attached staff within the practice, except when it is clinical, e.g. CPR [cardiopulmonary resusci-tation].’
Learning with the attached team
Practice managers raised concerns about their re-sponsibilities with regard to planning and preparing practice-based PLT events for attached staff. They felt that they did not always know their learning needs. There were also concerns about poor communication and the lack of joint planning between practice man-agers and CHP nursing managers.
‘I do appreciate that the whole of the primary care team should have an input into in-house events, but practice managers do not know the training needs of district nurses etc. It would be helpful if practice managers could have support, perhaps from nursing managers.’
‘I don’t mind organising the events, what I do mind is organising events with community staff in mind then finding out at the last minute that training has been arranged elsewhere for them. [This is] something that is happening more and more these days.’
‘I agree that they should continue as it is a good way of getting the whole team together – find the community staff don’t always attend and also find it difficult to cater for all disciplines especially community staff (maybe [there could be] better links with community staff man-ager).’
Relevance of topics in practice-based events
A dominant theme expressed was that practice-based events were usually considered more relevant to the team than those topics chosen for larger centrally organised meetings. However, several practice man-agers raised the issue that it was difficult for them to plan and prepare practice events that were relevant for the entire team.
This study set out to elicit the perceptions of practice managers about their role in practice-based PLT and the study achieved this aim. It also adds to the literature on PLT with a particular focus on practice managers.
There were various strengths of the study. One strength was the use of a pilot to clarify the wording and ease of completion of the questionnaire. The questionnaire had a very good response rate (90%). This was perhaps aided by the use of a web-based questionnaire and email, which seemed a fast and effective way of collecting data. Responses from prac-tice managers were based on a considerable experience of practice-based PLT educational events, as most practice managers in NHS Ayrshire and Arran had been involved in PLT for four or five years. This period of time had allowed PLT to become embedded into practices, and thus the responses should reflect on the sustainability of PLT and on maintaining momentum.
There were several weaknesses to the study. Practice managers were asked to estimate the attendance of different members of the primary care team. Their responses were subjective and based on their opinions and memory. They were not asked to examine records of attendances which, if taken, might have been more accurate. There was no independent means of verify-ing their responses. There is a possibility that practice managers may have over- or underestimated attend-ance of the various members of the primary care team as a result. Practice managers were also asked to report whether they evaluated practice-based PLT events and also whether they used that evaluation information for further planning. We did not ask practice managers for evidence to support their responses to these two questions. It was possible that they may have responded to indicate a view that they perceived as being the right response, rather than an honest one.
There was no neutral option in the questionnaire given to practice managers. This may have encouraged practice managers to form an opinion, but it is pos-sible that some indicated ‘don’t know’ or left this response blank when they would have preferred to have indicated a neutral response to the statement.
Practice managers felt strongly it was their responsi-bility to arrange education for A&C staff, even more so than for the GPs (who employ them) or for practice nurses. That they did plan and prepare education for most of the team does reflect the increasingly import-ant role of practice managers in modern primary care, and illustrates their willingness to take on new work.
It was clear from the survey that most practice managers considered it was their responsibility to organise training for most of the primary care team except the attached team. Some of the free-text re-sponses suggested they felt that the CHP nursing managers were responsible for arranging training for district nurses and health visitors. Other free-text comments mentioned that practice managers found it difficult to arrange meetings that would interest the attached members of the team. This was possibly as a result of not knowing the attached staff members’ learning needs, or not knowing what the attached staffs members’ roles fully entailed. As a result, at-tendances at practice-based meetings by the attached staff have declined to the level that the majority of them are not attending regularly. This was in contrast to the attendance rate of the rest of the primary care team.
It is not known from this questionnaire if the attached staff had educational events arranged for them centrally, separate from their primary care teams. Further research is needed to explore the attached teams’ perspective of PLT to see what the barriers and conflicts are that prevent them from participating regularly in practice-based PLT. It may be that their educational needs are met by other means. Also it is not known what factors encourage attached staff to attend some events but not others. A further difficulty highlighted by this research is the lack of networking between practice managers and the nursing managers attached to the CHPs. There is a need to strengthen communication links with CHP nursing managers in order to improve learning opportunities for the at-tached staff. Some primary care teams are not working in the same building as their attached staff, and help is needed to overcome this problem of communication if PLT is to flourish, and to enable team learning for quality improvement in patient care.
If primary care teams are to meet the expectations of the Scottish Executive then they may need to improve the ways in which they learn together.[1,3] This study has shown that not all teams are always learning together within PLT. If learning and planning services together does not take place, then teams will remain frag-mented. This study has shown that primary care staff may be working in a team but not as a team, and that teams may not be ready for collective learning. It may be more difficult to provide a comprehensive and seamless healthcare service as a result.
There are considerable barriers to the creation of quality education that involves all of the primary care team. Some of these issues are ingrained and cultural in type, and considerable change may be needed if primary care teams are to become learning organis-ations. Further work is needed to assess the educa-tional skills of practice managers in the CPD process, and how these can be improved. It is not known how varied their own educational and learning back-grounds are, and what impact this has on PLT within their practice.
Practice managers need more support from within the primary care team in order to provide quality edu-cation at practice-based PLT events. It cannot be assumed that all practice managers have the knowl-edge and skills to do this. In addition, there needs to be a change in the relationships between the core practice (GPs and the staff they employ) and the attached team.
If the attached team is not invited to practice-based PLT, do not feel welcome, or find events irrelevant then the struggle to provide team-based care will continue. More research is needed into the learning culture in primary care, and about how barriers to learning together may be overcome.
Ethical Approval was received from Ayrshire and Arran Research Ethics Committee (05/S0201/8). Re-search management and governance approval was granted by Ayrshire and Arran PCT.
The lead author is the chairman of North Ayrshire CHP PLT steering committee.