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BMJ No 7104 Volume 315 Editorial Saturday 9 August 1997 Educating doctors, to improve patient care A choice between self directed learning and sitting in lectures struggling to stay awake See p 353 The postgraduate education allowance for general practitioners in the UK was introduced in 1990, amidst the turmoil of the "contract row" between the secretary of state for health and general practitioners. It makes up just under 5% of general practitioner' intended net remuneration, replacing direct reimbursement of educational expenses under "section 63" with a payment to which conditions are attached. To qualify for the allowance, general practitioners must satisfy regulations of byzantine complexity, the essence of which is the requirement to attend 30 hours of approved continuing education in each of the previous five years. Educational theory, supported by research and most people's experience, suggests that active learning - in small groups, using interactive computer packages, or even reading - is more likely to change clinical behaviour than sitting in large lecture theatres struggling to stay awake. But for many general practitioners, the allowance poses bureaucratic hoops through which they jump with the minimum possible effort and cost. Lectures, ideally free and therefore sponsored by drug companies, are the easiest way to do this. A paper in this week's BMJ suggests that more and more general practitioners take this route (p 353).(1) The authors suggest that educational expenses should be directly reimbursed. The London initiative zone educational incentives programme (LIZEI), which was intended to help develop primary care and improve morale among general practitioners, provides valuable experience of this direct approach. Since 1995, general practitioners in the London initiative zone who produce a personal development plan can obtain funding for educational costs and protected time. They have to make clear what impact their plan will have on patient care and how they will measure this. It is too early to tell whether the London initiative zone educational incentives programme will improve patient care; but even asking doctors to think about the impact they expect their education to have on patients is a step forward. It is not, however, cheap. Considerable educational support is needed to develop and implement an effective education plan, and it often encourages the more expensive forms of education such as Master's degrees, diplomas, or the membership exam for the Royal College of General Practitioners. The government has recognised that the postgraduate education allowance is unsatisfactory, and the chief medical officer is currently conducting a review. Devising a satisfactory new system will not be easy. Direct reimbursement of expenses is not without problems. Section 63 covered course fees, travel, and subsistence, and general practitioners could choose which if any courses to attend and where to study. Some obtained great educational benefit at reasonable cost, some took no public part in continuing education, whilst others travelled to distant parts of the UK at public expense for their courses. There was no attempt to link the costs to benefit to the NHS. The postgraduate education allowance has at least ensured almost universal participation, and has largely avoided accusations of sleaze which would no doubt be rampant if the system had continued unchanged. The purpose of continuing medical education is the improvement of services to patients. The refreshment of professional enthusiasm that comes from interacting with colleagues and encountering new ideas is only a means to that end, albeit worthwhile in itself. Section 63 and the postgraduate education allowance both emphasise process rather than outcome, largely because it is easier to measure. There are no free lunches, and if the NHS pays for general practitioners' continuing education then it has a right to expect evidence that this is likely to improve patient care. However, professional leadership and freedom of choice are essential if education is to generate the enthusiasm needed for it to be effective. Striking the right balance will not be easy. The allowance's arbitary classification of educational activity, and the incomprehensible concept of a "course" of study, stem from the scheme having been introduced unpiloted and without sufficient forethought. The London initiative zone educational incentives programme too has faced problems resulting from lack of advanced planning and preparation. There must be time for any new system to be thoroughly planned, and for those who have to make it work to understand its philosophy and its mechanisms. Only thus will we avoid jumping out of the frying pan into the fire, and have a continuing professional development system to deliver "a service with ambition."(2) Peter Toon General practitioner 206 Queensbridge Road, London E8 3NB (petertoon@aol.com) References 1 Murray T S, Campbell L M. Finance, not learning needs, makes general practitioners attend courses: a database survey. BMJ 1997;315:353. 2 Secretary of State for Health. The National Health Service. A Service with Ambition. London: HMSO, 1996. Home | Current issue | Past issues | Classified ads | Career Focus | Feedback Collections | About this site | About the BMJ | BMA | Medline