Quality in Primary Care 2006;14:225–33 # 2006 Radcliffe Publishing

Research paper Protected learning time in general practice: a questionnaire study of practice managers’ perceptions of their role David Cunningham BA MB ChB MPhil FRCGP 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

ABSTRACT Introduction Government recommendations have their role to plan and prepare practice-based events. encouraged the primary care team to learn together However, only 11% of managers felt it was their in order to improve both teamworking and the responsibility to arrange educational events that quality of care for patients. Protected learning time included the attached team of health visitors and (PLT) has become an established method of learn- district nurses. They also reported that the attached ing for many primary care teams. PLT offers teams team only attended a minority of practice-based the potential of learning together by providing time PLT events. that is protected from service delivery. Practice Conclusion Practice managers need more support managers are often tasked with the organisation of from within the team when planning and preparing practice-based PLT events for the primary care team. PLT, and need help to overcome the exisiting bar- Aims The aim of this research was to elicit the riers that prevent learning together with the at- perceptions of practice managers about their role in tached team. Primary care teams and primary care this task. organisations who fund and commission PLT need Methods A 16-statement questionnaire was de- to work differently if they are to improve practice- vised and emailed to the practice managers of 56 based PLT. general medical practices that take part in PLT within NHS Ayrshire and Arran. Keywords: continuing professional development, Results A response rate of 90% was achieved. The medical education, practice-based learning, pri- results showed that managers considered that it was mary care team

How this fits in with quality in primary care What do we know? Protected learning time (PLT) has become a popular method for primary care teams to learn together. Practice managers are often tasked with the organisation of practice-based events. Research has shown that some practice managers find the organisation of events difficult. There are also problems organising events which include the attached team of health visitors and district nurses. What does this paper add? This paper shows the opinions of practice managers in one primary care trust with regards to PLT, with particular focus on their role in organising practice-based PLT events. Practice managers want PLT to continue and they are generally positive about the impact of PLT on the practice team. They do not think it is their responsibility to organise events for the attached team. 226 D Cunningham, C Stoddart and D Kelly

Introduction 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 The Scottish Executive’s plan for health care involves a Education for Scotland (NES) is a special health board shift in emphasis from acute secondary care to pri- and advises other health boards within NHS Scotland mary care with the expectation that more complex on educational matters. Two NES associate advisors in care will be provided by the primary care team rather continuing professional development have given ad- than just by general practitioners (GPs). Some of these vice to the three CHPs within NHS Ayrshire and Arran challenges include increasing levels of health pro- on the development of PLT. motion, anticipatory care and chronic disease man- An unpublished evaluation (2003) of two PLT 1 agement within communities. It is clear that much schemes managed by North and East Ayrshire CHPs change in healthcare delivery is anticipated, and it is was undertaken by the first author. This evaluation likely that teams, who learn together and from each showed that GPs and practice nurses valued PLT other, may be better equipped to meet the challenges highly, but that attached staff (health visiting and set by this plan. district nursing teams) valued it less. Similarly admin- Government recommendations encourage team- istrative and clerical staff (A&C) and practice man- based learning within primary care as a way of improv- agers did not share the enthusiasm of the GPs and ing the quality of care and range of services offered to practice nurses within the team. 2,3 patients. These recommendations are also supported Free-text comments submitted by practice man- by established educational theory, which emphasises agers as part of the evaluation alluded to their per- the need to develop the whole team rather than just ceived difficulties in planning and preparing for 4 single professional groups. practice-based PLT educational events. A qualitative Protected learning time (PLT) has become an estab- focus group study involving practice managers cor- lished method of learning for primary care teams in roborated these findings, and emphasised the diffi- many parts of the UK. It was introduced to primary culties faced by practice managers.15 The extent to care by schemes such as TARGET (Time for Audit, which other practice managers within NHS Ayrshire Reflection, Guidelines, Education and Training) from and Arran agreed with some of the issues raised was Doncaster and Portsmouth, and CREATE (Clackman- not known. nanshire Resource for Education, Audit and Team Thus a questionnaire study was commissioned to 5,6 working) from central Scotland. Many primary care elicit the perceptions of practice managers in NHS organisations have used PLT to allow teams to have Ayrshire and Arran towards practice-based PLT events. time dedicated to learning. The aims of the study were to: There is some evidence of clinical and service . improvements from PLT schemes and that PLT can quantify practice managers’ perceptions of their provide time to teams for problem-based learning.7–9 responsibilities in organising PLT practice-based Evaluations of PLT schemes are few but generally events for different members of the primary care positive.6,10–12 PLT has also allowed teams to