Reshaping Medical Education and Training to Meet the ...



Reshaping Medical Education and Training to Meet the Challenges of the 21st Century

A Report to the Ministers of Health and for Tertiary Education from the Workforce Taskforce

March 2007

Acknowledgements

The Workforce Taskforce would like to acknowledge and thank the following organisations and individuals for their contributions and helpful comments in the preparation of this report.

Organisations

Association of Salaried Medical Specialists

Australian and New Zealand College of Anaesthetists

Clinical Training Agency

Council of Medical Colleges in New Zealand

DHB Chief Medical Advisors

DHBNZ Medical Workforce Strategy Group

Hutt Valley DHB junior doctors, physicians

Medical Council of New Zealand

New Zealand Medical Association

New Zealand Medical Students’ Association

New Zealand Resident Doctors’ Association

Royal Australasian College of Physicians

Royal Australasian College of Surgeons

Royal New Zealand College of General Practitioners

Individuals

Dr Stephen Child – Clinical Director, Clinical Education and Training, Auckland DHB

Joanne Griffin – Clinical Nurse Specialist – Paediatrics, Capital and Coast DHB

Associate Professor Annette Huntington – Massey University

Mrs Anne Kolbe – Deputy Chief Medical Officer, Waitemata DHB

Margot Mains – Chief Executive, Capital and Coast DHB

Stephen McKernan – Director-General of Health

Dr Garry Nixon – Chair, Rural Hospital Doctors Working Party

Susan Shipley – Director, Policy Advice and Government Services, Tertiary Education Commission

Dr Iwona Stolarek – Intern Supervisor, Hutt Valley DHB

Helen Weston – Junior Doctor Roster Co-ordinator, Hutt Valley DHB

Dr Robin Youngson – Intern Supervisor, Waitemata DHB

The Taskforce would particularly like to acknowledge the contribution from officials at the Tertiary Education Commission and thank them for their participation.

The Taskforce would like to gratefully acknowledge the work of Marilyn Goddard who led the Workforce Taskforce Secretariat at the Ministry of Health. She was supported by Amanda Burgess.

Citation: Workforce Taskforce. 2007. Reshaping Medical Education and Training to Meet the Challenges of the 21st Century: A Report to the Ministers of Health and for Tertiary Education from the Workforce Taskforce. Wellington: Ministry of Health.

Published in May 2007 by the Ministry of Health, PO Box 5013, Wellington

ISBN 978-0-478-19114-1 (Online)

HP4393

This document is available on the Ministry of Health website: t.nz

Contents

List of Recommendations 1

Recommendation 1a 1

Recommendation 1b 1

Recommendation 2 2

Recommendation 3 2

Recommendation 4a 2

Recommendation 4b 2

Recommendation 5a 3

Recommendation 5b 3

Background 4

Introduction 6

Desire for change 6

Leadership of change 6

What needs to be done 7

Oversight and implications of the continuum of learning 8

Undergraduate years 8

Transition years 8

Vocational training 9

Funding 9

The way forward 10

Oversight body 10

Implications for registration 11

Outcome monitoring 11

Implications for other professions 11

Recommendation 1a 12

Recommendation 1b 12

A commitment to ongoing self-sufficiency for the medical workforce 14

Recommendation 2 14

New roles and inter-professional collaboration 15

Recommendation 3 15

Accountability for clinical training 16

Interdependence of training and service delivery 16

DHB responsibilities 16

Funding 17

Use of other providers 17

Recommendation 4a 17

Recommendation 4b 17

An increasing focus on generalism 18

General practitioner numbers and training 18

The way forward 19

Recommendation 5a 19

Recommendation 5b 19

Conclusion 20

Appendices

Appendix 1: Investment in medical education and training 21

Appendix 2: Workforce taskforce membership 22

Appendix 3: Workforce taskforce – terms of reference 23

Appendix 4: List of submitters 25

List of Recommendations

Recommendation 1a

That a body to be known as the Medical Training Board, involving providers of education and training and health care, be established to oversee medical education and training in New Zealand. It is proposed that the Board be jointly accountable to the Minister of Health and the Minister for Tertiary Education, and be required to:

← ensure effective oversight and co-ordination of the continuum of medical education and training in New Zealand; from entry to medical school to registration in a vocational scope of practice

← develop an educational framework for the transition years between the university environment and clinical practice

← receive advice from the District Health Boards (DHBs) and other providers of health care on the number and mix of medical practitioners required to meet future health care needs

← develop a national view on the appropriate number of training positions required to allow all trainees to complete their requirements to graduate MBChB, achieve general registration and, subsequently, registration in a vocational scope of practice with the Medical Council of New Zealand. The numbers must focus on meeting the projected health care needs of the New Zealand population

← approve clinical training specifications and funding intentions

← promote the recruitment and retention of medical trainees to meet the predicted future demand for the provision of health care services in New Zealand by vocationally registered medical practitioners, and take steps to ensure that the available programmes meet this demand

← develop mechanisms to collect appropriate data including regular longitudinal surveys of cohorts of students, trainees and medical practitioners, which will facilitate medical workforce development.

That:

← the Minister of Health and the Minister for Tertiary Education appoint the Medical Training Board

← the Medical Training Board be jointly serviced by the Ministry of Health and the Tertiary Education Commission.

Recommendation 1b

That the Medical Council of New Zealand:

← be asked to develop a process for limited registration for trainee interns

← work with the Medical Training Board to develop a process for competency-based assessment and progression to general registration.

