AUGUST 2013 - New Zealand Doctor

The Royal New ZealandCollege of General PractitionersReview of the delivery of generalpractice vocational trainingProposal for the management of educational delivery,employment and/or provision of administration servicesrelated to the training of General Practice Registrars

RNZCGP Review of the delivery of general practice vocational training August 2013Project BoardProject Board MemberEmeritus Professor Dr Campbell MurdochMD, PhD, FRCGP, FRNZCGP (Dist)Dr Liza LackBMedsci, MB, BS, DRCOG, DCH, DFFPA,MRCGP, FRNZCGPProfessor Lorraine StefaniBSc, PhD, DipHERD, FSEDA, FHEADr Tana FishmanFRNZCGP (Dist)Dr John LanghamMBCHBHelen Morgan-BandaCEO RNZCGPRoleMedical Educator, GPEP Years 2 and 3National Clinical Leader, GPEP Years 2 and 3Professor of Higher Education StrategicEngagement, The University of AucklandSenior Lecturer, The University of Auckland,Department of General Practice and PrimaryHealth CareGPEP 2 registrarProject OwnerProject teamRochelle Leahy, Group Manager Business Services – Project LeaderDavid Vige, GPEP Year 1 Implementation Manager – Lead, Current State reportDr Samantha Murton, National Clinical Leader for GPEP Year 1 and the Postgraduate GeneralistPlacement Programme, Medical Director – Lead, Future State reportGlenn Cooper – Project ManagerTracy Woods – Business Analyst3

RNZCGP Review of the delivery of general practice vocational training August 2013Consultation processThe College has done considerable research and evaluation for the Training Delivery Review (TDR),but it is aware that, given the number and importance of the many external, and internal, stakeholdergroups, there is need for a broad and robust discussion about the points of consultation outlined inthis document.This document has been set out in four main sections:• The current state of training delivery• The predicted future state of training delivery• Options identified through research and evaluation• Points for consultation.The College is seeking the views and comments of the general practice community, and the widerhealth sector, to ensure that the proposals are thoroughly considered and critiqued. Following theconsideration of all submissions, the College will produce a final Training Delivery Report and beginthe development of any material and structures required for the programme. It is anticipated that anysignificant change would be implemented from the training year starting on 1 December 2014.The key dates for this consultation are:9 August 2013 Consultation document released.13 September 2013 End of consultation period.18 October 2013 Completion of final report.18 October 2013 Development of new training delivery model.December 2014Introduction of new training delivery programme.The College welcomes feedback on the points for consultation outlined below. All correspondenceshould be addressed to review@rnzcgp.org.nz4

RNZCGP Review of the delivery of general practice vocational training August 2013IntroductionThis review of how general practice vocational training is delivered had its genesis in significantchanges made to the training programme in 2012.After a competitive tender process, the College was successful in being awarded a contract byHealth Workforce New Zealand (HWNZ) to become the employer of General Practice EducationProgramme (GPEP) Year 1 registrars. The shift from registrars receiving a bursary to becomingemployees was part of a broader recognition of the need to make general practice an attractivecareer option to postgraduate registrars.This new agreement complemented the contract the College already had to provide vocationaltraining in general practice, providing the College with an opportunity to further partner with HWNZand general practice to create a sustainable general practitioner workforce.A review was also timely because it built on major changes to the GPEP curriculum made in 2012. Itmade sense to first change what is being taught and then explore the best way of delivering the newcurriculum.There are six phases to the review:1. A review of the current state of training delivery;2. A future state analysis to evaluate scenarios for potential changes in training delivery;3. Identifying options for how the College might deliver training in the future;4. Recommendations to reach the desired future state;5. Consultation with a wide stakeholder group; and6. Implementation of the updated training delivery programme.The first four phases have been completed and this report represents the fifth, consultative, phase.The College has already received the views of many individuals and interest groups, which, alongwith a wide range of other input, has allowed the project team to thoroughly assess the current stateof training and to identify the areas for consultation contained in this document.The options and recommendations presented in this paper are a result of collaboration between theCollege and a number of different interested parties.• Options were sought from the College membership and GPEP registrars, teachers and MedicalEducators (ME) via a survey. Responses were received from 165 people (GPEP Year 1 registrars37; GPEP Years 2 and 3 registrars 44; GPEP educators 43; other members 41).• A series of workshops were held with different groups of attendees:− − College National Advisory Council workshop, with representatives from the College Faculties,Te Akoranga a Maui, the College’s Training Chapter and the College Board;− − Educators workshop with GPEP Year 1 ME representatives from six of the 11 training regions,GPEP Years 2 and 3 Medical Educators and GPEP registrars; and− − Project Board and other stakeholders workshop, with representatives from Te Akorangaa Maui, Rural Hospital Medicine, Primary Health Organisations (PHO), universities andAuckland School of Medicine.• Peer review of the preliminary documentation by various MEs, GPEP registrars and Collegemembers.• Review and agreement on final report content from the College Board.5

RNZCGP Review of the delivery of general practice vocational training August 2013Executive summary1. General practice is playing an increasingly important role in New Zealand’s health system as, likeall developed countries, we face the challenges of ensuring better patient outcomes by enablingmore health services to be delivered closer to home.2. Having a vocationally trained general practice workforce is a fundamental building block inensuring that a wider range of high-quality patient care, and outcomes, occur within generalpractice.3. At a system level, we are in the process of transitioning from a training environment whereregistrars have been coming into general practice after spending four or more years in districthealth boards (DHBs) even though general practitioner (GP) training can start at the beginning ofa registrar’s postgraduate year 3 (PGY3).4. It is expected that future trainees will have increasing drivers to enter vocational training earlier,reducing their years of experience prior to coming into general practice. Some of this will bemitigated by the Medical Council of New Zealand’s (MCNZ) development of a curriculumframework for PGY1 and PGY2 within DHBs, with a focus on the attainment of basic skills withinthese years and time spent in community-based settings.5. Taking these changes into account, the TDR has investigated the current state of GP training inNew Zealand, determined a future state founded on best practice and evolving trends, evaluatedthe gaps and developed options to achieve the desired future state.6. The options developed propose some bold new models for GP training delivery. They explorea more even spread of training over three years and the delivery of training to a larger numberof registrars than at present, with the costs of training spread more equitably. The aim is toproduce high-quality, vocationally registered GPs with a commitment to continuing professionaldevelopment, who are able to practice to the top of their scope, allowing more health care to bedelivered within general practice.7. It should also be noted that many of the assumptions made in this report are based on thefuture development of programme-related activities. Given the time and funding needed for thedevelopment of any material around the proposed programme, it is anticipated that any significantchange would be implemented from the 2014/15 training year.8. General practice is not the only community-based vocational scope for doctors. With increasingnumbers of registrars entering other training programmes, such as accident and medicalpractice and urgent care, family planning and reproductive health, sexual health medicine andmusculoskeletal medicine, there is competition for registrars. This report reflects the expectationthat the number of registrars in GPEP will, in time, reach the Government’s target of 172 newgeneral practice registrars each year.9. Any change to training and education programmes will require evaluation which will needto assess the effectiveness of the programme by ensuring that the educational delivery andassociated learning is occurring in an appropriate manner.10. Another consideration is how training within general practice compares to training overseas, andto that provided for doctors training in other vocational scopes in New Zealand, and how best toaddress the imbalance that currently exists.11. The current GPEP training has 80% of training/educational delivery occurring in Year 1. Othertraining programmes have the education more evenly spread over all of the training years. Tospread GP training more evenly will require changes across all three years of training with thetime spent in education no less than the minimum required in other vocational scopes.6