focus team . on improving the quality of the services they provide gauge whether practice managers felt they had and enabling team members to learn from each enough time to organise for practice-based PLT other.13 It has been shown that some practitioners in events . primary care are ready to learn from each other by elicit practice managers’ estimates of how many engaging in interprofessional learning within PLT.14 of the primary care team were regularly attending None of the published PLT evaluations has focused practice-based PLT events . on the role and responsibilities of practice managers establish whether evaluations of PLT practice- with regard to the planning and preparation of practice- based events were being performed, and whether based PLT educational events.6,10–12 Practice man- they influenced further educational activities . agers are often tasked with arranging practice-based quantify how many practice managers felt PLT educational events, and these make up the majority of should continue. sessions within PLT. Practice managers’ perception of their role in planning and preparing for practice-based PLT educational events is not known. Method 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 A questionnaire was developed by the authors based serves a mixed population of rural areas and small on previous comments from practice managers and towns, and has a degree of deprivation. Practices A&C staff.15,16 Sixteen statements were devised, and usually have six or seven practice-based educational respondents were asked to indicate whether they Protected learning time in general practice 227 strongly agreed, agreed, disagreed or strongly dis- for any other purpose, and a guarantee was given of agreed to the statements. A ‘don’t know’ option was confidentiality and anonymity. Two reminders were also given. It was decided not to use a neutral option in sent at weekly intervals. The web-based questionnaire the scale so as to encourage participants to give an was closed three weeks after the initial introductory opinion. Free-text comments were also encouraged email. for the last two statements, so that managers could Data were collated from the website and converted provide more detailed replies. into an Excel spreadsheet and tables constructed. Free- Statements in the questionnaire were grouped into text comments were collated and interpreted using five themes. Practice managers were asked to: thematic analysis.18 The comments were read and reread, and sorted into themes. . 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 Results events for different members of the primary care team. The team was considered to be made up of There were 58 general medical practices in NHS A&C staff, attached staff (of district nurses and Ayrshire and Arran at the time of the study. Two health visitors), GPs, practice managers and prac- practices did not take part in PLT and two practices tice nurses learned together as they were about to merge to . estimate the level of attendance of the different become one larger practice. Four small practices, members of the primary care team at practice- located on an island, pool resources and learn together based PLT educational events (it was clear from and replied as one unit. Forty-seven practice managers informal communications with practice managers completed the questionnaire out of a potential 52 and CHP managers that registers of attendance practice managers who are involved in PLT, giving a were not always kept for practice-based PLT edu- response rate of 90%. cational events) The proportions of practice managers who agreed . estimate the percentage of practice-based edu- with 14 of 16 statements are outlined in Table 1. The cational events that they had evaluated and results of the remaining two statements are incorpor- whether these evaluations had resulted in change ated into the text below. to future educational events The practice managers’ estimates of attendance at . express an opinion as to the overall value of PLT, practice-based PLT educational events for various their opinion on which members of the primary groups showed a wide variation. Their estimates for care team benefited from PLT and their opinion those members of the team who attended 76% or more concerning whether PLT should continue. of the events were: health visitor 9%, district nurse A copy of the questionnaire is shown in the appendix. 15%, GP 70%, practice nurse 73%, A&C staff 87% and The questionnaire was piloted with six practice practice manager 90%. managers (approximately 10% of Ayrshire and Arran Practice managers’ estimates of the proportion of practice managers) who completed it, and gave their practice-based educational events that had been comments on ease of completion and clarity of the evaluated were: questions. The six practice managers in the pilot were . 0–25% of meetings: 8% well known to the first author as they worked in his . 26–50% of meetings: 30% locality, and it was hoped that they would give frank . 51–75% of meetings: 39% feedback. As a result of the practice managers’ com- . 76–100% of meetings: 17% ments, minor amendments to the wording of the . no answer: 6%. statements were made to increase their clarity. The questionnaire was then converted to a web-based Analysis of the questionnaire results showed that 59% questionnaire and linked to the NES website.17 of practice managers considered that they had enough Practice managers from practices who took part in time to organise educational events. The majority of PLT were sent an introductory email from the authors respondents perceived that the organisation of edu- in April 2006, explaining the nature of the research cational events was their responsibility, for practice and containing a hyperlink that took them directly to nurses (79%) and GPs (76%). In particular 96% of the web-based questionnaire. They were asked to enter respondents agreed or highly agreed with the state- their unique NHS practice-identifying number as a ment about their responsibilities for organising edu- way of preventing duplication of entries and to iden- cation for A&C staff. In contrast, only 11% of practice tify practice managers who had not responded to the managers thought it was their responsibility to do this first invitation. This identifying number was not used task for the attached staff. 