Recommendation 2

That:

← the number of medical graduates produced by the training system be increased to ensure that New Zealand moves towards achieving ongoing self-sufficiency for its medical workforce

← the Medical Training Board review no less frequently than every five years the number of medical training places, both undergraduate and graduate, that should be funded by the government.

Recommendation 3

That:

← the Medical Training Board, in consultation with health care providers and consumers, consider the need for new roles to support medical practitioners and advises the Medical Council and education providers accordingly

← inter-professional collaboration and care, communication and teamwork be taught and assessed by universities as part of the medical undergraduate curriculum and throughout the continuum of learning, and that the same principles be reflected in work environments within DHBs and other health care providers.

Recommendation 4a

That:

← through their district annual plans, DHBs be required to demonstrate and report on their commitment to the education and training of their present and future workforce. This should include the development of an appropriate culture and environment for training, inter-professional collaboration and taking responsibility for providing both the necessary facilities and adequate supervision and guidance for doctors in training.

Recommendation 4b

That, to support clinical training:

← a national curriculum be developed by the Medical Training Board for the transition years, which clearly defines the standards and competencies required for entry to vocational training

← specific contracts for training be developed by the Medical Training Board to ensure and demonstrate the allocated funding is spent on training

← employers of doctors in training be made accountable for ensuring that the funds received are used to the best advantage

← DHBs ensure that senior doctors are trained and supported to deliver training for trainee doctors

← DHBs appoint Directors of Clinical Training

← working with the DHBs, the Medical Training Board should ensure all providers of training have appropriate standards and external accreditation of their training programmes

← hospital and community settings for training include both private and public providers of health care.

Recommendation 5a

That the Medical Training Board work with educational and training organisations to ensure that:

← all medical practitioners acquire a broad general foundation, which includes community and regional hospital experience, before entering vocational training

← the training system produces sufficient numbers of doctors entering the New Zealand workforce with training in general vocational scopes of practice.

Recommendation 5b

That, in relation to general practitioners in particular:

← universities be invited to bring forward proposals to the Medical Training Board for a primary care based undergraduate programme which is targeted to areas of need such as rural, Māori and high deprivation populations and is linked to postgraduate training for general practitioners

← further work be undertaken to submit an education and training programme for general practice to meet New Zealand’s needs, taking into account experience of innovative programmes overseas

← those factors both educational and non-educational that influence the choice of students and trainees for general practice as a career be identified and addressed.

Background

As its first task, the Workforce Taskforce was charged by the Minister of Health with advising on how to streamline the current New Zealand medical education and clinical training arrangements to produce medical practitioners who are fit for purpose and for practice in the minimum time period. The full terms of reference are in Appendix 3.

The Taskforce has received submissions and invited presentations from a range of interested parties on the specific issues detailed in its terms of reference.

In formulating its recommendations for action, the Taskforce has sought to connect all background information and current streams of work to ensure a consistent approach to the development of the medical workforce into the future and its education and training. However, the Taskforce recognises that further work needs to be done in some areas, such as consulting with Māori and Pacific medical groups, and in the areas of primary health care and overseas trained doctors.

In previous years there have been a number of reviews of the health workforce for New Zealand. In particular, during 2005/06, an extensive amount of work on the medical profession was undertaken by the Medical Reference Group of the Health Workforce Advisory Committee and the Doctors in Training Workforce Roundtable, culminating in two reports to the Minister of Health, Fit for Purpose and for Practice and Training the Medical Workforce 2006 and Beyond.

Key points from the latter two reports are outlined below:

← There is an overall shortage of medical practitioners, evidenced by the use of locums and reliance on overseas-trained doctors, which will be exacerbated in the future as the population ages and competition for medical practitioners increases in the international market.

← There is a ‘maldistribution’ of the available medical workforce, with rural and non-metropolitan areas finding it increasingly difficult to recruit and retain doctors. Māori and Pacific peoples are currently under-represented in the medical profession in New Zealand. Those from lower socioeconomic backgrounds are also under-represented. There is a need for strategies to increase recruitment into medical schools from these groups.

← New Zealand needs to train more medical practitioners locally to meet the demand. To achieve this, the level of the cap on funded undergraduate medical places should be raised and further clinical training positions made available.

← The quality and relevance of medical education and training could be improved by greater continuity between undergraduate medical education and subsequent clinical training and increased responsiveness of the whole system to the needs of the health sector.

← The health sector is complex, and there are many players involved in educating and training medical practitioners – there is a need for a central body to co-ordinate and oversee medical education and training.

← The difficulties for training in clinical settings created by the inherent tension between service delivery and training needs, the changing service delivery patterns in public hospitals and the implications of industrial agreements over the last 20 years, are putting pressure on the current apprenticeship model.

The Taskforce is also aware that a considerable amount of work relating to the medical profession has been, or is being, undertaken by other groups, notably the District Health Boards New Zealand’s (DHBNZ) medical workforce strategy group, the Tertiary Education Commission (TEC) on the funding of undergraduate medical programmes and the Clinical Training Agency (CTA) on vocational training for general practitioners. Also of relevance are the findings of the New Zealand Institute for Economic Research (NZIER) in its report prepared for the Ministry of Health Ageing New Zealand Health and Disability Services: Demand projections and workforce implications, 2001–2021 and The Treasury’s statement on New Zealand’s Long Term Fiscal Position June 2006, both of which highlight the pressures that will be brought to bear on the health and disability system over the next 20 years as a result of New Zealand’s ageing population and an increasing demand for services.

This Taskforce report in considering all the previous reports and submissions, now strongly advises the establishment of an implementation plan based on the recommendations of this report.

