Professional and practice development plans for primary care teams

The spread between the best and the worst of the 10 000 practices in the United Kingdom is wide. In a matter of minutes we can travel from paperless practices with integrated teams which have developed nurse practitioners, physiotherapy, and in house phlebotomy to those where the prescribing is suspect and the consultations perfunctory—all performed with the sole aids of prescription pads, sick notes, and unchecked sphygnomanometers. Like the gap between evidence and practice, there is a gap too between continuing medical education and professional and practice development.

Professional and practice development plans aim to fill that gap and are destined to replace the postgraduate education allowance. The concept is a direct result of the Chief Medical Officer’s review of continuing professional development in general practice, which adds another surge of energy to the “corporate” rather than the “independent practitioner” vision of primary care. The review was a response to the criticism that the postgraduate education allowance has been based on an educational model which is “didactic, uni-professional and top-down,” rarely involves the whole practice team, and shows little evidence of any “convincing benefits to patient care.”¹

The postgraduate education allowance system, which enables general practitioners to obtain part of their income for, essentially, attending meetings, has a uniprofessional focus and allows doctors to play to their strengths rather than identify true educational needs.² Although attempts have been made to allow self directed learning, the system is based on a discredited didactic model³ that has more often provided the pharmaceutical industry with a convenient marketing opportunity.

Although there is little detail yet, professional and practice development plans are clearly a hybrid approach which combines documented personal learning with an organisational development framework. As Stanton and Grant’s review⁴ and other work⁵,⁶ confirms, “credit based” educational schemes do not lead to changes in behaviour or organisational improvements. Successful interventions contain features that predispose to, enable, and reinforce change—that is, that deliver information, rehearse behaviours, and provide reminders and feedback. Effective strategies also use contextual and motivational influences. Professional and practice development plans are likely to call for the construction of learning portfolios for all the practice team (doctors, nurses, and managerial staff) which take account of the development needs of the working unit as well as the individuals in it.² The plans therefore combine a systems approach to change management with self directed learning.⁷ They represent a gradual shift away from individual to organisational performance as a proxy measure for quality.⁸ The involvement of patients could strengthen the process, ensure local responsiveness, and guard against the loss of personal care.⁹

Asking practices to construct development plans will have significant benefits. Teamwork will be required if the plans are to represent a consensus view about how best to deliver organisational priorities. Perhaps nurses should become responsible for immunisation procedures?¹⁰ Should warfarin and lithium monitoring services be available? Does the appointment system provide reasonable access? Plans could become tools for measuring the achievement of priorities—a form of stepwise practice reaccreditation. By linking the professional development of individual practitioners to an organisational development strategy that recognises variable starting positions, professional and practice development plans could be the most effective lever for change in primary care yet devised.¹¹

But there are traps for the unwary. Firstly, will the funding be combined for those disciplines that work together in primary care? General practitioners have grudgingly accepted the postgraduate education allowance system, but practice nurses and managers bemoan that their training and professional development is in a mess, restricted by staff budgets and the goodwill (or otherwise) of their general practitioner employers. Community nurses do have access to professional advice but struggle to obtain a slice of hard pressed trust budgets. Will the funds for the postgraduate education allowance be diverted to team development as a carrot for taking part? General practitioners will have less argument with the new development plans if postgraduate education allowance money is preserved within net income.

Ensuring multiprofessional educational accreditation is no easier, as anyone who has tried arranging joint training events will know. The accreditation system for the postgraduate education allowance is an open book compared with the various nursing board procedures, which seem unwittingly to block the development of interprofessional learning.

The system will need enough flexibility to include part time professionals and to recognise individual learning that may not always be based on organisational requirements. But the main concern centres on how, and by whom, the plans will be supported. How will small or singlehanded practices cope? Moving away from a didactic uniprofessional educational system immediately creates the need for a new structure to facilitate, maintain, and appraise professional and practice development plans? General practice tutors and the structures for supporting primary care audit provide a basis for a new system and could be augmented by facilitators from the nursing and managerial professions, so that the artificial fence between “education” and “quality” may be finally dismantled. Primary care groups (and the Welsh and Scottish equivalents) could start by merging the community nursing and general medical services staff budgets and by creating and hosting development units for professional and practice development plans.