RNZCGP Review of the delivery of general practice vocational training August 201312. If the College starts training less experienced registrars, for example PGY3 and 4, there willneed to be more time spent in training. This will make registrars ‘fit for purpose’ as they areprogressively trained to get generalist skills and provide more secondary care in the community.13. The intention is to introduce a three-year vocational scope training programme that requires fourhours per week of protected learning time in line with international training programmes and NewZealand resident medical officers (RMOs). This programme would guarantee employment forregistrars and give practices certainty about a three-year tenure of registrar employment.14. Every doctor who undertakes vocational training, whether in New Zealand or overseas, hasprotected education time throughout, and is employed to achieve this for the length of theirtraining. This means three years employment and three years training which will enable a clearpath to Fellowship of the College.15. The options presented in this report illustrate how this could occur, with time spent in educationbecoming equivalent to the minimum required in other vocational scopes.7

RNZCGP Review of the delivery of general practice vocational training August 2013BackgroundProject scopeThe College is the New Zealand training and education body for general practice and providesspecialist medical training and education programmes enabling vocational registration with theMCNZ as a GP.Training is provided by medical educators, teachers and practices under contract to the College.Training delivery is funded by the Crown through a contract to HWNZ, an agency of the Ministry ofHealth. The College and HWNZ are constantly managing the balance between operational efficiencyand vocational efficacy.GP training schemes began in New Zealand in the 1960s in Southland and Lower Hutt, and theCollege has delivered general practice training and assessment since the formal inception ofa national training programme in 1974. Since then there have been many changes including aminimum formal patient contact level set in 1982, a 36 day ‘day release’ scheme in 1984 and majorfunding cuts in the 1990s.Since 2004, registrar training has been encapsulated within GPEP which is the standard pathway toFellowship of the College and vocational registration as a GP in New Zealand.In July 2012, the College provided HWNZ with a Proposal for the management of employment and/or provision of administration services related to the employment of GPEP Year 1 registrars. TheCollege initiated the TDR as part of this agreement in order to ensure there was a vocational trainingprogramme for general practitioners, delivered in a sustainable way, that would meet the futureneeds of trainees and the profession as a whole.To that extent, the TDR is the next step in the evolution of GP training delivery in New Zealand.The project scope was documented in a Terms of Reference which determined three keydeliverables:• Review of the training delivery model and operations of the College;• Identify future state options for training delivery and operations; and• Agree options and make a recommendation to the College Board.The project scope excluded any review of the College curriculum, regulations or strategy.Three key themes1. There is a requirement for greater equity across all facets of training delivery and funding.Training delivery should be more equitably spread across all three years and utilise a bettercombination of the various methods of education delivery. Costs of training should be moreequitably spread across the stakeholders - those who provide training, those who receive trainingand those who are potentially advantaged by having registrars.2. There is a growing need for more, and closer, relationships between health care educationproviders, including medical schools, DHBs, primary health organisations (PHOs), othercommunity-based vocational scope trainers and the College.3. Some of the consultation options could potentially move straight to implementation, howevermany are more complex and require detailed feasibility and design work to be done priorto implementation. Funding is required for subsequent phases of work which may be bestapproached within the framework of an implementation project.8

RNZCGP Review of the delivery of general practice vocational training August 2013Project principlesParameters• Having a focus on 2025, including the future of (primary) health care needs and delivery, andensuring that training is congruent with future trends.• Researching how other programmes evaluated themselves, noting measures of effectiveness andefficiency.• Recognising the growing mobility of the workforce.• Recognising the need for more collaboration with partners.• Recognising that training begins at PGY1, not PGY3+.• Ensuring sustainability of general practice.• Recognising “best practice”.• Ensuring accountability of GPs in terms of their professional obligations to patients, to the sectorand to funders.The TDR set out to look at:• how the College’s training delivery measured up against similar programmes;• the use of technology in delivering educational programmes;• the best way to meet learning requirements of GP registrars; and• deliver a programme that met the future needs of vocational general practice.The review was undertaken by a project team comprising College staff and key stakeholders andincluded a stakeholder engagement programme to ensure the views of all sections of generalpractice that had an interest in training delivery were consulted.Project objectives• Review the effectiveness and efficiency of programme delivery against similar programmes.• Investigate innovative delivery models, including better use of information and communicationtechnology (ICT) and approaches used in other sectors.• Ensure that the College business model, management and methods for delivering training areoperationally cost effective and efficient.• Recommend innovations that will improve service delivery and/or reduce costs.• Ensure the model and/or recommendations for change acknowledge the needs of the vocationalpathway, education standards and learning requirements of GP registrars.• Ensure the needs and expectations of the various stakeholders of GP training are being met orareas for improvement are identified.9

RNZCGP Review of the delivery of general practice vocational training August 2013THE CURRENT STATE OF TRAININGDELIVERYThis section of the TDR outlines the current state of GP training in New Zealand, how it is deliveredover three years and how the current training model provides a pathway to Fellowship of the College.There is also a discussion on how GP training in New Zealand differs from other countries and otherprofessional vocational training programmes in this country.Comparison of GP training to other training programmesThe tables below provide a descriptive comparison of the College’s GP training programme withinternational GP training programmes.New Zealand GP training is comparable with international programmes in terms of its pre-requisiterequirements, start point and length of programme. However, the New Zealand programme doesnot provide as many hours of formal training for its registrars when compared to other GP trainingprogramme.Training start and prerequisite requirementsCountryNew ZealandAustraliaCanadaUKUSAPre-requisites for GP trainingTwo years (PGY1 & PGY2) as registrar (hospital-based) prior to GP trainingfrom PGY3.Full unconditional medical registration which is usually obtained at the end ofPGY1 so GP training starts in hospital in PGY2, then two further years with aminimum of 18 months in general practice.A four year degree prior to a four year medical programme after which doctorsare balloted into the speciality of their choice and then complete two years ofGP training.Two year foundation programme following graduation and prior to vocationalGP training of three years.A degree is required to enter medical school (four years), which is followed by a3-4 year residency in family medicine.10

