INTRODUCTION
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In the United Kingdom, Health Education England is responsible for the education and training of all health professionals. In each of its regional offices, a postgraduate medical and dental education function supports the continuing professional development of general practitioners (GPs). Health Education North West (HENW), for example, has commissioned variations of an accredited postgraduate 'professional education and development' (PED) course for GPs since 1994 \[[@b1-jeehp-12-31]\]. The rationale for the course is to support GPs, especially in their early years of practice, to enable them to access development opportunities within a supportive schema. PED is designed to encourage the development of a range of theoretical and practical leadership skills necessary to thrive in a constantly changing, increasingly complex primary healthcare landscape so that participants are better able to provide effective and efficient services, enhancing care for patients and safeguarding their own wellbeing. The course is predominantly focused on enabling professional and practice development, using reflective learning techniques in peer-groups of up to eight doctors for at least 18 months. It comprises the core modules of an MSc program accredited by one of the regional universities, devised and taught by local GP educationalists. Participants are required to submit practice development plans, personal education plans and a portfolio of work which includes a significant event analysis (SEA) and review of progress against the personal and practice plans. This approach enables participants to review and justify their work in an academically rigorous way. [Table 1](#t1-jeehp-12-31){ref-type="table"} illustrates the structure, content and assessment of the PED course in more detail. The aim of this study is to identify whether and how the PED course might benefit participating GPs resulting in, for example, well-organised practices able to offer better and safer patient care.

METHODS
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A qualitative approach to data collection and analysis was adopted in order to enable a detailed exploration of the benefits of the course as a case study of such educational interventions. As part of the course, participants submit a number of academic written assignments including a portfolio which documents reflection on progress. The content of each portfolio gives individual accounts of the impact of the course on personal and practice development, including planned changes, as well as patient safety issues. The research team therefore decided to base the investigation on extant portfolio submissions rather than data collected via interviews or surveys.

Data collection
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We secured permission to undertake this research from the university which accredits the PED course as well as the HENW research governance committee which reviews proposed studies for scientific quality and ethical integrity. Approval from the National Health Service (NHS) National Research Ethics Service was not required. Each academic year approximately 15 GP participants submit the requisite portfolios as part of their final assessment for their PED qualification. Between January and March 2013 we wrote to a random sample of 30 PED participants who had successfully completed the course in the past five years, requesting permission to access and analyse their portfolios for key themes in relation to personal development, practice development and patient safety issues.

Participants were sent a detailed information sheet about the study and assured that their portfolios would be rendered anonymous by an administrator before being allocated to the research team for analysis and that no participating GP, his/her patients or practice colleagues would be identifiable in any publications arising from the research. Written permission was obtained from 16 participants (53%) who returned a consent form and their portfolios formed the basis of the case study.

Data analysis
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Portfolios were analysed for recurring discourses and themes using a thematic framework analysis \[[@b2-jeehp-12-31]\]. The research team acted as co-analysts and a coding framework was devised as a result of their deliberations. This construction of codes and thematic categories was done by the co-analysts working independently, and deliberating together on interpretations until agreement was reached. The quality of the findings is highly dependent on the rigour of the data collection and subsequent analysis and interpretation. We attempted to achieve rigour by using established techniques to ensure credibility, transferability, dependability, and confirmability \[[@b3-jeehp-12-31]\]. Inter-rater reliability ensured that multiple coders were involved in identifying areas of agreement to ensure consistency and to minimise any potential for bias in interpretation. There were very limited disagreements about coding definitions and all were successfully resolved. The research team engaged in constant comparison, involving checking the consistency and accuracy of interpretation and especially the application of codes, as well as careful consideration of negative cases. Records of all data analysis activities were maintained so that genesis of interpretation could be tracked, ensuring auditability.

RESULTS
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We identified seven major thematic categories in the data, as summarized in [Fig. 1](#f1-jeehp-12-31){ref-type="fig"}. Themes with illustrative data extracts from participants are in [Appendix 1](#app1-jeehp-12-31){ref-type="app"}. Seven major thematic categories can be described as follows.

Leadership
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Increasing leadership skills was an important goal for participants and a motivating factor in deciding to undertake the PED course. The most consistently reported areas which were felt to be useful by participants were the development of non-clinical managerial skills (e.g., staff employment skills, chairpersonship and planning/timetabling), self-awareness and self-confidence, assertiveness, change management, team working, and skills in negotiating conflicts. These correlate closely with areas of the Medical Leadership Competence Framework \[[@b4-jeehp-12-31]\]. The increase in leadership skills was not without disadvantage; however, as participants reported finding themselves exposed to assuming responsibility for resolving conflicts in their work environment.

