Teaching v Service Time

In the context of General Practice in 2017, it would have been astonishing if the tension between teaching and service had not arisen.

I suppose our biggest challenge at the moment [is demand]…We are all very committed to teaching but I mustn’t look at things through rose-tinted spectacles because…these are very challenging times for general practice and demand on the practice is very, very high. And at times of high demand there are subtle, and sometimes less subtle, pressures on teaching. ‘Do you really need to have that tutorial? Can we maybe use a little bit of blue slot time because someone's on holiday?’ or whatever. (M1)

(Blue slot time is protected teaching time represented on the practice appointment template)

This quote was typical of the feeling across all the GPs interviewed and on several occasions supervisors described the need to try and defend teaching or balance it against clinical pressures.

I found we were teaching a little but by the skin of our teeth because … we are busy…Sometimes you were teaching and folk were knocking

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on your door and wanting things done and actually [you just have to say, ‘I’m not here’. (M6)

I’d love to have more time for tutorials and things, to have more time to talk. [We work across] split sites [so] we have to travel between them… [and] I'm not a ten-minute-consulter so…it's not as if my day can split like that…I finish an hour late every day… so sometimes it feels like you sacrifice the teaching to get the job done…[It] would be nice if it wasn’t like that but there's no way around that. (M9)

Just under half of interviewees discussed the stress of teaching while trying to deliver service and this will be described in 7.6.2.

7.5.2.1 Protected time for teaching

As a result of these stressors and external postgraduate accreditation

requirements, practices have adopted a range of strategies to try and represent the work of teaching within practice schedules. The commonest of these was the provision of “protected time” for teaching. This arrangement is widely accepted for tutorials with tutorial slots the most likely time to remain protected during peaks of clinical pressure. There was much more variation when it came to the rules relating to supervision of STs or FY2s consulting or teaching students in your own surgery time.

So, she (FY2) is on twenty minute appointments just now but you’ll see here that one GP has got some debrief slots booked off for her to come in between patients and ask about things… She’s got a clear go- to person for that day. [They have] space and time to…chat to her between patients if needed…When [FY2s} first come…they do half an hour [appointments] and…every third appointment of ours is blocked so that basically the last ten minutes of each of their patients, there should be a GP free. (M4)

GPs supervising FY2s generally have more time blocked off for their supervision than those supervising GPSTs. The time allocated decreases as the STs become more senior, assuming they are increasing in competency as expected. Where these systems sometimes fall down is when GPs are running behind in their surgeries.

And what the trainees are supposed to do is…to come and ask…the person that has got the catch up slot. But in reality what happens is they ask the person who is running best to time. Which is invariably me! But that’s fine. (F7)

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In this particular case, she would like to change the system to have an “On Call GP” who would not be consulting but available in the surgery and therefore more accessible to trainees. Unfortunately, as they are currently understaffed, this is not possible. This was not the only example where GP vacancies and appointment capacity had influenced practices delivery of teaching or supervision.

You’re meant to have two slots…blocked off in your surgery if you’re supervising the FY2. That doesn’t always happen…[it depends] on demand for appointments. (F2)

7.5.2.2 Activity Theory interpretation

Various rules exist within practices related to the management of time for teaching. Some of these are locally agreed within the practice while others may a requirement from the deanery related to time allocated to teaching and

supervision. However, secondary contradictions occur within the practice system when service demand exceeds capacity or there are staffing gaps which then impacts on the division of labour (Figure 7-16). This can put pressure on both individuals and the service as a whole and reflects the underlying primary contradiction between teaching and service.

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Figure 7-16 The place of protected time to support teaching in multilevel learner practices

7.5.2.3 Teaching on days off and pulling your weight

There were a number of ways that practices had tried to alleviate the tension between teaching and service. As the third year students attend for seven separate teaching days spread across the academic year, several of the part- time GPs who take third year students were able to provide teaching in their own time. In return for this, they either took time back in lieu or received the payment for teaching personally. These agreements were worked out locally between the practices and their individual tutors and were felt to be mutually beneficial.