RNZCGP Review of the delivery of general practice vocational training August 2013Number and spread of training hoursProgrammeNZ GP 406Total formalteachinghoursIncludes CMEin GPEP Years2 and 3, ACLScourse etc.Average annualformal teachinghoursFormal teaching hours made up of135 Year 1: 7.5 hours/week, (1.5hrs/wk withteacher, 40 x 6 hour seminars and two4hr IPVs)Year 2 & 3: 35mins/week (8 hrs IPV,32 hours learning )Australia GP 719 240 1 st 6 months: 9 hours/week2 nd 6 months: 7.5 hours/weekYear 2: 7 hours/week(after their first vocational year at PGY2in the hospital)Canada GP 442+ 220+ Years 1 & 2: 4-6 hours/week over 48weeks, varies according to rotationNetherlands GP 672 225 Years 1 & 3: 6 hours/weekYear 2: 6 hours/monthNZ Psychiatry* 1920 380 Years 1, 2 & 3: 12 hours/week for 48 weeksYears 3 & 4: 4 hours/week for 48 weeksNZ Physician* 1152+hours 192 Minimum educational time for any RMOaccording to MECA* All other registrars employed in a DHB are entitled to four hours per week of protected teachingtime for the length of their vocational programme.General Practice Education Programme (GPEP)Since 2004, registrar training has been encapsulated within GPEP which is the standard pathwayto Fellowship and vocational registration as a GP. The current programme is based on registrarsworking in general practice, with opportunity to experience a variety of practice environments.Acceptance into GPEP Year 1 is based on, amongst other things, educational and hospitalprerequisites and a formal interview. The programme can be completed either on a full-time (eighttenths)or part-time (five-tenths) basis.During GPEP Year 1, registrars are attached to an accredited teacher in an approved trainingpractice. In 2012/2013 there were two six-month attachments beginning December 2012 (previouslyeach attachment was 21 weeks).This is an immersion experience in general practice, where the registrar sees patients and receivesa minimum of 1½ hours of protected teaching time from their GP teacher, as well as teaching andguidance from other members of the practice team. Registrars spend the majority of their time seeingpatients, which provides the main basis for learning.11

RNZCGP Review of the delivery of general practice vocational training August 2013Diversity of attachments is encouraged with registrars completing GPEP Year 1 in two differentpractices. There are no compulsory attachment requirements i.e. rural or high needs, but financialallowances and incentives are available to registrars in rural or high needs areas. The objective isto give registrars experience in full-time general practice while providing opportunities to reflect onthe learning that is occurring. The registrars also attend 40 day-release seminars and workshops,primarily in small groups facilitated by medical educators. There is also an allowance of five furtherdays of conference attendance or other educational activity within GPEP Year 1.The standard full-time GPEP programme (Years 1-3) is 36 months. During GPEP Year 1, registrarsare employed by the College and the College arranges attachments for the registrar. In GPEPYears 2 and 3, registrars are required to source their own placements and they are employed by thepractice(s) in which they work. The following diagram shows how the training programme fits into aregistrar’s postgraduate years.During the three years of GPEP, 18 months of training must be based in a traditional generalpractice. The remainder of the programme may be made up of a combination of placements,including varying lengths of time in the following:• traditional general practice;• minimum of six months in another vocational scope;• generalist primary care or community-based services e.g. student or geriatric health, armedforces, accident and emergency, rural hospital, after-hours clinics;• general practice research;• specialist community-based services, e.g. sports medicine, alcohol and drug medicine, familyplanning, occupational health;• urban/provincial hospital environment, e.g. palliative care, emergency care;• clinical practice in another country (prior approval required); and/or• clinical education and/or research relevant to general practice (prior approval required).12

RNZCGP Review of the delivery of general practice vocational training August 2013Current GPEP Year 1 delivery methodsIn-practice training with GP teacherThe purpose of clinical practice attachments is to develop the registrars’ specialist skills in generalpractice consultation and to enable the translation of prior learning to a community-based primary healthsituation.There are two 26-week attachments in 2013, where registrars typically spend eight half-day sessionsper week in the practice. During the attachments the majority of registrar time is spent with patients, butnumbers are held at a level that reflects the registrar’s needs and experience. To begin with, registrarpatient loads are normally five consultations per session (half-day). By the middle of the first placementthis should have increased to eight to 10 per session and by the middle of the second placement patientloads should be more than 13 per session.At each attachment the registrar is assigned an approved GP teacher, who has responsibility for theregistrar’s on-site teaching and supervision. This relationship is facilitated by an ME who also undertakesone half-day site visit during each attachment.GP teachers are contracted to meet with their registrar for a minimum of one-and-a-half hours each weekfor teaching purposes.In-practice visits by MEAn ME will have a three hour visit with the registrar in their attachment practice six to eight weeks intoan attachment, although it can be requested earlier. The purpose of the visit is to ensure the attachmentis meeting the registrar’s learning needs and that the attachment meets the requirements of theprogramme.Following the visit, the ME will provide a written report to the registrar, the GP teacher and the GPEPYear 1 Clinical Leader.Day-release seminars and workshopsDay-release seminars are run in conjunction with attachments and are focused on:• orientation;• the 34 curriculum-based training scaffolds;• four communication modules; and• mock GPEP clinical and written exams (formerly known as Primex).Forty full days are allowed for the seminars for which there are two formats:• Regional workshops are held once a term and focus on communications training, combined withanother related topic which provides ‘real life’ examples for the communication skills being learned.Actors are used to simulate practice consultations and guest speakers may also be invited.• Group seminars are held one day a week, except in regionally difficult areas such as Otago whichhave block courses. Group seminars are facilitated by MEs and involve the teaching of core topics,clinical skills and knowledge, with each seminar involving a minimum of six hours of educational time.In addition to the teaching outlined above, registrars are required to complete a number of educationalrequirements or learning tasks in order to develop scholarship skills and to increase their clinical expertise.These include vignettes, ‘what the evidence-base suggests’ (WEBS) or MATCH questions (a form of quizsimilar to the format for GPEP written assessments), videoed consultations and community visits.13

RNZCGP Review of the delivery of general practice vocational training August 2013Training environment – roles of the teacher/supervisorReflectionAll medical vocational training in New Zealand, be it in primary or secondary care, occurs in unisonwith work place activities and is supervised by senior colleagues which allows for reflection onthe learning in practice. This reflective process often needs to be facilitated by peers or seniorcolleagues.Learning opportunitiesSupported on-the-job patient care provides valuable learning opportunities for developingcompetencies in general practice whilst ensuring patient safety. Whether it is through a formalisedlearning opportunity or simply from seeing a range of patients over a period of time, there is no doubtthat patients offer a unique view that can enhance the acquisition of skills, and change attitudes.Role modelling and peer supportRole modelling is a normal part of any vocational training and it is important that a variety ofexperiences and role models are seen. In Australia, UK and New Zealand registrars are allocated todifferent practices at times in their training which is a strength of these programmes. Peer supportduring training allows registrars to learn from others at the same level, provides support to thoseinvolved and also develops relationships that are long-lasting.AssessmentFormative assessment throughout training aids in the development of skills. Assessment needs tobe undertaken by those who are trained in this process. There needs to be a consistent approachas well as a formal process by whoever is assessing registrars for the development of these skills,knowledge and attitudes.Clinical Leader supportIn both GPEP Year 1 and GPEP Years 2 and 3 oversight of the programme is provided by ClinicalLeaders. The Clinical Leaders provide support to the registrars, teachers, MEs and administrationstaff as well as overseeing the strategic direction of the programme.MaterialsRegistrars require ready access to up-to-date material to aid their learning, but with the move to moreelectronic media there is requirement for educational resources to also be available online. Whilesome resources are available as documents on the learning platform, access to an electronic libraryis not, and is an option that needs to be explored.EducatorsThe education of educators is provided in a variety of ways including professional development days,conferences and the College’s Education Convention. Having trained teachers, facilitators, educatorsand/or supervisors is vital in supporting registrars and requires focused professional developmentplans for these individuals. It is also important for registrars to have opportunities to be educatorsthemselves. The Education Convention is well supported by educators across general practice and isself-funding.14