Introduction

The Taskforce began by considering the recommendations of the reports from the Medical Reference Group[1] and the Doctors in Training Workforce Roundtable[2] to the Minister of Health. Comments received from key organisations and individuals delivering medical services and medical education and training proved to be consistent with those of the reports and also the outcomes of previous reviews commissioned by governments over the last 20 years. Most of the problems identified by the Taskforce are not new. They are, however, becoming more apparent, and the need to address them more urgent, as pressures on the health system increase. Collectively, they have resulted in an inability to produce the best outcomes from the taxpayers’ investment in medical education and training at both undergraduate and postgraduate levels.

The question that must be addressed is why, given the consistency of expert advice, there have been no effective changes? This report, therefore, identifies the barriers to change and makes recommendations for overcoming them.

Desire for change

The Taskforce’s consultation has revealed a widespread desire for change initially focused on the transition years from completion of undergraduate studies to practice as a doctor. However, effective change will be achieved only by a national, systematic, integrated and collaborative approach that recognises the uniqueness of New Zealand’s health needs and the importance of linking workforce training, in this case medical, to meeting them.

Of particular importance will be the issue of sustainability. The system must be flexible enough to react to change, reward improved productivity, produce the number and mix of doctors to match the needs of the health care system and be affordable. In addition, the environment in which medical practitioners work must be supportive, including such features as acceptable rosters, collegial support and access to appropriate professional development.

Leadership of change

Fragmented innovation reduces the ability of the system as a whole to learn and, as a consequence, gains in effectiveness and productivity are diminished. The introduction of leadership of the whole medical training system is required to give coherence and balance to the provision of training, while retaining the vigour that individual components variously bring. It will ensure that the cumulative effect of the changes made by those involved have a sustainable impact on increasing the productivity of health services.

In the absence of any oversight of the medical training system there is a tendency for individual participants to respond to changing circumstances in ways that reinforce or sustain the value of their own roles, rather than considering the needs of the system as a whole.

What needs to be done

Faced with the uncertainties inherent in long-term workforce development, it is important to have effective and responsive leadership. The Taskforce considers that enhancements could be made within the existing structural arrangements that will ensure that the value of the government’s investment in medical education and training is maximised, improve accountability, meet the objectives of the Tertiary Education Strategy and meet the needs of the health sector.

This report makes five recommendations as the first step toward making changes that will result in a sustainable medical education and training system to produce medical practitioners who are fit for purpose and for practice in the minimum time period. The recommendations cover the following areas:

1. Oversight and implications of the continuum of learning

2. A commitment to ongoing self-sufficiency for the medical workforce

3. New roles and inter-professional collaboration

4. Accountability for clinical training

5. An increasing focus on generalism.

Oversight and implications of the continuum of learning

Medical training is a continuum from the levels of novice to expert that includes acquisition of knowledge and basic skills with increasing clinical confidence and competence. Initially, this is directed at meeting the Medical Council’s requirements for general registration and, thereafter, vocational training and maintenance of competence through a lifetime of practice.

The undergraduate curriculum is funded by the TEC, and postgraduate clinical training, including vocational training, is funded by the CTA and the District Health Boards (DHBs). Learning, however, is seen less as a continuum but rather as a series of poorly co-ordinated steps. Currently, steps taken in isolation at one point in the continuum may be inconsistent with desired outcomes at another point. The lack of oversight and co-ordination of the medical training continuum means that the current funding arrangements are not achieving the best outcomes from investment in medical education and training.

New Zealand is part of a global market for health care professionals and, accordingly, any changes to our current systems and content of training must continue to meet international accreditation standards. New Zealand and Australia have many accreditation standards and governance processes in common for undergraduate and vocational training. These may not uniquely reflect the needs of the New Zealand health care system but they enable a higher degree of global relevance for New Zealand qualifications than we might otherwise be able to ensure from our resources alone.

The learning continuum should be flexible in order to meet the changing aspirations of individuals, the frequently unforeseen needs of the health sector and changes in service delivery. It should also provide a framework for connecting the different perspectives and interests of all involved.

Undergraduate years

The degrees of Bachelor of Medicine and Bachelor of Surgery (MBChB) are currently conferred at the end of a six-year undergraduate programme. This begins with a first generic year in which students study health sciences and other subjects, with selection for medical training at the end of the year. It concludes with the trainee intern year in which students have largely clinical experience in a variety of settings.

Transition years

There have been significant changes in the trainee intern year. In the early 1990s what was a payment by the hospitals for clinical services from Vote Health, was transferred to Vote Education to be a training grant to individual medical students administered through their university. At the same time, the hospitals, partly because of concerns about risk management, greatly reduced the clinical responsibilities of trainee interns. Currently, many of the DHBs are finding that trainee interns, by the time they reach their first postgraduate year, have less than optimum clinical experience in preparation for work as a house surgeon. Previous reports from the Medical Reference Group and the Doctors in Training Workforce Roundtable expressed concern about the effectiveness of the trainee intern year, which they suggested should be reviewed in the light of the changing hospital environment.

On graduation, the medical practitioner in training undertakes one year’s supervised clinical experience under registration in a provisional general scope of practice. The training received by doctors at this stage has also been a subject of concern, particularly from intern supervisors, and reflects an undue emphasis on achieving service outputs within the DHBs at the expense of training. There is concern at the lack of rigour and consistency in the process for determining whether the interns have met the Medical Council’s requirements for general registration at the end of that year.