I tend to just take some time back…if I need it… I’d rather do it that way. We [discussed] it and the money was offered but I didn’t feel that was why I was doing it, so, I would rather…be able to use the time and be more flexible elsewhere. (F4)

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It was very easy because what I decided I wanted to do was that if I [taught 3rd year students, I would keep the]… payment directly for that. I used my day off to do it so that I could basically not be accountable to the practice for having to do full clinics that day. It made it a much more enjoyable experience for me. (F6)

We do a lot of our teaching on our days off. You come in and do teaching locums…We use income from teaching to fund teaching locums which basically is a 16-patient-day rather than a 32-patient- day. So we teach at [slower] intervals but that’s 16 extra…

appointments for the practice. So…the way I keep my administrative staff sweet is that…teaching leads to a net gain in appointment numbers, not a big one but a little one. We don’t lose

appointments…which is crucial. I think if we were losing appointments to teach at a time of such high demand that would be very difficult. (M1)

These GPs appreciated being allowed the extra time they felt necessary to deliver high quality teaching to the students. However, the loss of appointments to student teaching was felt to be unacceptable to some practices or on a couple of occasions to the GP actually doing the teaching.

Basically I get a free reign…As long as you’re seeing the same number of patients as everybody else there's not a huge lot of griping about what way we…spread that…I guess I'm just conscious of being quite careful with my timetabling because I don’t want to look like I'm not pulling my weight in the practice. (F6)

F5: When the student comes it's a busy time for me. I'm trying to slot in as many student surgeries [as I can] so I use my admin time for that. Or I’ll maybe start my surgery a bit earlier…so that we can…have some protected time at the end to do a student surgery...I try as much as possible to see the same number of patients but it probably works out maybe two or three less slots if I've got a morning with the students.

Interviewer: And is that something that comes from within you that you want to see the same number of people rather than the practice saying everybody must still see the same number of people?

F5: That’s me (laughter).

7.5.2.4 Activity Theory interpretation

The various models described are attempts to resolve the contradictions

emerging from the underlying primary contradiction existing between teaching and service. This could involves modifying rules (e.g. appointment duration) or

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making changes related to division of labour (e.g. individuals taking time back in lieu for teaching). Some GPs and their practices demonstrated learning as they found ways to adapt how they organise teaching to suit their circumstances e.g. creation of new teaching locum model.

7.5.2.5 Teaching “crunch points”

A significant number of practices are understaffed. Even those practices that are fully staffed identify GP leave as causing a crunch point when it comes to their ability to provide teaching in practice. Although practices are willing to pay for, or funding exists for, locum cover, locums are often not available and certainly not at short notice. As a result, practices either have to temporarily withdraw from teaching or modify what they are able to deliver.

We had… a student scheduled in and I had to cancel. I've only ever done that once but … we've had quite a lot of sick leave amongst partners over the last year so we just…felt under pressure and under staffed and we just felt we didn’t have time to do it. (F5)

I think that it's time isn’t it. That is always the problem. It's making sure consistently… that the trainees have enough of our time. The tension with that is if someone is on holiday and there are only two of us here when there really should be three…How do we manage that? Poorly probably… We just have to. One person teaches, one person covers the practice or…sometimes we try different things to see what works actually. [For example] we sometimes do … a shorter condensed teaching time of both of us teaching and then we all go and cover the practice later. (F7)

Other than annual leave, another predictable crunch point for practices with multilevel learners is the start of trainees’ posts. Some practices will modify their availability for undergraduate teaching at this time of year as these are more intensive periods of training and extra time is needed to gauge trainees’ level of competence. One GP described his practice not taking students in August or September as they had a new FY2, two new ST1s and an ST3 all starting on the same day.

If you were to ask some of my colleagues I think they would say ‘Well…at a time when we’re under all the pressure, maybe we

shouldn’t have students all the time.’ And [you need flexibility]. You can’t have them all the time. I mean you can’t have medical students

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in August when you’ve got four other people joining. So I think you have to be pragmatic. (M1)

7.5.2.6 Activity Theory interpretation

The described ‘crunch points’ could be represented as tension for resources between three separate activity systems that co-exist within practices:

undergraduate teaching, postgraduate training and clinical service. Successful adaptations to the system, attempting to resolve contradictions, can be seen as learning e.g. practices modifying their intake of students at the start dates for trainees. In this way, the practices are endeavouring to effectively deliver on all of their intended outcomes. The current shortage of locums adds a new tension as, if this was not the case, practices may be better able to cope with ‘crunch points’.