228 D Cunningham, C Stoddart and D Kelly (%) No response n (%) Don’t know n (%) Strongly disagree n (%) Disagree n (%) Agree n (%) 9 (19)9 (19) 27 (57) 28 (60)0 (0) 5 (11)0 (0) 5 (11) 4 5 (9) (11) 21 (45) 3 (6)2 (4) 22 (46) 1 (2) 11 (23) 1 28 (2) (61) 14 (30)5 (11) 1 (2) 4 (9) 11 (23) 1 (2) 5 12 (11) (26) 10 (21) 0 (0) 1 12 (2) (26) 1 (2) 3 3 (6) (6) 3 13 (6) (27) 2 (4) 20 (43) 25 (53)14 (30) 1 (2) 30 (64) 011 (0) (23) 2 (4) 27 (58) 0 (0)13 (28) 0 (0) 4 (8) 1 32 (2) (68)17 (37) 1 (2) 1 (2) 2 (4) 22 (47) 0 (0) 3 (7) 0 (0) 2 (4) 1 (2) 0 (0) 1 (2) 0 (0) 4 (8) 1 (2) n I have enough time to organise PLT educationalIt is events my responsibility toPLT organise educational training events for the doctors at It is my responsibility toat organise 2 PLT training (4) educational for events practice nurses It is my responsibility toat organise PLT training educational for events the A&C staff It is 26 my (55) responsibility toat organise PLT training educational for meetings attached staff The primary care team valueseducational my events efforts 16 in (35) organising PLT All the primary care teammeetings are invited to PLT educational Evaluation information is 3 used (6) toteam plan PLT future educational primary meetings care I think that practice-based clinicaleducational staff meetings benefit from PLT I 0 think (0) that attached staffmeetings benefit from PLT educational I think that non-clinical staffmeetings benefit from PLT 0 educational (0) I think that managers benefit from PLTI educational think meetings that PLT is worthwhile 9I (19) think primary care teamcontinue PLT educational meetings should 21 (46) 12 (25) 16 4 (34) (8) 24 (52) 1 (2) 4 (8) 0 (0) 1 (2) 2 (4) 0 (0) Table 1 Statement Strongly agree Protected learning time in general practice 229

There were clear differences in the practice man- ‘They should continue as long as topics are both edu- agers’ opinions of who they thought benefited from cational and informative for those in attendance. We practice-based PLT educational events. Eighty-one generally try to stay in-house due to mishaps in the larger percent of practice managers agreed or strongly agreed events. Thus we are able to arrange meetings to suit the that practice-based clinical staff (GPs and practice needs of the practice.’ nurses) benefited from these events; 96% thought ‘I am not convinced that for A&C staff there are enough that non-clinical staff (A&C staff and practice man- subjects which can be planned for group learning/training agers) benefited; but only 37% felt there was a benefit at specific PLT meetings. I prefer to see individuals given for attached staff. In general, practice managers con- time to develop their own training and learning needs.’ sidered that PLT was worthwhile (86%), and they also ‘I think the whole concept of PLT is essential in a general thought PLT should continue (84%). practice setting. I do however have difficulty in organising Free-text responses were invited to give further training for the attached staff within the practice, except details about whether PLT should continue, and for when it is clinical, e.g. CPR [cardiopulmonary resusci- further feedback generally. Twenty-five out of 47 tation].’ practice managers entered free-text comments into the online questionnaire. It was decided to analyse the data from both responses together. Eighty percent of Learning with the attached team comments were essentially positive about PLT. The Practice managers raised concerns about their re- main themes of the responses are considered under the sponsibilities with regard to planning and preparing headings that follow. practice-based PLT events for attached staff. They felt that they did not always know their learning needs. Practice-based events provide an There were also concerns about poor communication opportunity for the entire team to and the lack of joint planning between practice man- learn together agers and CHP nursing managers. ‘I do appreciate that the whole of the primary care team Some practice managers felt that practice-based PLT should have an input into in-house events, but practice events were the only time when the whole team could managers do not know the training needs of district come together to discuss their work and plan changes nurses etc. It would be helpful if practice managers could for the future. A dominant theme in the free-text have support, perhaps from nursing managers.’ comments was that this time was valuable and would ‘I don’t mind organising the events, what I do mind is be missed should PLT end. organising events with community staff in mind then ‘It is the one time we can all come together without finding out at the last minute that training has been constant interruption. Dedicated time without the worry arranged elsewhere for them. [This is] something that is of visits, telephone calls or having to be somewhere else happening more and more these days.’ has to be a bonus for all of us taking part.’ ‘I agree that they should continue as it is a good way of ‘This is the only time that all the GPs, practice staff and getting the whole team together – find the community attached staff get the opportunity for networking and staff don’t always attend and also find it difficult to cater learning.’ for all disciplines especially community staff (maybe [there could be] better links with community staff man- ‘PLT educational meetings provide valuable training and ager).’ updates from clerical staff through to the GPs. The fact that a complete afternoon is dedicated to this certainly makes a difference.’ Discussion Relevance of topics in practice-based events This study set out to elicit the perceptions of practice A dominant theme expressed was that practice-based managers about their role in practice-based PLT and events were usually considered more relevant to the the study achieved this aim. It also adds to the team than those topics chosen for larger centrally literature on PLT with a particular focus on practice organised meetings. However, several practice man- managers. agers raised the issue that it was difficult for them to There were various strengths of the study. One plan and prepare practice events that were relevant for strength was the use of a pilot to clarify the wording the entire team. and ease of completion of the questionnaire. The questionnaire had a very good response rate (90%).19 This was perhaps aided by the use of a web-based 230 D Cunningham, C Stoddart and D Kelly questionnaire and email, which seemed a fast and to the attendance rate of the rest of the primary care effective way of collecting data. Responses from prac- team. tice managers were based on a considerable experience It is not known from this questionnaire if the of practice-based PLT educational events, as most attached staff had educational events arranged for practice managers in NHS Ayrshire and Arran had them centrally, separate from their primary care teams. been involved in PLT for four or five years. This period Further research is needed to explore the attached of time had allowed PLT to become embedded into teams’ perspective of PLT to see what the barriers and practices, and thus the responses should reflect on the conflicts are that prevent them from participating sustainability of PLT and on maintaining momentum. regularly in practice-based PLT. It may be that their There were several weaknesses to the study. Practice educational needs are met by other means. Also it is managers were asked to estimate the attendance of not known what factors encourage attached staff to different members of the primary care team. Their attend some events but not others. A further difficulty responses were subjective and based on their opinions highlighted by this research is the lack of networking and memory. They were not asked to examine records between practice managers and the nursing managers of attendances which, if taken, might have been more attached to the CHPs. There is a need to strengthen accurate. There was no independent means of verify- communication links with CHP nursing managers in ing their responses. There is a possibility that practice order to improve learning opportunities for the at- managers may have over- or underestimated attend- tached staff. Some primary care teams are not working ance of the various members of the primary care team in the same building as their attached staff, and help is as a result. Practice managers were also asked to report needed to overcome this problem of communication whether they evaluated practice-based PLT events and if PLT is to flourish, and to enable team learning for also whether they used that evaluation information for quality improvement in patient care. further planning. We did not ask practice managers If primary care teams are to meet the expectations of for evidence to support their responses to these two the Scottish Executive then they may need to improve questions. It was possible that they may have responded the ways in which they learn together.1,3 This study has to indicate a view that they perceived as being the right shown that not all teams are always learning together response, rather than an honest one. within PLT. If learning and planning services together There was no neutral option in the questionnaire does not take place, then teams will remain frag- given to practice managers. This may have encouraged mented. This study has shown that primary care staff practice managers to form an opinion, but it is pos- may be working in a team but not as a team, and that sible that some indicated ‘don’t know’ or left this teams may not be ready for collective learning. It may response blank when they would have preferred to be more difficult to provide a comprehensive and have indicated a neutral response to the statement. seamless healthcare service as a result. Practice managers felt strongly it was their responsi- There are considerable barriers to the creation of bility to arrange education for A&C staff, even more so quality education that involves all of the primary care than for the GPs (who employ them) or for practice team. Some of these issues are ingrained and cultural nurses. That they did plan and prepare education for in type, and considerable change may be needed if most of the team does reflect the increasingly import- primary care teams are to become learning organis- ant role of practice managers in modern primary care, ations.20 Further work is needed to assess the educa- and illustrates their willingness to take on new work. tional skills of practice managers in the CPD process, It was clear from the survey that most practice and how these can be improved. It is not known how managers considered it was their responsibility to varied their own educational and learning back- organise training for most of the primary care team grounds are, and what impact this has on PLT within except the attached team. Some of the free-text re- their practice. 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 Conclusions it difficult to arrange meetings that would interest the attached members of the team. This was possibly as a Practice managers need more support from within the result of not knowing the attached staff members’ primary care team in order to provide quality edu- learning needs, or not knowing what the attached cation at practice-based PLT events. It cannot be staffs members’ roles fully entailed. As a result, at- assumed that all practice managers have the knowl- tendances at practice-based meetings by the attached edge and skills to do this. In addition, there needs to be staff have declined to the level that the majority of a change in the relationships between the core practice them are not attending regularly. This was in contrast (GPs and the staff they employ) and the attached team. Protected learning time in general practice 231

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Appendix 1 Protected learning time in general practice 233