The supportive funding provided by the CTA for approved training runs has not been clearly identifiable as targeted towards the actual training. The resources and infrastructure necessary to achieve an appropriately supported national educational approach to the first postgraduate year (PGY1), which would include consideration of existing and proposed programmes in other countries, are lacking. There must be a clearly accountable stream of funds for training.

Following completion of PGY1, doctors undergo a second year of training (PGY2), while working in a collegial relationship within a variety of clinical settings. There is, however, no specification for what is required in this year and with many junior doctors undertaking locums, oversight is variable and often less than ideal. Some of the vocational training programmes that they later enter do not give credit for experience in this year.

The Taskforce was not convinced by the arguments that have been put forward for retention of this year, which include opportunity to broaden experience, giving trainees more time to make a vocational choice and increasing the capacity of hospitals to deliver services.

Vocational training

Medical practitioners can practise independently once they have successfully completed a vocational course of their choice and have been accorded registration in one of the Medical Council’s vocational scopes of practice. This is a three-year programme for general practice and five years or more for the other vocational scopes.

Concerns have been raised in submissions about the lack of consistency in recognition of prior learning in some of the vocational programmes. Overseas jurisdictions have clearly defined the clinical competencies required in early postgraduate years to provide a common and agreed platform for entry to vocational training.

Funding

The funding for medical education and training is split between Vote Education and Vote Health. An analysis of the recent history of the funding for medical education and training is included in Appendix 1.

A fundamental feature of the Tertiary Education Strategy is that the providers of tertiary education must be responsive to the economic and social needs of New Zealand. The Taskforce has heard that the TEC, in respect to the health sector, sees its role as ensuring that the universities are appropriately funded to deliver a quality output, but it does not see its role as being involved in the detail of what is taught. Rather, it would be supportive of an approach that involved the providers of health services having input into the undergraduate programme, particularly in the trainee intern year.

The CTA, a business unit of the Ministry of Health, currently contracts with providers of training in clinical settings leading to general registration. It also contracts with, and funds, providers of vocational training programmes.

The Taskforce has heard that that there are issues with the current arrangements for the transition years. Specifically that there is not enough exposure to clinical settings in the trainee intern year, that the current PGY1 programme is not adequate for entry to vocational programmes and that programmes in PGY2 lack focus.

The way forward

The Taskforce believes that the final year of undergraduate medical training and the early phase of postgraduate training should be seen as a continuum leading to entry to vocational training. This should be characterised by agreed standards and competencies achieved through a structured programme of education and increasing responsibility for patient care under appropriate supervision.

The Taskforce anticipates that, for most trainees, the competencies required to enter vocational training will be achieved following the completion of two transition years, after which trainees should be ready to enter vocational training.

Since the publication of the reports of the Medical Reference Group and the Doctors in Training Workforce Roundtable, several groups have considered the issues identified in those reports, and a consensus is emerging on a way forward that will improve the quality and relevance of the transition years from the university environment to general registration. After considering the presentations and submissions that it has received, the Taskforce recommends the following approach which involves:

← limited medical registration at the end of the undergraduate year 5 to enable trainee interns to undertake a more meaningful learning programme in year 6

← a competency-based transitional clinical training programme. Trainees would be granted general registration on evidence that they have achieved the Medical Council’s required competency standards. They will then be eligible to enter a vocational training programme

← the medical colleges developing a common and consistent basis for recognising the learning and competencies achieved in the years prior to formally entering vocation training.

One part of the continuum cannot be considered in isolation. Granting a form of registration to students would involve consideration of the clinical experience and competencies that have been achieved in years 1 to 5 and, on entry to a vocational training programme, account would be taken of competencies achieved in years 6 and 7.

Such an approach has the potential to reduce the total number of years spent in training. Although graduation with a medical degree is a significant point in the path to obtaining registration, the Taskforce believes that improvements in clinical training in both the undergraduate and postgraduate years will have a greater impact in shortening the total duration of training than changing the point at which the medical degree is conferred.

Once the recommendations of this report have been put in place, shortening the undergraduate period of training should be reconsidered.

Oversight body

Innovations in technologies and treatments and improved collaboration offer a great opportunity to raise productivity across the health and disability workforce. Leadership and ownership of the whole training process are needed for these benefits to be fully delivered. We require a better understanding of the dynamics of the health and disability sector in which people train and work, to appreciate the factors that underpin successful new developments of the education and training system as a whole. Critical success factors for this system should be developed and monitored.

Because of the number of organisations involved, the Taskforce recommends that a body be established to provide strategic oversight of medical education and training from entry to medical school to registration in a vocational scope of practice.

The oversight body will provide a forum for collaboration between the providers of education and training and the providers of health care to ensure that medical education and training are effective and responsive to the needs of the health sector.

The Taskforce believes that an effective oversight body can be established to work within existing structures.

Implications for registration

The Medical Council of New Zealand is responsible, under the Health Practitioners Competence Assurance Act 2003, for setting the standards required to be met in order to practise medicine in New Zealand. Our recommendations suggest alternatives to the current registration requirements and assessment processes.

The Taskforce was strongly advised that an important part of medical training is learning to take increasing clinical responsibility for patient care. In order to do this effectively, trainees will require some form of limited registration. This will make it easier for the DHBs to provide the appropriate support for training and access to clinical experience.

Figure 1 on page 14 shows the proposed changes to education and training within the continuum of learning.

