Introduction

The Department of Health and General Medical Council recommended that medical services and undergraduate medical education should change from being hospital based to being community based. ^{1 2} We devised a course to enable medical students at the University of Leicester to experience the health needs of society and the community based organisations whose actions affect people's health, in preparation for working in the multidisciplinary teams of the future.

Published accounts of changing to community orientation in the medical curriculum warn of difficulties.³ The challenge increases with the integration of non-health statutory and voluntary organisations into the curriculum to reflect policy initiatives that give impetus to multidisciplinary collaboration for health. ^{4 5} In line with recommendations of the World Federation for Medical Education,⁶ we believe that students and community organisations should be involved in developing a community based course (which should be based on sound teaching principles) and that such a course should be supported by the university's faculty of medicine and the local NHS community trust.

We describe the background, development, course structure, course delivery, assignment outcome, and evaluation of the first community oriented, multiagency, problem solving course for third year medical students at Leicester.

	Method

Background to development of course
The course operates in the St Matthew's inner city housing estate, Leicester. The estate, with a ward Jarman index of 64.1, has substantial housing problems, social disadvantage, and unemployment, and many residents have unhealthy lifestyles. A multiagency approach to these problems resulted in the establishment of a centre through which statutory and voluntary organisations and residents communicate more effectively. Multiagency teaching experiences for professionals are provided, and this course is one outcome of this collaborative work.

Development of course
A proposed structure developed by the authors on problem based principles ^{7 8} was presented to members of student and staff committees and to 16 of AL's teaching groups from years 1 and 2. The proposal included the outline course, including objectives, teaching method, clinical presentations, agencies involved, timetabling, presentations, assessment, and feedback. The purpose of the course and its place in the curriculum were explained. Students understood that they were to refine the course. Their reactions were gauged with a semistructured questionnaire incorporating a 5 point Likert scale. Students were also free to add comments.

Course objectives
The aim of the course was to use the social and behavioural sciences and the humanities to enable students to gain a richer understanding of the individual patient: to show the range and roles of professionals working to meet the health needs of the population; to develop in the students an understanding of the contribution of economic, practical, and environmental factors in the causes and prognosis of illness and in the use of services; and to provide learning experiences and an exposure to diverse common health problems not normally seen in secondary health care.

Course programme
The medical students took the course in semester five. About a third of their curriculum had been spent studying human behaviour, psychosocial aspects of health, epidemiology, and communication skills. For the course the students worked in groups of three or four, but were part of a larger cohort of 24. 

Patient case mix
Table 2 shows the details of the case mix. Criteria used for selection of case mix were (a) wide age range; (b) a range of patient compliance; (c) a range of diseases (physical and mental); (d) social consequences of illness (poverty, unemployment, single parenthood, and isolation or loss of independence); (e) patients articulating health priorities differing from those of the community services; and (f) patients involved with various community organisations.

Feedback
A questionnaire requesting feedback was distributed to all participating students at the end of the course. The questionnaire asked about the course structure, teaching method, tutor, suitability of the patients and agencies, and presentations. It also asked students to comment on the future development of the course, its place in the curriculum, and links with theoretical teaching. A 5 point Likert scale was used for responses (only positively phrased questions were asked). Students were invited to add comments throughout the questionnaire.

	Results

Assignment outcome
In all, 168 students completed the course within two months. The key components to be considered in management were included in the students' workbook. The assignment was marked against a criterion referenced, three point scale (box). In addition, case specific priorities, judged by the authors, were required to be incorporated into the management plan.

Evaluation of course

Student feedback
Altogether, 166 (99%) students completed the questionnaire. Results are summarised in table 3. The students responded positively to all aspects of the course. In all, 432 written comments were recorded, an average of 2.6 per student.

Of the 106 students who commented on the teaching method and structure of the course, 74 made positive comments; 20 of the 28 negative comments cited a lack of time. No negative comment was made by any student on the role of the tutor, and 45 students chose to compliment the work of the tutors.

Thirty of the 33 students who commented on their patients praised their role. Thirty eight students commented on the role of the agencies; many students (14) highlighted the problem of interviewing agency representatives who were not directly involved in their patient's care. Twenty students commented on the format and educational experience, 15 of whom offered praise. The negative comments applied to the time constraints.

In all, 149 students felt that the course linked their theoretical teaching with the practical experiences gained in the community, at an appropriate time in the medical curriculum. Altogether, 159 students wanted the course to continue in the present format of hands-on practical experience. In all, 154 students commented on this subject: 146 of their comments were positive; 66 students felt too pressurised because of the time restrictions of the course, limiting the potential benefit of their experiences; in contrast, 20 students felt positively challenged.

Patient feedback
Patients unanimously supported the course and their involvement in it. All would repeat this experience, describing their interviews as interesting and enjoyable. The agoraphobic patient felt an increased self confidence, describing the course as therapeutic. No patient felt harmed, even though the subject matter was at times distressing and probing in nature.

Agency feedback
All the agencies felt adequately prepared for their role in the course, most noting the time constraint of the interview as appropriate, challenging students to be time efficient. All were able to facilitate students to achieve the course objectives and show the impact of interagency communicationpositive and negative. Most participants found that the course had an impact on their clinical commitments, but all were willing to participate in future courses.

	Discussion

We have developed a viable mechanism through which to address the recommendation of the General Medical Council to prepare the doctors of tomorrow to handle society's medical problems.

The students' enthusiastic responses are encouraging. Many described gaining valuable and relevant medical experiences, in particular a greater awareness of psychosocial factors in the causes and management of illness. The students' responses show that they felt that the objectives of the course were achieved and that teaching and learning experiences were successfully delivered. Their success in the course assessment confirms this. Many students asked for the course to be expanded, and this should be possible to do. We believe that the experiences gained by these students will increase their ability to access and use community organisations after qualification.

We accept that all the participants in this study may have performed better than usual ("Hawthorne effect"), and this may have helped in the success of this venture into multiagency medical student training. We believe that the further development of a supporting infrastructure will establish this course, with the Fosse Health (NHS) Community Trust being ideally placed to fulfil this role. The course has subsequently run succesfully in an expanded form.

We continue to run the course at Leicester University, and its success depends on many factors. Firstly, medical students and the multiagency network of community organisations in the St Matthew's housing estate were closely involved in the planning of the course; the community organisations also help us to implement the course. Secondly, the course focuses on relevant, high priority, community oriented problems and builds on the students' learning experiences over the first four semesters. The teaching method of problem based learning is ideally suited to this student directed learning experience. Thirdly, the University of Leicester values and supports this development, resolving difficulties in timetabling and ensuring the course is integrated into the curriculum. Fourthly, the Fosse Health (NHS) Community Trust facilitates the implementation of this course, providing the tutors and many of the agency representatives. Fifthly, the participation of non-medically qualified tutors is successful. Our health visitor tutors are knowledgeable about community organisations and have the right combination of professional and teaching skills. Students showed overwhelming support for this facilitation, and it is generally thought that medical students who are "taught" in an interagency environment will integrate more successfully into multidisciplinary teams. ^{9 10} Sixthly, the course is facilitated by funding from Service Increment for Teaching.¹¹ Finally, St Matthew's estate is a community within easy reach of the university. Students can therefore experience the medical problems of a society in a small geographical area.

This course has tapped the potential for community based, multiagency education in primary care for medical students in Leicester. The course has been implemented with minimal inconvenience to agencies yet provides a quality experience for all third year students. We hope that our experience will produce a useful model for colleagues in other medical schools who are striving to meet the same objectives.