Resilience
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Participants were often working in difficult situations, with challenging patients and colleagues. The portfolios provide evidence of their developing hardiness in dealing with challenges through descriptions of increased resilience or approaches and attitudes that were likely to increase resilience. Recurrent themes attributed to PED included improved positivity; enthusiasm; flexibility, particularly for problem solving; personal and team resilience; team building, with the ideas prompted from the course material and discussions facilitating a happier and more effective practice team; peer support, including its beneficial role in burnout prevention; and a greater awareness of maintaining work-life balance. Increased confidence was a strongly emergent theme and was mentioned in various contexts including leadership, colleague interaction, educational expertise, practice management, and problem solving.

Quality improvement
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Improving quality in general practice is an outcome which course participants were keen to achieve. Every portfolio was found to have references to finding better ways of doing things and the great majority also commented about strategies to more effectively monitor performance. All participants documented how their experience on the PED course had resulted in improved services at their practice. The evidence suggests that the tools used within the course are transferable to everyday practice. A number of portfolios reflected upon providing enhanced services beyond the requirements of the quality outcomes framework. We also found evidence of specific learning tools from the course, especially the use of SEA, being used to directly enhance services.

Change management
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Practice plans illustrated how management of day-to-day challenges affected participants' ability to respond to external changes, including those implemented by Government. The PED course looked at change management specifically and how to approach it. Participants reflected that attempting to bring about change was often difficult, both emotionally and practically. A new awareness of the possibility of change led some participants to feel frustration towards partners and staff who did not share their vision and to unrealistic expectations. Becoming a change-maker could also affect how the individual was perceived by the practice, both positively and negatively.

New services
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Participants' practice plans revealed a range of new services, including new clinics, improved access and the development of services open to other practice patients. Whilst many of these would have happened anyway, it is possible the rigour of producing the plan with smart objectives may have supported the process. In addition, plans reveal the use of Gantt charts, SWOT (strengths, weaknesses, opportunities, and threats), and a range of other tools introduced by the course. Participants' reflected on what had aided success, such as the benefits of project management techniques, which may help in the development of future services and plans. We also found evidence of a range of methods being used to evaluate new services, often involving both user- and staff feedback, whilst also acknowledging the difficulties of evaluation. In some instances there were helpful reflections on why planned services did not go ahead.

Educational expertise
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The increased confidence gained by participants in using reflection and in planning their own learning is frequently mentioned in the portfolios. Education of self and others was an important theme, as was developing an educational environment within the practice, both through improving the fabric of the building and by developing resources and approaches to learning. We found evidence of the development of self-directed learning, as well as reflection on the way that an organization learned and then modified the approach taken (i.e., triple loop learning). A significant number of participants also highlighted that they had been able to improve staff training or the staff appraisal processes within their organization in order to improve quality. On a personal level, PED written assignments can be challenging and we found evidence that participants' writing and analytical skills had been developed by the course.

Patient safety
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A wide range of incidents were discussed relating to patient safety. The SEA described in the portfolios demonstrate the amount of thought that goes into analysis of each incident as well as the impact that adverse events can have on the ability of GPs to cope with work stress. We found evidence of significant learning from reflection and through complaints. Discussing patient safety issues with the team at practice meetings was thought to significantly assist in ensuring positive outcomes and reduce the possibility of staff burnout. Recurrent outcomes of the SEA were specific actions agreed by a practice to improve patient safety. It is notable that in the instances where GPs are not part of a team the potential stress of the incidents was particularly noted, as well as identifying the loss of ability to share learning more widely with the team.

DISCUSSION
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In considering whether this type of educational intervention may be of benefit to GPs, we purposefully focused upon extant documentation produced for personal and practice development planning. The plans formed a significant component of participants' coursework submitted for formal assessment and in totality this reflective material provided a rich seam of qualitative data on the impact of the PED course. In each of the seven thematic categories extrapolated from the data, we found evidence that the supportive framework provided by the course did enable development of practitioners by enhancing knowledge and skills which, in turn, had a positive impact upon their self-perceived effectiveness and motivation.