Outcome monitoring

Training performance is not recognised in the performance measures of individual institutions within the health system. Critical success factors go beyond addressing the performance of institutions individually, because it is the linkages between them that contribute most to changing the efficiency of the system. Monitoring might include review of measures such as:

← numbers of New Zealand and overseas graduates achieving general registration in minimum time

← numbers of New Zealand and overseas trainees with general registration awaiting entry to a vocational training programme

← numbers of New Zealand and overseas trainees with general registration in posts for which they will receive no vocational training credit

← assessment pass rates, progression and completion rates in each training programme

← monitoring the discrepancies between vacancies and applications for vocational training.

The establishment of a Medical Training Board would provide an opportunity to document the performance of the training system, which will serve to monitor the effectiveness of the Medical Training Board itself.

Implications for other professions

Concerns have been raised with the Taskforce that the establishment of a training board that is responsible solely for medical training would send an inappropriate message to other health professional groups. The Taskforce is very conscious of the need to break down the barriers between the health professions by promoting inter-professional collaboration and multi-disciplinary teamwork to ensure the most efficient use of resources and skills, if future health care delivery needs are to be met.

However, given that the Taskforce’s first task relates to addressing medical education and training, it considers that the focus of the training board should be on addressing the urgent issues relating to medical education and training as a first priority. The Taskforce recognises that, in future, it may be appropriate to extend the training board’s role to other health professions.

Recommendation 1a

That a body to be known as the Medical Training Board, involving providers of education and training and health care, be established to oversee medical education and training in New Zealand. It is proposed that the Board be jointly accountable to the Minister of Health and the Minister for Tertiary Education, and be required to:

← ensure effective oversight and co-ordination of the continuum of medical education and training in New Zealand; from entry to medical school to registration in a vocational scope of practice

← develop an educational framework for the transition years between the university environment and clinical practice

← receive advice from the DHBs and other providers of health care on the number and mix of medical practitioners required to meet future health care needs

← develop a national view on the appropriate number of training positions required to allow all trainees to complete their requirements to graduate MBChB, achieve general registration and, subsequently, registration in a vocational scope of practice with the Medical Council of New Zealand. The numbers must focus on meeting the projected health care needs of the New Zealand population

← approve clinical training specifications and funding intentions

← promote the recruitment and retention of medical trainees to meet the predicted future demand for the provision of health care services in New Zealand by vocationally registered medical practitioners, and take steps to ensure that the available programmes meet this demand

← develop mechanisms to collect appropriate data including regular longitudinal surveys of cohorts of students, trainees and medical practitioners, which will facilitate workforce development.

That:

← the Minister of Health and the Minister for Tertiary Education appoint the Medical Training Board

← the Medical Training Board be jointly serviced by the Ministry of Health and the Tertiary Education Commission.

Recommendation 1b

That the Medical Council of New Zealand:

← be asked to develop a process for limited registration for trainee interns

← work with the Medical Training Board to develop a process for competency-based assessment and progression to general registration.

Figure 1: Overview of proposed changes to the continuum of learning

[pic]

A commitment to ongoing self-sufficiency for the medical workforce

Of all OECD countries, New Zealand relies upon the highest proportion of overseas-trained doctors to meet its medical workforce needs. Currently some 41 percent of all doctors registered in New Zealand received their primary medical qualification overseas. This proportion is higher in particular areas, for example, psychiatry and rural general practice. There is a significant gap between the overall numbers we train and the requirements of the New Zealand health system. Although for a small country the “brain exchange” that results from a significant influx and efflux of doctors has benefits for the system, the size of this long-term net deficit is unsustainable. Changing workforce patterns and expectations of doctors are likely in their own right to increase the number of medical practitioners required in the future.

The Taskforce heard multiple submissions that indicated the difficulties caused by the lack of self-sufficiency in the medical workforce. The Medical Council reported the very significant increased workload associated with registration and supervision of overseas-trained doctors. Health care providers indicated serious difficulties with medical workforce recruitment.

The direction of the other recommendations contained within this document are designed to create an adaptive system that can produce doctors appropriately qualified and experienced to work in New Zealand. Such a system will inevitably be compromised if we continue to rely upon such a large proportion of overseas trained doctors to meet medical workforce needs. Numbers should be matched to New Zealand’s medical workforce requirements.

Projections are needed based on high-quality workforce information and production of appropriate numbers of New Zealand graduates to meet these projected needs. The Taskforce looks forward to the results of DHBNZ’s Health Workforce Information Project which is a strategic framework that will deliver a health workforce information system to establish a central point for:

← the collection of health workforce data throughout the health sector

← comprehensive analysis, modelling and forecasting of that workforce data that will produce key information for health workforce management and planning.

There exists within the current undergraduate and postgraduate training system, the potential capacity to train more medical practitioners.

Recommendation 2

That:

← the number of medical graduates produced by the training system be increased to ensure that New Zealand moves towards achieving ongoing self-sufficiency for its medical workforce

← the Medical Training Board review no less frequently than every five years the number of medical training places, both undergraduate and graduate, that should be funded by the government.

New roles and inter-professional collaboration

Some tasks that have traditionally been carried out by medical practitioners could be delegated to other people, specifically trained for this purpose. This would free medical practitioners to concentrate on their unique role in the workforce team and allow better utilisation of their skills for clinical teaching and ancillary roles.

Roles that could be explored and developed are those of the physician assistant, who would complete a formal tertiary qualification and work under the supervision of a medical practitioner, and the personal assistant, who could provide clerical and administrative support for medical practitioners in clinical settings.

Many activities currently carried out by medical practitioners could be undertaken by other practitioners. Nurse practitioners, already established in New Zealand, will play an increasing role in health service delivery in both hospital and community settings.

