The wider picture

An ambitious interprofessional programme sought to teach healthcare staff about the wider issues of clinical governance.Jody Raynsford explains It is no mean feat to develop a training programme that leads to a direct improvement in patient care. And it takes vision to deliver and evaluate this consistently across an area the size of London, on a flexible basis and using existing resources by training doctors, nurses and other professionals together.

The joint programme by five of London's workforce development confederations and the London Deanery, which is responsible for postgraduate medical and dental training in the capital, was shortlisted for last year's HSJ Awards for its ambitions and objectives, not least because of the enthusiasm of those driving it.

The programme, Managing Life in the NHS: educating towards clinical governance, sought to address the importance of understanding the wider aspects of patient care to ensure quality improvements and initiatives make an impact. It took as its basis the belief that, traditionally, training in the NHS was geared to specific patient care and within the framework of a particular profession. Equipped with a wider understanding, professionals would be better able to support clinical governance.

Explaining the philosophy behind the programme, dean of postgraduate medicine Dr Shelley Heard says: 'In many ways, clinical governance was a way of making sense of a group of disparate activities that didn't quite work well together and where the accountability was very dispersed. Our motive was to build a curriculum which people think is important in getting these things across.'

In 1998 the consortia and London Deanery undertook a survey across the north Thames area to identify training being delivered. 'We went to all trusts in the patch and asked what sort of general training they were doing, who they were offering it to and who was taking it up, ' says Dr Heard. Although 30 different areas of training were being offered to all staff, very few medical staff participated in training that was not specifically focused to their profession.

To develop the findings, a steering group was set up, consisting of the organisations which provide postgraduate education for the various professions. Now five years old, its first task was to develop an interprofessional curriculum to encourage and support all healthcare professionals to train together, with a target of an equal number of doctors, nursing staff and other health professionals making up the course numbers.

The group recommended that the programme focus on three key elements - knowledge, skills and attitudes to learning about clinical governance.

Each element would be delivered as a five-day module, so the whole 15-day programme could be staggered over a long period of time and across locations, if needed.

The programme offered flexible, multiprofessional training delivered locally but with London-wide evaluation and objectives and funded from existing resources.

'The draft curriculum was developed off the back of the needs analysis and a consultation document went out to the service asking their views, ' explains Dr Heard, adding that this included employers of healthcare workers, the consortia and other interests.

'We developed the specific learning aims and objectives for each of the modules, but the main principle of the programme was that standards set by the steering group were Londonwide standards, but with local delivery.'

The modular nature of the programme aligns with a need for a flexible training regime, acknowledging the peripatetic nature of healthcare professionals in the London area.

'There was recognition of the unique character of the healthcare workforce in its mobility by having the programmes locally delivered, ' continues Dr Heard.

In evaluating the delivery of the programme and the impact on patient care, the workforce development confederations and London Deanery took a novel approach.As well as inviting feedback on questionnaires after each day of training, at the end of each five-day module professionals were asked four 'key' questions.Dr Heard explains:

'The four crunch questions were important because it said: did you improve your understanding of governance, is it going to make you work better in a team, is it going to influence how you treat patients in the future, and would you recommend it to a friend?

'We could therefore look at programmes across the patch and we could say our quality evaluators were the end users - if they do not think the education is going to do much for them, then it is unlikely to.'

The evaluation of Managing Life in the NHS was published in 2002, with 200 five-day modules having been examined, amounting to over 1,300 training days. Results were impressive, with the second, third and fourth questions achieving positive results from 96 per cent, 97 per cent and 99 per cent of end users respectively.

Even though the first question received a 92 per cent positive rating, there was some concern when compared with the other figures. One particular training module was identified as falling short and the group was able to act on it quickly.

Despite concerns that five-day module blocks were difficult for nursing staff with little training allowance and high replacement costs, Dr Heard explains the explicit motives of steering group members in rejecting the idea of delivering modules as five oneday courses.

'The steering group felt strongly, and the evaluation has showed, that one of the big benefits was people sitting in a room together from different professional backgrounds.

'It is pretty hard to sit in a room and not engage with people if you are there for five days.We were very keen that people became engaged in this, and that meant spending time together.'

Faced with the challenge of time constraints on nurses, the steering group is already looking to respond to this - 'the programmes have evolved and we are now looking at a nine-day programme'. Other challenges seem more ominous as greater numbers join the programme:

'The educational framework is there, but It is the capacity and the numbers that are always the problems.'

But in discussing the future, Dr Heard talks positively about the potential impact of the initiative on the foundation programme: 'The next really big stage will be whether it is appropriate to form a generic curriculum for the foundation year and whether we can be extremely clever and still deliver it on a multiprofessional basis.

'What was really exciting and unique about this programme, and a London-wide strategy, was that it would be quite easy to do this on a national basis. I hope to hear there is a national foundation curriculum with national standards but delivered locally, and monitored by a national Further information l Dr Shelley Heard 020-7692 3360 www. londondeanery. ac. uk