RNZCGP Review of the delivery of general practice vocational training August 2013GPEP Years 2 & 3The goal of GPEP Year 2 and 3, collectively known as GPEP2, is to assist senior registrars to furtherdevelop their skills and knowledge in general practice, building on the learning achieved in GPEP Year1, and culminating in assessment for Fellowship.Registrars are eligible to enter GPEP2 on completion of GPEP Year 1 or accepted equivalent. Seniorregistrars must be working at least four-tenths in a clinical area. While GPEP2 can be completedwithin two years, due to various factors the average completion time is 4.7 years. GPEP2 is based onregistrars completing two components: the education programme (annual activities) and clinical time.Completion of clinical time can extend beyond the period of the education programme.GPEP2 training delivery methodsPlacement supervisionUnlike GPEP Year 1 registrars, registrars in GPEP2 are responsible for finding a practice in whichto complete their required clinical hours. GPEP2 registrars are employed by their practice andsupervision of their practice work is as per standard employer/employee supervision and will bedifferent in each practice.While GPEP2 practices and the Fellows within them do not receive financial remuneration forteaching, teaching of GPEP2 registrars does occur in practice. This teaching is often informalopportunistic discussions or corridor teaching to respond to on-the-spot queries and concerns, butmore formal teaching and review may occur depending on the practice.Allocated MEEach registrar in GPEP2 is allocated an ME who facilitates the progress of registrars through theGPEP2 programme via regular contact with them. The ME is required to read and discuss with eachregistrar their Professional Development Plan and assist the registrar to identify their professionaldevelopment and learning needs.Learning groupsEach GPEP2 registrar is allocated to a learning group facilitated by an ME. Traditionally learninggroups have met physically, out of work hours, with groups structured around the geographic locationof registrars. The increasing use of Skype and other video conferencing tools has changed thisdynamic, with mixed and ‘Skype only’ groups being created in recent years. Traditional learninggroups consist of 6-12 registrars while Skype-based groups have 5-8. Learning groups meet everysix weeks (eight per year) for around two hours outside work hours.ME practice visitOnce a year, the allocated ME will visit each GPEP2 registrar at their practice. During the visit, whichusually takes four hours, the ME will:• observe a series of consultations;• assist in videoing consultations as appropriate;• view practice premises, resources and equipment;• review a selection of the registrar’s patient records;15

RNZCGP Review of the delivery of general practice vocational training August 2013• discuss with the registrar what they have observed during the visit;• review the registrar’s personal development plan; and• provide other information and advice as appropriate.360° multi-source feedbackThe 360° multi-source feedback (MSF) is an independent report using feedback from peers, otherhealth care professionals and patients. Registrars have a choice of two types of MSF, both of whichare a number of short online questionnaires in which registrars assess themselves and then ask10-12 others to provide feedback via specific questionnaires.Learning tasksRegistrars in GPEP2 are expected to complete various learning tasks during each of the two 12month cycles of GPEP2. These include:• Professional development plan (one per year/cycle)• BPPQ or clinical audit (one per year/cycle)• In-practice visit from an ME (one per year/cycle)• Attend six out of eight learning group meetings• One MSF, normally completed near the end of the final year.Ongoing educational requirementsUpon completion of the two GPEP educational cycles and until attaining Fellowship, GPEP registrarsare required to meet annual educational requirements similar to that of Fellows:• Professional development plan• Clinical audit• Peer review meeting of at least 10 hours per year• A minimum of 20 hours continuing medical education (CME)• Meet annual requirements for clinical supervision.Fellowship assessmentOn completion of all GPEP2 requirements, a Fellowship assessment visit occurs in the registrar’sworkplace, which is undertaken by an experienced Fellowship Assessor. The final consideration toaward Fellowship lies with the Censor in Chief and one other censor.16

RNZCGP Review of the delivery of general practice vocational training August 2013FUTURE STATE OF GP TRAININGIN NEW ZEALANDThis section of the TDR consultation document examines the trends that will determined the GPtraining environment in the future and the dynamics that will influence the models of training. It alsoexplores the likely profiles of registrars, teachers and practices as they evolve over the next 10-15years.IntroductionGP training in New Zealand must change to align with the required skill sets and workingenvironments of doctors who will be GPs in 2020 and beyond. To ensure that the College develops atraining programme suitable for the GPs of the future, a number of guiding principles were identified.• The patient experience of care when a doctor is in training should not jeopardise their health care,however doctor training should be primarily experience-based.• Doctors need to be trained to work in a variety of settings, hence they must be trained in thosesettings, i.e. aged care facilities, as well as gaining experience with more vulnerable populationssuch as Māori and Pacific Island groups.• Training must reflect team-based work environments.• Ensuring that GPs have training which reflects the patients they will be treating and thetreatments they will be providing.• Working to increase the number of practicing GPs in New Zealand.• Equality, both financial and educationally, with other training schemes, allowing for the uniqueenvironment of GP training.Future trendsAs the population of New Zealand ages, not only does the care required by this population changebut so too does the age of the doctors treating them. The New Zealand Medical Workforce in 2011report identified that, on average, New Zealand has 75 GP full time equivalents (FTE) per 100,000people, but a number of regions have less than 64. The age structure of the current GP workforce isexpected to show an increase in average age, followed by a high proportion of these GPs retiring in2020/2025. The tagging of health training money to vocational training programmes from PGY3, andincreasing amounts of secondary level health care being provided in community based settings, willhave an impact on the training required by GPs in the future.The GP registrars of the future are likely to be:• 60% or more female, although the number of male GP registrars is increasing;• younger, a result of increased funding tagged to vocational training and doctors being encouragedto decide on their vocational scope earlier. This lowering of the average age of commencementin GPEP Year 1 may reduce the number of registrars being involved in parenting during theirtraining;17