The best use must be made of all available workforce resources to improve service delivery. Traditional professional boundaries often hinder this. To improve teamwork, curricula should therefore emphasise inter-professional collaboration and care, communication and teamwork, which should be explicitly taught and assessed.

The Taskforce’s recommendations for streamlining the transition years will impact on service delivery, particularly in acute hospitals, and reinforce the need to develop new roles that complement the changes in those years. The Medical Training Board will have a critical role in ensuring that national standards for these new roles are developed in a timely way.

Recommendation 3

That:

← the Medical Training Board, in consultation with health care providers and consumers, consider the need for new roles to support medical practitioners and advises the Medical Council and education providers accordingly

← inter-professional collaboration and care, communication and teamwork be taught and assessed by universities as part of the medical undergraduate curriculum and throughout the continuum of learning, and that the same principles be reflected in work environments within DHBs and other health care providers.

Accountability for clinical training

Interdependence of training and service delivery

The DHBs and those responsible for training must recognise the interdependence, with potential for both conflict and synergy, between training and inter-professional, organisational and industrial matters. Any change in one is likely to impact favourably or unfavourably on the others.

DHB responsibilities

The Taskforce reinforces the importance of preserving the apprenticeship model for clinical training but recognises that there is no one generic approach to apprenticeship learning. The apprenticeship model is a concept and educational paradigm rather than a universal process and can be modified and adapted to incorporate sound educational processes. The DHBs must accommodate and support the apprenticeship model as part of their commitment to training within the service framework.

Training for trainees in the transition years differs from that for registrars who have chosen a vocational training programme for which a medical college is responsible. The experience for trainees in the transition years can be less satisfactory and even frightening. The training system is insufficiently supportive of trainees during this challenging period. For example, those who have not yet achieved sufficient skills and experience, or have no clear direction for their career, may have difficulty coping with the increasing demands of the service environment.

Because trainees have limited clinical capabilities and there is a perceived potential risk to the DHBs, there is a reluctance to devolve clinical responsibility to them. Training opportunities are reduced because trainees spend a large percentage of their time on largely administrative activities, or tasks that could be carried out by other staff members.

The primary focus of the DHBs and their provider arms is to deliver health services within the limits of the resources available. This has resulted in tension between the needs of service delivery and training and has led to senior medical officers experiencing considerable conflict between their responsibilities in their service role and as a trainer.

If clinical training of junior doctors is to improve, either DHBs will have to take greater responsibility for creating an environment of learning within hospitals that encourages senior medical practitioners to teach and trainees to learn or the education component of the transition years will need to be provided through universities or generalist colleges. Particular attention should be given to supporting and training teachers (train the trainer programmes) who are essential to the success of the apprenticeship model.

Medical training requires the co-operation of patients at all levels of health care. Currently trainees not infrequently encounter difficulty obtaining such co-operation, particularly in urban areas. DHBs should encourage collaborative relationships between health services and patients, in which both recognise their obligations to one another, including participation in training.

The Taskforce believes that creating a positive learning experience will not only produce better doctors but will have a significant effect on their recruitment and retention.

Funding

The CTA funds DHBs more than $60 million per year to provide training for the future medical workforce. However, often the senior medical officers who deliver the training are unaware that the funding exists, because it is incorporated into overall DHB funding streams for service delivery.

The CTA funding was originally paid to what are now DHBs to compensate them for the down-time involved in senior medical officer teaching. Educational contracts need to be far more explicit and DHBs more accountable for ensuring that funds for training are spent appropriately and their use identifiable in relation to specific training requirements. The appointment of Directors of Clinical Training in DHBs will be an important step towards achieving this.

Explicit allocation of funds for training allows for their most effective use. One example is the establishment of Skills Laboratories, which enable trainees to increase their competence and confidence in undertaking procedures required in their clinical practice.

Use of other providers

Currently there is a range of clinical training opportunities not available in public hospitals. If trainees are to gain broad or adequate experience they must have significantly greater opportunities to train in other facilities. There is no easy answer to the question of who should pay for training outside the public system. This includes private hospitals as well as general practices and NGOs. The Taskforce believes that it is important for workforce development that training opportunities be created within such environments, and that the private sector accepts a commitment to support the training of the future medical workforce. As for all other health care providers these facilities will need to be appropriately accredited.

Recommendation 4a

That:

← through their district annual plans, DHBs be required to demonstrate and report on their commitment to the education and training of their present and future workforce. This should include the development of an appropriate culture and environment for training, inter-professional collaboration and taking responsibility for providing both the necessary facilities and adequate supervision and guidance for doctors in training.

Recommendation 4b

That, to support clinical training:

← a national curriculum be developed by the Medical Training Board for the transition years, which clearly defines the standards and competencies required for entry to vocational training

← specific contracts for training be developed by the Medical Training Board to ensure and demonstrate the allocated funding is spent on training

← employers of doctors in training be made accountable for ensuring that the funds received are used to the best advantage

← DHBs ensure that senior doctors are trained and supported to deliver training for trainee doctors

← DHBs appoint Directors of Clinical Training

← working with the DHBs, the Medical Training Board work to ensure all providers of training have appropriate standards and external accreditation of their training programmes

← hospital and community settings for training include both private and public providers of health care.

An increasing focus on generalism

There is widespread support both in New Zealand and internationally for the view that broad generalist skills are desirable for all medical practitioners and should be the basis of learning in the undergraduate and early clinical training years leading to general registration.