The successful integration of newly-acquired managerial skills into the working environment appears to involve a complex interaction of self-awareness, team awareness, confidence factors and assertiveness. The structure of the PED course would appear to be facilitative in allowing participants to try out their skills and rehearse new techniques in a safe group environment before transferring them to the workplace. As well as evidence of developing leadership competencies we also identified perceptions of PED as a positive influence on confidence, hardiness and other indicators of resilience. The impact of PED on levels of resilience may lie in providing participants with opportunities for discussion and analysis of potentially stressful situations that occur in general practice combined with peer support and the development of creative problem solving and organizational skills.

The portfolios reveal evidence of increasing skills in reflection and self-directed learning, with improved educational skills being used to help others within the practice. PED's promotion of leadership and creative approaches to problem solving appear to have helped with the development of an educational environment and learning cultures within several practices. In an NHS which is seeing significant emphasis on accountability for quality of service and additional regulation, participants evidently value the acquisition of quality improvement, monitoring, and evaluative skills.

Participants clearly welcomed the opportunity to develop change management skills, although a number of them subsequently encountered a reluctance to change in their partners and staff. The extended period of the course, however, allowed participants to receive on-going support as they handled these issues of resistance and learned how to overcome the associated challenges. Substantial changes are required in primary care to incorporate developments in medicine and new models of delivering care \[[@b5-jeehp-12-31]\]. PED's facilitation of reflection on both successful and failed practice-based initiatives will arguably stand participants in good stead, given that delivering new services will underpin general practice in future and practitioners will require clinical and strategic understanding to identify the most appropriate developments, as well as the skills to plan and implement them \[[@b6-jeehp-12-31]\].

Our case study relates to a small sample of participants who have undertaken a PED course in a single region, so there are inevitable limitations in terms of generalizability in the quantitative sense. A further limitation relates to the fact that the study was based on analysing portfolio entries that have been completed as part of an assessment process. There is a possibility that the entries were completed by students in a way that met learning outcomes and satisfied tutors rather than reflect their own views, although the likelihood of this happening is perhaps minimised by the fact that students were encouraged to draw upon both positive and negative aspects of their professional lives and day-to-day experiences in general practice, a profession where reflective practice is ingrained. In addition, although all portfolios were made anonymous by an administrator before being allocated to researchers for analysis, some of the researchers had previous experience of the PED as course tutors. Because of this connection, the whole research team collectively discussed each developing theme during data analysis in order to minimise any potential bias in interpretation. The team also included a non-clinical education researcher, with no prior knowledge or experience of the PED course, as an additional safeguard.

In conclusion, in seeking to determine the impact of PED on participants, we found evidence of positive benefits in terms of the acquisition of enhanced leadership skills, confidence in developing/delivering new services and continuous quality improvement. We also found evidence of PED's contribution to the development of resilient, reflective practitioners, attuned and responsive to personal, practice and health service need. Leadership development amongst participants appears to translate into improved and safer patient care, as well as positivity in doctors. The costs of running PED-type courses, whilst significant, are small compared to the overall cost of training a GP and this study suggests the added benefits they can bring to primary care. There are significant potential changes in postgraduate medical training as a result of the 'shape of training' review \[[@b7-jeehp-12-31]\]. The situation in general practice is particularly dynamic given the potential extension of GP specialty training from three to four years. Research into recent pilot programs suggests that extended training may be an effective method of developing leadership capabilities in future GPs \[[@b8-jeehp-12-31]\]. Courses like PED, however, can provide a bridge for those completing three year programmes as the graduates of longer training enter the workforce. Such courses may also serve a valuable purpose for the existing workforce which will be responsible for leading the shift towards community-based service delivery in the NHS alongside a clear and continuing role for the specialist-generalist--the GP.

No potential conflict of interest relevant to this article was reported.

SUPPLEMENTARY MATERIAL
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Audio recording of the abstract.

Leadership
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The session on conflict and negotiation using the modelling technique was particularly valuable in allowing a clearer understanding of the dynamics of conflict. Some circumstances had appeared on the surface to be virtually irresolvable, but using the role play/modelling technique, gave the scenarios more clarity and demonstrated a more balanced and democratic view of the situation (gp38).

The study of leadership skills has increased my confidence professionally. Prior to the Professional Education and Development (PED) course I would have felt uncomfortable if asked to contribute at meetings at Primary Care Trust level or with other colleagues whom I considered perhaps more experienced than me. However, having learned more about myself and having learned about topics such as assertiveness, negotiation and conflict, I now feel that I have begun to acquire the necessary skills to provide leadership and thus have the confidence to get further involved with health-care management (gp184).