RNZCGP Review of the delivery of general practice vocational training August 2013Future training• more technologically savvy and more comfortable using online self-service channels and usingsocial media to interact with their peers;• comfortable with on-the-job, team-based learning and learning in a small group environment;• location immobile and expect that they can work and train in locations that are in close proximityof each other, or use technology to ‘close the distance’;• frequently changing their place of work, practice environment and/or their role within theirpractice;• able to make their own choices about their work and training locations and hours; and• providing a higher level of care within the community.The GP teachers of the future are likely to:• be aging, meaning for the next 10 years the age gap between the GP registrar and the GPteacher will grow. By 2020 there may be a shortage of GP teachers/supervisors as GPs retire;• have greater demands on their time, as a shortage of GPs will require GPs to manage a greaternumber of patients;• be increasingly female, as male teachers/supervisors retire. Depending on the number of femaleGPs who work part-time, the pool of potential teachers/supervisors may be further reduced, or theavailability of these teachers/supervisors may be reduced;• share teaching/supervision responsibilities with others; and• demand greater professional development.The GP practices of the future are likely to:• be owned by a group of professionals, who may, or may not, be doctors;• employ a wider range and larger number of healthcare professionals, including doctors;• provide better opportunities for peer review and support;• have reduced on-call and after hours work; and• deliver higher scope procedures.The College has developed forward-looking propositions which it believes will ensure that the GPtraining programme is fit for purpose for the GP of the future. These are outlined below.Pre-vocation trainingIn New Zealand, PGY1 and PGY2 training is completed in a hospital without any, or minimal, inputfrom or contact with GPs or the College. On the other hand, PGY1/2 interns are interacting withspecialists on a daily basis and seeing, or hearing about, the ‘cutting edge’ developments beingmade.18

RNZCGP Review of the delivery of general practice vocational training August 2013The 2011 survey by the New Zealand Medical Association (NZMA) showed that the average time fortrainees to decide on a career choice was three years after graduation. By the end of PGY2, 44% oftrainees had decided on a vocational training programme, 78% by the end of PGY4, and 13% tookmore than six years to decide.The same survey showed a very different picture for general practice, with trainees who decide toenter the GPEP programme doing so much later. For example 97% of general surgery registrars hadmade the decision to enter that training programme by PGY4. By comparison, only 58% of GPEPregistrars had made the decision to enter the GPEP training programme by PGY4.If the College is to increase the profile of a career pathway in general practice, more interaction isrequired between the College and the PGY1/2 interns. To achieve this, the College and the DHBsneed a more structured relationship which allows the College access to PGY1/2 doctors.The proposed introduction of community based training in PGY1/2 will expose more interns to generalpractice, however there will be greater pressure placed on limited general practice training positionsand teachers.19

RNZCGP Review of the delivery of general practice vocational training August 2013Starting point and length of training programmeInvestigations into international GP training programmes show that the starting point of NewZealand’s GP training is comparable and therefore the College recommends that the starting point ofthe training programme remain unchanged at PGY3.Similarly, comparisons of the length of training programmes show that the New Zealand programmeis comparable with those overseas and therefore the College recommends that the length of thetraining programme remain unchanged at three years.Time in general practiceOver the three year training programme, registrars are currently required to spend six monthsin another vocational scope and 18 months in ‘traditional general practice’. The registrars havesome flexibility regarding where they practice for the remaining 12 months although the majority ofregistrars spend this time in general practice. The time spent in general practice in New Zealand iscomparable with international training programmes.The majority of GPEP registrars spend more than 24 months in general practice. However, making24 months in general practice a requirement for the GPEP training programme would restrict therural hospital and Accident and Medical Practitioners Association (AMPA)/College of Urgent CarePhysicians (CUCP) programmes, therefore the College recommends that the required time spent in‘traditional general practice’ remains at 18 months.Number and spread of training hoursWhile the start point and length of New Zealand’s GP training programme are comparable with otherinternational training programmes, the number and spread of training hours is not.The formal teaching hours for the GPEP training programme are well below that of other internationalGP training programmes and other New Zealand vocational training programmes. The Collegeproposes that the total number of educational hours does not decrease as it would put theprogramme more ‘out of step’ than it currently is compared to other vocational training.The New Zealand GP training programme has, through a mixture of history and evolution, adisproportionate number of hours occurring within the first year of training with minimal formaltraining in the second and third years. This does not match any other programme in general practiceglobally or within New Zealand’s overall medical training environment. The College proposes that amore even spread of formal training hours between the programme years be implemented. The totalnumber of hours will take into account self-directed learning, with the expectation that this learningwould occur during working hours.Registrar employmentIt is important that registrar employment, employment conditions and funding interact with the GPtraining programme in such a way as to maximise the learning outcomes for registrars. To ensurethat the training programme and registrar employment will achieve this, the College proposes that:• doctors are provided with continuity and certainty of employment over the full length of thetraining programme;• the employer must ensure that the registrar’s learning time is protected and that learning canoccur during business hours;• those parties which benefit from the services provided by GPEP registrars make a contributionto the registrars’ salaries. It is envisaged that, as per the Australian model, the proportion ofcontributions by funders will change as registrars gain more experience and their ability togenerate revenue for a practice increases; and20

RNZCGP Review of the delivery of general practice vocational training August 2013OptionsOption 1: Number and spread of training hoursPoints for consultation1. That the total number of educational hours does not decrease as it would put the programme more outof step than it is currently compared to other vocational training.2. That increased hours of education be delivered within the current financial constraints.3. That a more even spread of formal teaching hours between the programme years be implemented.These hours may be delivered in a different format than currently.4. The total number of hours will take into account self-directed learning (or directed self-learning), withthe exception that allowance will be made for this learning to occur during work hours.Formal teaching hours for the New Zealand GP training programme are well below those of otherinternational programmes. Additionally the programme has a disproportionate number of hoursoccurring within the first year of training with considerably less formal training in the second andthird years. This does not match any other programme in general practice globally or within the NewZealand medical training environment.ProgrammeTotal formalteaching hoursAve. annualformal teachinghoursFormal teaching hours make up ofNZ GP 406Includes CMEin GPEP Years2 and 3, ACLScourse etc.135 Year 1: 7.5 hours/week, (1.5 hrs/wkwith teacher, 40 x 6 hour seminars andtwo 4hr IPVs)Year 2 & 3: 35mins/week (8 hrs IPV,32 hours learning)Australia GP 719 240 1 st 6 months: 9 hours/week2 nd 6 months: 7.5 hours/weekYear 2: 7 hours/week (after their firstvocational year at PGY2 in the hospital)Canada GP 442+ 220+ Years 1 & 2: 4-6 hours/week over 48weeks, varies according to rotation.Netherlands GP 672 225 Years 1 & 3: 6 hours/weekYear 2: 6 hours/monthNZ Psychiatry 1920 380 Years 1, 2 & 3: 12 hours/week for 48weeksYears 3 & 4: 4 hours/week for 48 weeksNZ Physician 1152+hours 192 Minimum educational time for any RMOaccording to MECA22