There is, however, a trend in many countries to increasing specialisation and sub-specialisation, a trend that is influenced in New Zealand to a large extent by the Australasian medical colleges. Because of the size and distribution of its population, New Zealand has a greater need for vocationally trained generalists, such as in general medicine, general surgery, general paediatrics, general practice. This should be reflected in the Medical Training Board’s contracting arrangements.

General practitioner numbers and training

Over recent years, New Zealand has allocated considerable resources to implementing the Primary Health Care Strategy. If this is to be effective, training must match service delivery needs by placing more emphasis on the importance of the role of the general practitioner as a key member in the primary health care team.

“Greater emphasis on primary care can be expected to lower the costs of care, improve health by means of more appropriate services, and reduce inequities in the health of the population.”[3]

The CTA forecasts at least a three-fold increase in general practitioner graduates will be required to meet primary care service delivery needs in the future. Undergraduate training must focus on both increasing the student output and increasing the percentage of those graduates who will enter into general practice. The latter must be based on an understanding of the aspects of learning and training which influence students’ career choice.

At present, some 30 percent of medical practitioners in primary care settings, some of whom have been practising for many years, have met only the requirements for general registration, and are working in a collegial relationship with a vocationally registered general practitioner. The Taskforce stresses the importance, for safety and quality of practice, of general practice vocational training. All medical practitioners who wish to practise in primary care settings should be encouraged to complete the vocational training programme. Under the Health Practitioners Competence Assurance Act 2003, only practitioners who have met the requirements for vocational registration in general practice may practise independently as general practitioners.

Difficulties similar to those in New Zealand regarding recruitment and retention of general practitioner s have occurred in other countries and have led them to consider innovative ways to train medical students for general practice.

In New Zealand:

← programmes are already under way to give medical students more experience in general practice settings, particularly in rural areas

← funding has recently been increased for undergraduate medical education, some of which could be directed to further developing such programmes

← the CTA has been working with the Royal New Zealand College of General Practitioners to enhance the current vocational training programme.

The way forward

The Taskforce believes that there are significant further opportunities for students and pre-vocational trainees to gain more experience in communities rather than hospital settings, in programmes orientated towards generalism and community primary care. These will require significant development of training resources.

One option is to expand one or both of the existing medical schools into community settings and regions with the necessary population and clinician resource. Another option is to consider more radical approaches such as a completely new medical school based in an area with the required resources, namely an appropriate population and with sufficient suitable clinicians and community facilities. However establishment of a new medical school is likely to be substantially more expensive especially in an environment where staffing and workforce is already constrained. Expansion of both current schools into new regions is now happening, assisted by the recent increase in funding. Existing schools should report performance in these activities.

Recommendation 5a

That the Medical Training Board work with educational and training organisations to ensure that:

← all medical practitioners acquire a broad general foundation, which includes community and regional hospital experience, before entering vocational training

← the training system produces sufficient numbers of doctors entering the New Zealand workforce with training in general vocational scopes of practice.

Recommendation 5b

That, in relation to general practitioners in particular:

← universities be invited to bring forward proposals to the Medical Training Board for a primary care based undergraduate programme which is targeted to areas of need such as rural, Māori and high deprivation populations and is linked to postgraduate training for general practitioners

← further work be undertaken to submit an education and training programme for general practice to meet New Zealand’s needs, taking into account experience of innovative programmes overseas

← those factors both educational and non-educational that influence the choice of students and trainees for general practice as a career be identified and addressed.

Conclusion

Recommendations alone are of little value. What is important is achieving necessary change. The Workforce Taskforce believes the establishment of the Medical Training Board is fundamental for the implementation of strategies which will lead to the professional, organisational and cultural changes required to ensure a sustainable medical education and training programme. This will have a major impact on the delivery of health and disability services and the workforce that provides those services.

One of the first tasks of the Medical Training Board must be to establish a timeline for implementation of strategies to reshape medical education and training to meet the challenges of the 21st century in New Zealand.

Appendix 1: Investment in medical education and training

In 2004, the Tertiary Education Commission (TEC) and the Ministry of Health undertook a joint project to analyse the costs of education and training of health practitioners.

In relation to medicine, the analysis, based on 2002 data, showed that:

← $121 million per annum was spent on medical education and clinical training by the government, of which $43 million was met by the TEC on undergraduate and postgraduate education, $62.9 million by the CTA on clinical training and an estimated $15 million on clinical training indirectly by DHBs

← the cost of undergraduate education, in terms of equivalent full time students (EFTS) funding was $199,000 per student, of which 71 percent was met by the government and 29 percent by the student

← of the total annual cost of tertiary education of approximately $1,900 million, around 2.3 percent was spent on medical education.

The cap on medical programmes was set at 285 funded places in 1981 and was not increased until 2004. The cost of the 40 additional funded places in 2004 added $5 million per annum in EFTS funding and an additional $4.8 million per annum has been budgeted to meet the cost of clinical training as the graduates enter the health system.

From 2006, the level of the trainee intern grant was increased from $16,756 EFTS to $26,756 EFTS.

In December 2006, the Minister for Tertiary Education announced an increase in the EFTS funding rate for medicine of $13,566 per student, injecting a further $22.2 million into the system for medical education.

The CTA took over responsibility for clinical training on 1 January 1995 with “discretionary funding for allocation” of $45.2 million. In 2006/07, it spent $80.5 million on medical clinical training.

Appendix 2: Workforce taskforce membership

Mr Len Cook

Government Statistician from 1992 to 2000, and National Statistician of the United Kingdom from 2000 to 2005. Currently a visiting professor in the Department of Epidemiology and Public Health at University College London, and Research Associate of Population Studies Centre at Waikato University.