Resilience
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The learning objectives of ... \[PED\] \... are broad but ... I would summarise them as tools to enable me to survive (and even enjoy) medicine. I have survived, I am enjoying medicine more than ever and I certainly feel that I understand the process of learning better (gp184).

My confidence in handling a recent patient complaint was enhanced by my learning on the course; I used some aspects of the stress reducing techniques discussed on the course \... The resulting significant event ... illustrates that I have developed the ability to cope with a challenging situation, and the resulting practical outcomes will improve our service to other patients (gp187).

Quality improvement
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Much of the work we did in teams during the course can be extrapolated to the work done in practice and I have found many of the concepts useful when organising team events for our surgery, for example, using the team building exercises utilised by the PED course on our recent 'protected learning time' day (gp38).

I think my GP colleagues have also benefited from me contributing more, both in terms of me bringing in fresh ideas that will hopefully result in a better service for patients (e.g., the new appointments system with telephone consultations/triage, ideas on training), and by me getting more involved in management areas (e.g., instigating and managing changes, practice finances, staff appraisals) thus taking some of the pressure off more senior partners (gp103).

Change management
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The lessons learned in the management of change are that structured planned change can be successful, and \[there is a\] need to prioritise, time manage and re-evaluate more frequently to allow a more pragmatic and flexible approach that will accommodate pressures of workload, limited resources and external influences. \[It\] has instilled faith that change is possible and can have tangible and meaningful positive effects (gp1023).

The desire to improve and progress has sometimes unveiled an enormous workload and I have at times swamped the practice manager and staff with new initiatives (gp1416).

New services
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Our plan to establish a clinic for the assessment of peripheral arterial disease in primary care has progressed well.... it was evident throughout the clinic that there were many inappropriate referrals which could have been deflected within primary care... I have proposed a business plan for the setting up of a peripheral arterial assessment clinic at my practice which will accept referrals from GPs within our PBC cluster. This was delivered to our PBC Executive Board in mid-September and was well-received (gp1315).

The requirement to be more structured has proved I think beneficial to the practice in that we have had a more defined and time limited plan to work to which has helped the team to work together better and improved service development. We have felt able to provide extra services such as the cardiovascular clinics and extended hours (gp192).

Educational expertise
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Researching the practice development plan has taught me to identify resources (Saving a Million Years of Life data, triangulation tool, quality and outcomes framework data, significant event analysis etc.) useful for assessment of practice learning and development needs. I have learnt how to plan my personal and practice learning i.e., learnt how to learn. ... I have found the research around how to devise a personal learning plan useful in my role as appraiser (of GPs and our own nursing team) and trainer as I am now able to identify sources for the appraisee to assess to identify their personal needs (gp13).

I am now convening medical students' special study modules, and my experience of undertaking 'academic work' has given me more confidence in this supervision (gp187).

Patient safety
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We have been reminded to check the background to our patients' problems, and to listen carefully to both patient and family. It is easy to see only what is expected, but as GPs we must be alert to the possibility of the unexpected. We have revealed one of our 'unknown unknowns'; the causative link between \[...\] and \[...\]. This learning will be shared with the whole practice team (gp187).

There are several areas of practice identified here that could have been done better and could maybe have prevented such an adverse event.... These will be discussed at a clinical meeting and circulated to all clinicians.... Changes made as a result of this analysis will help to prevent such an unfortunate incident from happening again (gp103).

![Seven major thematic categories in the data from 16 general practitioners for a qualitative investigation of participants' assessed coursework portfolios in United Kingdom.](jeehp-12-31f1){#f1-jeehp-12-31}

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Structure, content, and assessment of the professional education and development course

                                                                                             Description
  ------------------------------------------------------------------------------------------ ------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
  Structure                                                                                  18 months duration, 3×three day residential modules+4 study days, 2-4 hours personal weekly study time; facilitated small group work with discussions and activities promoting creative thinking; online resources using a Moodle platform; independent individual and group study
  Content                                                                                    Time management, planning, appraisal, conflict, and leadership
  Motivation, teams, delegation, creative problem solving, and transactional analysis        
  Adult learning, team role theory, negotiation, management of change, and assertiveness     
  Stress and burnout, meetings, observing groups, giving feedback, and presentation skills   
  Assessment                                                                                 Personal education and practical planning process; significant event analysis; implementation review and reflection on personal development