RNZCGP Review of the delivery of general practice vocational training August 2013A question proposed in a survey undertaken for the project asked if the programme’s training hourswere adequate and if they should be more evenly spread across the three years.ResponseGroupAre hours adequate?Too much Too little Just rightDon’tknow80/10/10(current)How should traininghours be spread?50/30/20 EvenlyGPEP1 0 1 36 0 9 23 5GPEP2 1 11 32 0 12 25 7MEs 0 1 37 0 18 22 3Others 0 8 19 9 11 15 10TOTAL 1 21 124 9 49 85 25While the total formal teaching hours for the New Zealand GP training programme are below those ofother programmes, teachers, educators, registrars and Fellows of the College appear to be comfortablewith the current level. However, an increase in these hours would provide the opportunity to delivermore training to younger registrars, ensure completion to Fellowship, and increase generalist training in‘top of scope’ skills, thereby enabling more provision of secondary care in general practice.While the total number of formal teaching hours maybe adequate, the spread of these hours isinconsistent with the spread of hours within other programmes, and does not appear to be meetingthe needs of registrars. The questionnaire results, outlined above, would indicate desire from thosesurveyed to have training hours more evenly spread across the years of the GPEP programme.Spread Of Educational HoursThe current educational delivery model has a focus towards GPEP Year 1, with 80% of trainingoccurring in this year. The main driver for this has been funding as the majority of funding is taggedto GPEP Year 1 with minimal funding in GPEP Years 2 and 3.The TDR recommends that there should be a rebalancing of education across all three years of theprogramme. This would mean a significant change in the delivery of the programme from the existing80:10:10 model, where registrars receive 80% of their training in Year 1 and 10% in each of Years 2and 3, to a proposed model of 50:30:20. The proposal recognises both the requirement for educationthroughout all years of training, as well as skills development and increased self-directed learningover time.With a proposed 50% of education delivery occurring in Years 2 and 3, when the registrars are nolonger College employees, there is a significantly reduced ability to ensure that registrars are able toaccess the education they require unless there is also a change to the model of employment.It is proposed that the total number of education hours delivered equal 480 hours across three years,compared with the current 406 hours, including continuing medical education (CME) and advancedcardiac life support (ACLS) in GPEP Years 2 and 3.The proposition is that training hours are spread across the three years in a 50:30:20 ratio (currently80:10:10) and that the hours are spread between the educational components (see pages 13-16):• Immersion training: 30%• Small group seminars: 50%• Online education: 15%• Workplace assessments: 5%23

RNZCGP Review of the delivery of general practice vocational training August 2013The proposed hours are shown below with current educational hours shown in the brackets:Education component GPEP Year 1 GPEP Year 2 GPEP Year 3 TotalImmersion training 72 (72) 43 (0) 29 (0) 144 (72)Small group seminars 120 (240) 72 (16) 48 (16) 240 (272)Online education 36 (0) 22 (0) 14 (0) 72 (0)Workplace assessments 12 (8) 8 (4) 4 (4) 24 (16)TOTAL 240 (320) 145 (20) 95 (20) 480 (360*)*Excludes 46 hours (proposed 96 hours) of self-directed learning24

RNZCGP Review of the delivery of general practice vocational training August 2013Option 2: Employment and use of fundingPoints for consultation1. That equitable education funding is obtained for the GPEP programme in comparison with othervocational registrar training programmes.2. That agreement is obtained that once a registrar is accepted in to the programme that three years ofeducation funding will be provided at a predetermined level and that this level will be determined prior toApril each year.3. That the College enters discussions with HWNZ to introduce the alternative model of fundingemployment and training. This model of employment could be in effect for the 2014/15 cohort ofstudents.Education and Salary FundingThe sum of HWNZ funding for GPEP provides for both education and employment, in termsequivalent to the MECA scale, for GPEP Year 1. Education funding is provided through all threeyears with the majority in Year 1. In contrast for registrars training within DHBs, HWNZ pays for theeducation components, the teacher to deliver training and a portion of the salary for the registrarwhile they receive the education. DHB Registrar Medical Officers (RMOs) are entitled to four hours ofprotected teaching each week.In an ideal future state, the principles underlying training should be that GPEP registrars are able toundertake education with appropriate supervision throughout all the years of their training. To enablethis to occur, the employer should have control over employment conditions throughout the wholetime registrars are in the programme as occurs for all other vocational scopes.To be able to operate GPEP in the most effective manner, and to be able to attract the highestpossible number of registrars, the College needs agreement from HWNZ that once a registrar isaccepted onto the programme that the full three years of educational funding will be provided at apredetermined level.Option 2.1 (status quo): College employs registrars for GPEP Year 1, withpractice employment in GPEP Years 2 and 3The current employment model, in place since December 2012, has GPEP Year 1 registrars beingemployed by the College, with salaries being funded by HWNZ. The shift from registrars receivinga bursary to becoming employees was part of a broader recognition of the need to make generalpractice an attractive career option to postgraduate registrars.The registrar is assigned to work in a practice under the supervision of a teacher selected andtrained by the College. The majority of the GPEP education components (80%) are also deliveredduring this year, with funding provided by HWNZ under a separate training contract.In GPEP Years 2 and 3, registrars are employed directly by the practices in which they work. Thereis no HWNZ funding for the salary of these registrars. A small amount of funding provides for someeducation delivery. The registrar is required to pay a fee ($3700 in 2012) to be part of the programmeand this provides the balance of funding to allow the delivery of the education components in Years 2and 3.At present education funding for GPEP 1 registrars is $25,688 while GPEP Years 2 & 3 are fundedfor a maximum of $4640 for a maximum of 100 registrars.25

RNZCGP Review of the delivery of general practice vocational training August 2013This model works because the majority of training occurs while the registrar is a College employee,although it has its limitations such as the intensive early training leaving less time for on the jobeducation.Option 2.2: Alternative employment and educational funding modelThis model would see the College becoming the employer of GPEP registrars for the full threeyears that they are on the programme. The College would continue to place registrars in a variety ofpractices enabling ongoing focus on high needs and rural practices.The registrars would be sub-contracted to the practice in which they train. The practice would paythe College for the services provided by the registrars. The subcontract rate may be less than thetotal salary as a reflection of the teaching and supervision required by a registrar and his/her level ofexperience.As employer of the registrar, the College would have significant input into the conditions and hoursthat the registrar is required to work and could therefore protect a registrar’s learning time. This wouldallow an increase in the amount of educational delivery in GPEP Years 2 and 3 and also endorse thelearning to occur during daytime hours rather than the current evening groups that are run.The College would also be able to set the salary rates for the registrars. At present GPEP registrarsalary rates, especially in Years 2 and 3, are more than those of their hospital-based peers who arepaid based on the MECA salary scale. This option would pay GPEP registrars using MECA as aguide and in accordance with the MECA scale.As an incentive to join the programme, practices would be guaranteed a GPEP registrar, althoughthere would be no guarantee of the year of that registrar. This would enable the practice to build upa patient base to ensure income from the registrar’s service (capitation funding). Practices would beentitled to generate income from the registrar’s service and this income (less subcontract paymentsto the College) would pay the practice for time spent teaching/supervising.This model would allow the College to spread HWNZ funding over the three years of training tobetter reflect the hours of educational delivery in each year of the programme. It would rely onfunding being commensurate with other vocational scope funding over the three years of training.HWNZ would continue to pay at the same rate as currently, but less of that money would go towardsemployment as this cost would be shared by the practice.The practice would not pay much more overall than currently for GPEP Years 2 and 3 employment,but they might be working at a loss with GPEP Year 1 registrars. Therefore it would encouragepractices to have multiple levels of registrars to mitigate against this loss and therefore supportvertical integration as part of education delivery.This is similar to the model currently used in Australian regional training programmes, with moneyfrom GP education and training going to both education and employment. In the earlier part oftraining, more money goes to offset employment costs and then reduces as expertise is gained andvalue to the practice increases. The College fee is separate from registrars’ contribution to education.26

