The educationalists formerly known as regional advisers are now directors. Why the change, and what do they do anyway? Jamie Bahrami explains

The regional adviser in general practice was born in about 1972,¹and died, though not without a fight, in 1996. The sole intention of its creation was to supervise vocational training for general practice, a new system of training that had been introduced, amid much acrimony, to improve the quality of general practice. The regional adviser was seen as the key person to implement the voluntary scheme and influence the attitudes of those in general practice and hospitals who were less than enthusiastic about it. Indeed, it was not until 1981 that the voluntary vocational training became a mandatory requirement for entry into independent medical practice.

Did the regional advisers achieve what was expected of them? There is no doubt that, despite the absence of any tradition of structured training in general practice and sometimes hostile opinion of the profession, they succeeded in establishing a good foundation for today"s vocational training.

	Commitments snowball

Top Commitments snowball Selected functions Appointing directors of... Working relationships The new contract The future References

Since 1972, the continual changes in practically every aspect of the NHS inevitably affected general practice education and training. These changes increased dramatically in the past decade, when the profession was suddenly faced with the paraphernalia of a market driven political ideology.² In addition, the gradual changes in vocational training (dictated by the Joint Committee on Postgraduate Training for General Practice),³ emergence of higher professional education, work on reaccreditation and recertification, consequences of the General Medical Council"s performance review procedure,⁴ and revised vocational training scheme regulations added to regional advisers" responsibilities. Not surprisingly, these new areas of responsibility affected the nature of the job by moving it away from an advisory remit towards an executive role within a tightly structured system of operation. These changes inevitably brought increased pressures for accountability in both academic and managerial functions. The job, which had started for most as a labour of love, became instead a demanding professional commitment.

It was against this changing landscape that the "old" regional advisers died. In their place 28 directors of postgraduate general practice education were appointed and were responsible for a wide range of functions (see box). They meet regularly as the committee of general practitioner education directors. This juxtaposition of words satisfies the national obsession with acronyms, in this case COGPED.

	Selected functions

Top Commitments snowball Selected functions Appointing directors of... Working relationships The new contract The future References

Career advice

Directors of postgraduate general practice education provide guidance and advice to those interested in general practice as a career, including students, and house officers, and those contemplating changing from a career in a hospital specialty. More challenging, in terms of career advice and counselling, are those doctors who, despite appropriate qualifications and experience, cannot progress beyond their current grade in their chosen specialty and wish to change to general practice.

Increasing numbers of doctors from the European Community and overseas require advice about vocational training, work, and immigration regulations in the United Kingdom. Directors need to show a full grasp of the subject and each doctor"s particular situation and circumstances, and their approach needs to be sensitive and impartial.

Underperforming doctors

With the introduction of summative assessment at the end of vocational training, some general practitioner registrars either fail (about 3-5%) or are flagged as underperforming in their training post, and the directors have the ultimate responsibility for their management. This means working, in accordance with a defined protocol, with trainers (general practice and hospital), course organisers, and others who have known and worked with the registrars concerned. It requires review meetings, counselling sessions, and ultimately arranging appropriate remedial or additional training to address the registrar"s learning needs. Throughout this process, a director must consider the legal implications of his or her actions, which can be serious.

In addition, doctors may be referred to their director of postgraduate general practice education by the GMC under the performance review procedure. This has become one of the most time consuming aspects of a director"s work. Similarly, health authorities have been referring increasing numbers of general practitioners whose performance is causing concern for mentoring and specific training. Without additional resources at the deanery (financial and human), the directors could become swamped by this growing area of responsibility.

Commissioning education

Directors manage the selection and appointment of trainers, course organisers, general practitioner tutors, and, of course, the general practitioner registrars. All appointments have to be made in accordance with the joint committee"s policy for approval and reapproval of trainers and national templates for the appointment of the others. With increasing concern about the quality of some general practitioner registrars, directors are now expected to focus on the arrangements for such appointments.

	Appointing directors of postgraduate general practice education

Top Commitments snowball Selected functions Appointing directors of... Working relationships The new contract The future References

Posts are advertised nationally, and the process of selection and appointment is based on a national template. This involves the local university, regional office, and, because of the importance of the job, the NHS Executive representatives. The contract of appointment is normally for five years but is renewable subject to satisfactory university based annual appraisal.

Although the post is full time, in some deaneries (particularly smaller ones) the post holder is allowed to have clinical sessions in general practice.

	Working relationships

Top Commitments snowball Selected functions Appointing directors of... Working relationships The new contract The future References

A director works in partnership with the local dean of postgraduate medical education. Any tension in this relationship can have devastating consequences for the individuals, deanery, and the educational network for which the dean and director are responsible. In this partnership (which can suffer from conflicts over sharing of resources or undue and inappropriate interference in each other"s area of work) a skilled manager at the deanery has an important role in "cementing over the cracks" and helping the director and dean to manage resources efficiently and equitably.

The director also works with colleagues involved in the educational network. Locally, they include course organisers, general practitioner tutors, trainers (general practice and hospital), clinical tutors, college tutors, postgraduate centre managers, primary care groups, health authorities, and trusts. Nationally, the director liaises with the NHS Executive, Royal College of General Practitioners, Joint Committee of Postgraduate Training in General Practice, and General Practitioners Committee to mention but a few.

Lastly, the director relies heavily on his or her deputies (sometimes referred to as associate advisers or directors) for the routine management of the network. Currently, there is some debate about the role and function of the deputies, which tend to vary from deanery to deanery.

	The new contract

Top Commitments snowball Selected functions Appointing directors of... Working relationships The new contract The future References

The new contract was agreed in broad terms some three years ago. It was based on the concept of dual accountability to the university and the regional office for specific areas of responsibility. However, neither party has signed this contract yet, although it has been implemented in practice.

	The future

Top Commitments snowball Selected functions Appointing directors of... Working relationships The new contract The future References

With the increasing range of responsibilities expected of the directors, their future, alongside that of the deans, seems reasonably secure. However, in the present climate of continuous organisational review and change, this cannot be taken for granted.⁵