Associate Prof Margaret Horsburgh

Associate Professor of Nursing in the School of Nursing and former Associate Dean (Education) in the Faculty of Medical and Health Sciences, University of Auckland. Currently a director of a Primary Health Organisation.

Dr Frances Hughes

Originally trained as a nurse, now a health policy consultant, WHO Pacific Island Mental Health Network Facilitator and Adjunct professor-UTS Sydney. A member of the Health Workforce Advisory Committee, and its Medical Reference Group.

Dr Robert Logan (Chair)

Specialist physician and the Chief Medical Advisor at Hutt Valley District Health Board. Previous Senior Lecturer in the Department of Medicine at the Wellington School of Medicine.

Prof Iain Martin

Professor of Surgery for the University of Auckland until 2005. Now Dean of the Faculty of Medical and Health Sciences, University of Auckland.

Dr David Stewart

Former Assistant Vice-Chancellor for Health Sciences at the University of Otago. A current member of the Otago District Health Board and the Hospital Advisory Committee of the Southland District Health Board.

Dr Jim Vause

A general practitioner for 25 years, former president of RNZCGP and a member of the Health Workforce Advisory Committee, and its Medical Reference Group. Kai Tahu is his iwi.

Ms Suzanne Win

Originally trained as a nurse and has been involved in the health and disability system for 39 years. Currently Chair, Nelson Marlborough DHB. A member of the Health Workforce Advisory Committee.

Co-opted member for the first task

Prof Don Roberton

A former paediatrician and now Pro Vice Chancellor, Division of Health Sciences, and Dean, Faculty of Medicine, University of Otago.

Appendix 3: Workforce taskforce – terms of reference

Objectives

The Workforce Taskforce is established by the Minister of Health as a standing committee to provide him with advice on the implementation of actions necessary to improve the capability of the health workforce to deliver services in the future.

The Taskforce’s prime purpose is to provide advice to the Minister of Health on the issues specified by the Minister.

Accountability

The Taskforce is established by, and accountable to, the Minister of Health.

Membership

The Taskforce shall comprise a core of six to eight members, including the Chair. Appointments to the Taskforce will be made by the Minister. The Taskforce has the ability to co-opt members with particular expertise for specific tasks after consultation with the Minister.

Members will be innovative and strategic thinkers who will make specific recommendations to achieve change.

Terms of taskforce members

Members of the Taskforce shall be appointed for a term of up to two years.

Secretariat support

Secretariat and administrative support will be provided by the Ministry of Health on a project by project basis.

Minutes of each meeting will be kept. They shall record the issues discussed, and the decisions and recommendations reached.

The frequency of meetings will be determined by the Chair according to the nature of the specific task. Meetings may be held face to face or by teleconference.

Performance measures

The Taskforce will provide the Minister of Health with advice on specific projects within the timeframe specified by the Minister and to the Minister’s satisfaction.

All advice is to be based on research, evidence, analysis and consultation with parties likely to be affected by the advice.

Conflicts of interest

Should a member of the Taskforce face a conflict of interest so significant that they believe they will be prevented from reaching an impartial decision, they must declare a conflict of interest and withdraw from discussion and decision-making.

Initial task

The first task will relate to medical education and clinical training, taking into account the work already done by the Medical Reference Group of the Health Workforce Advisory Committee and the Doctors in Training Workforce Roundtable.

The Taskforce is asked to advise the Minister of Health and the Minister for Tertiary Education, by the end of March 2007, on how to streamline the current medical education and clinical training arrangements to produce medical practitioners who are fit for purpose and for practice in the minimum time period.

Options to consider include:

← shortening the number of undergraduate years

← starting specialist training during undergraduate years

← moving to a method of “payment for output” for medical education

← collapsing the first and second postgraduate years (PGY1 and PGY2) into one year

← giving more recognition to prior learning in the specialist training years

← appraising the apprenticeship training model in view of modern service delivery models.

For the initial task, at the request of the Chair of the Taskforce, analytical support and the preparation of working papers will be provided by the Ministry of Health (including the Clinical Training Agency) and the Tertiary Education Commission.

Appendix 4: List of submitters

Organisations

Australian and New Zealand College of Anaesthetists

Canterbury DHB – Christchurch Hospital Staff Association

Canterbury Medical Research Foundation

Clinical Training Agency

DHBNZ Medical Workforce Strategy Group

Health Workforce Advisory Committee

Medical Schools of the Universities of Auckland and Otago

New Zealand Medical Association

New Zealand Medical Students’ Association

Royal Australasian College of Physicians

Royal Australasian College of Surgeons

Royal College of Pathologists of Australasia

Royal New Zealand College of General Practitioners

Tertiary Education Commission

Individuals

Professor D Beaven

Mr Chris Bossley

Dr Stephen Child

Dr David McHaffie

Mrs Anne Kolbe

Mr B L Krause

Dr Garry Nixon

Dr John Thwaites / Dale Sheehan

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[1] Medical Reference Group, Health Workforce Advisory Committee. 2006. Fit for Purpose and for Practice: Advice to the Minister of Health on the issues concerning the medical workforce in New Zealand. Wellington: Health Workforce Advisory Committee.

[2] Doctors in Training Workforce Roundtable. 2006. Training the Medical Workforce 2006 and Beyond. Wellington: Ministry of Health.

[3] B Starfield et al (2005). Contribution of primary care to health systems and health. The Milbank Quarterly 83(3): 457–502.

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