RNZCGP Review of the delivery of general practice vocational training August 2013Option 3: Start point, length of training programme and othervocational scope requirementsPoints for consultation1. To ensure MCNZ requirements are met, future registrars should be interviewed during PGY2 andattached to the GPEP programme from PGY3. There should be an option to complete the PGY3 withina DHB.2. Discussions to be held with HWNZ and DHBs to determine the feasibility and funding requirements ofa PGY3 training year being completed within DHBs.3. The length of the GPEP programme remains at 36 months, although some registrars may complete anadditional year (PGY3) in a hospital setting.4. The time spent in ‘traditional general practice’ during GPEP training remains at 18 months.5. That runs in either high needs, Māori/Pacific or rural practice are explored with the concept thatcompletion of six months in one of these runs is undertaken during training.Registrars who enter the GPEP programme do so with a range of medical training backgrounds,experience and other vocational learning.Currently registrars can start the GPEP training programme at PGY3 and go directly into generalpractice with no other vocational scope training required. Commencement of GPEP training at PGY3is often not possible as the prerequisite number of hospital runs has not been completed. Forty-twopercent of registrars do not begin GPEP training until PGY5+ often for this reason.INTERNATIONAL COMPARISONThe table below shows a comparison between the start point and length of the New Zealand GPtraining programme and other international GP programmes, as well as other New Zealand medicalprogrammes.ProgrammeStart oftrainingLength of vocational trainingNZ GP PGY3 3 years (4 years for rural hospital fellowship, reduced withrecognition of prior learning).Australia GP PGY2 3 years (4 years for rural and remote medical registrars, reducedwith recognition of prior learning).Canada GP PGY1 2 years (+1 extra year option taken by most trainees)Netherlands GP PGY3 3 yearsUK GP PGY3 3 yearsUSA GP PGY1 3-4 yearsNZ Psychiatry PGY3 5 yearsNZ Physician PGY2 6 years27

RNZCGP Review of the delivery of general practice vocational training August 2013In relation to the minimum time requirement in general practice, New Zealand general practiceregistrars are required to undertake at least 18 months, although many spend the majority of theirthree years in general practice. The exceptions are those registrars who want to achieve dualfellowship in rural hospital medicine and general practice and who are on the rural hospital medicineprogramme concurrently. For several international programmes, one year is compulsory and othertime is optional.PROGRAMME STARTThe review has identified two options available to the College regarding when to accept trainees ontothe GPEP programme.Option 3.1: Status quoThis option would see a continuation of the status quo. Registrars would be interviewed for theprogramme at a time in their career when they had determined they wished to enter general practiceand had completed the required prerequisite number of hospital runs. This is possible from PGY3,but would be likely to continue to attract registrars at PGY5+.Option 3.2: Encourage engagement with the programme from PGY3A PGY2 applicant could apply and be provisionally accepted subject to the completion of specifichospital runs. This would fit with the desire in the sector to have registrars assigned to trainingprogrammes earlier.The registrar would commence the programme in PGY3. However, there would be an option for thisPGY3 year to be completed in the DHB (under DHB employment), including six months of othervocational scope training and related educational activities. Educational activities could be providedfor the other six months by the GPEP supervisor for four hours per week.Although the future GPEP registrar might have less time in clinical medicine prior to coming into GPtraining, there appears to be little support amongst the profession to increase the length of trainingbecause of this.Implementation of this option would involve discussions with DHBs to ensure they were comfortablewith GPEP trainees remaining in their employment for the PGY3 year, and also willing to facilitate therequired other vocational scope training and educational activities.HWNZ would also need to agree that funding would be available for both DHB-based employmentand College-provided education for a hospital-based PGY3.Over the three year training programme, registrars are required to spend six months in anothervocational scope and 18 months in ‘traditional general practice’. The registrars have some flexibilityregarding where they practice for the remaining twelve months although the majority of registrarsspend this time in general practice.The majority of GPEP registrars spend more than 24 months in general practice. However, making24 months in general practice a requirement for the GPEP programme would restrict the ruralhospital medicine and AMPA/CUCP programmes, therefore the required time spent in ‘traditionalgeneral practice’ should remain at 18 months.28

RNZCGP Review of the delivery of general practice vocational training August 2013Option 4: Registrar placementsPoints for consultation1. That the current model of registrar placement allocation is retained, and continues to focus on promotingrural and high need practices placements to registrars.2. Investigate sponsorship options for rural or high needs placements, either for the registrar or the practiceor both.3. Continue to provide training in all regions, while exploring ways of funding ongoing training in thoseareas that have small numbers of registrars in any given year.4. Investigate the feasibility of establishing and providing virtual learning clusters, to supplement, augmentor potentially replace, registrar learning in high cost locations.At present, registrars are allocated to accredited teaching practices on the basis of their learningneeds and the region that they request on their application form. This does have the potential ofcreating a regional imbalance if many registrars request to go to the same regions, especially largeurban centres. However this may be overcome by using the following four principles:• The current model of registrar placement allocation is retained, continuing to focus on promotingrural and high need practices placements to registrars.• Sponsorship options for rural or high needs placements, either for the registrar or the practice orboth, are investigated.• The College continues to provide training in all regions, while exploring ways of funding ongoingtraining in those areas that have small numbers of registrars in any given year.• The College investigates the feasibility of establishing and providing virtual learning clusters, tosupplement, augment or potentially replace, registrar learning in high cost locations.One of the biggest challenges facing general practice is the need for GPs in all regions of NewZealand, both urban and rural. This issue is further complicated by the ageing population of currentGPs, particularly in rural areas.There is anecdotal evidence that a GP registrar trained in a particular physical location will, oncetrained, remain in that location. This is supported by College research which shows there is a strongconnection between where registrars complete their GP training and where they practice after that.Research undertaken by the College in the course of this project is outlined in the following graphwhich shows that approximately two-thirds of registrars were in the same location four years aftercompleting their GPEP examinations.29

RNZCGP Review of the delivery of general practice vocational training August 2013Much research has also been done over the years about recruitment to rural areas and how toimprove this. It has proven to be a difficult issue for rural areas globally and there is no easy answer.If trainees continue to stay where they train then a targeted approach to rural and high-needspractices should be factored into GPEP recruitment and training delivery. This support and leadershipshould come from the College with the support of other stakeholders including the Division of RuralHospital Medicine.REGIONAL DISTRIBUTION OF GP REGISTRARSResearch into the distribution of registrars and the capacity of current practices to take in registrars,has shown that often the areas in greatest need of GPs have the least ability to accommodate GPregistrars.GPEP1 training region2013 GPregistrarsPotentialcapacity of GPregistrarsFTE GPsper 100,000population*% GPs over 55years of ageCanterbury 11 25 90 32%Otago/Southland 12 15 87 32%Nelson/Marlborough 8 8 86 33%Hawkes Bay 2 9 83 32%Wellington, Hutt, Wairarapa 15 25 83 31%Northland 4 8 82 35%Waikato 20 25 82 30%Auckland 39 42 78 31%Tairawhiti 3 5 77 44%MidCentral 6 10 61 46%West Coast 0 2 59 30%Taranaki 2 5 58 33%* This ratio is calculated based on the Medical Council information but combining the relevant districthealth boards within each of the 11 GPEP1 training regions. On average, New Zealand has 75 GP FTEsper 100,000 people. http://www.mcnz.org.nz/assets/News-and-Publications/Workforce-Surveys/2011.pdf30

RNZCGP Review of the delivery of general practice vocational training August 2013Option 4.1 (status quo): No compulsory placementIn the current model of registrar placement, registrars are offered placements in practices thatare located within the region that they requested on their application form. Where there are noplacements within the preferred region, the registrar is given the option to accept a placement inother regions, but this is at their discretion.The College works with practices in rural and high needs areas to ensure that these practices arewell represented in the pool of possible placements.Option 4.2: One compulsory placementThis option would involve registrars being required to undertake at least one placement during theirtraining in either a high needs, a rural or a Māori/Pacific Island placement. Within each region thereare practices which would meet one of these three categories.Compulsory training requirements are often difficult to manage for registrars, practices and theCollege and carry with them the risk of dis-incentivising participation and completion of the GPEPprogramme.Option 4.3: Clustered practicesAt present, registrars are placed in geographically spread practices, with the only commonrelationship being regional seminar location. An alternative would be to ensure there were a numberof practices within a reasonably close geographical distance and registrar placements would bemade within this cluster.This would provide an educational community with teachers and registrars working in close proximitywhich supported the small group learning model and enabled registrars to move between practicesto gain a variety of experiences. This model currently exists in the smaller regions throughout NewZealand.Option 4.4: Imposing minimum numbers of registrars per region andrestricting training to regions with five or more registrarsThere is the option of imposing a target of a minimum number of registrars that must be reachedbefore training is delivered in a region, thereby reducing ME costs per registrar in smaller regions.Currently ME costs per registrar range between $7,000 in regions with high registrar numbers, to$24,000 in three regions where there are less than five registrars. There is concern about providingvariety and completing the required educational tasks when the group is less than four. However, thisneeds to be balanced against the need to have registrars training in hard to staff regions and thosewith high patient to GP ratios.This option would offer GPEP training only in those regions that have five or more registrars. Whilereducing costs of training, this option could have a negative impact on supporting the continuingsupply of GPs within rural and/or smaller regions. Additional regions with low numbers of registrarsare often regions with low numbers of GPs.Option 4.5: For regions with less than five registrars, a virtual learningcluster is createdAn option exists, for regions with fewer than five registrars, to create a virtual learning cluster, in whichthe registrars learn through internet conversations via Skype or similar. Although these registrarswould be located in different geographic regions, the difficulties they face as isolated GP registrarswould be similar. This option would reduce the number of ME tenths employed by the College,however there would be costs associated with the set-up and running of a virtual learning cluster.31

RNZCGP Review of the delivery of general practice vocational training August 2013Option 5: Immersion teaching and supervisionPoints for consultation1. The College should explore models of both clustered and vertically integrated practices and create amore formalised process for these forms of education delivery.2. The College continues to support practices unable to accommodate multiple registrars and exploresways of making this model of delivery more cost effective or finds alternative funding methods.3. The feasibility of the training models should be tested to determine whether trainees and practiceswould agree to the conditions of the model and/or whether these models warrant an increase infunding to compensate for training provided outside the scope of current training provision contracts.In any professional vocational training programme, on-the-job training is the key learningenvironment and ongoing supervision throughout all years of training is essential whether it is in asecondary care, general practice or community-based setting.At present, the College uses immersion training which is on-the-job supervised training in generalpractices. This is a common and thoroughly proven model for educating postgraduate trainees inmany professions, including all vocational scopes of medicine.For GPEP Year 1, a registrar is placed in a practice with an assigned GP teacher/supervisor, who iscontracted to supply the formal and informal teaching of that registrar while they are in the practicefor a limited number of hours. At present teachers are contracted to provide 1½ hours of teachingand supervision per week. Other educational delivery, including significant informal learning, alsooccurs through interaction with other members of staff and the practice team. In GPEP Years 2and 3, the registrar has no formal directed teaching from the Fellows in their practice, although theCollege is aware that informal teaching and mentoring occurs.In the DHB setting formal teaching from senior colleagues occurs throughout the years of training.The senior colleagues are paid to deliver this learning as part of their remuneration and it is notfunded separately as it is in general practice.In general practice currently, there are many trainees of a variety of disciplines alongside GPregistrars, medical students and PGY2/3. Moving to a group teaching model within practices couldcreate issues around capacity and funding as medical students, PGY2/3 and GPEP registrars are allfunded from different sourcesOption 5.1: In-practice supervisionThe one teacher to one registrar training model is currently used to train GPEP Year 1 registrars inthe practice setting. The current model allows a practice to have multiple registrars, but there mustbe an equal number of teachers to registrars, a level of supervision that meets the MCNZ supervisionrequirements.In many practices, both rural and urban, there are insufficient consultation rooms, resources and/orpatients to have more than one registrar, and therefore a 1:1 ratio is the only option.As senior registrars progress through training in other vocational scopes they gather a broader setof skills, but there is often more individual time spent with their senior colleagues as these skills arefine-tuned.32

RNZCGP Review of the delivery of general practice vocational training August 2013Currently senior registrars in GPEP have small group time facilitated by a Medical Educator,but no formal ongoing supervision within their practice. This is at odds with all other vocationalscope programmes where regular observation of practice occurs beyond the current workplaceassessments in GPEP Years 2 and 3.This model is sometimes considered costly, with immersion teaching and supervision for GPEP Year1 registrars costing approximately $13,000, including $8,000 teaching costs. It should be recognisedthat this payment is for 1½ hours of teaching, but research shows that on average teachers arespending seven hours per week with their GPEP Year 1 registrars. While the GPEP Year 1 registraris at no cost to a practice, practices are providing, on average, 5½ unpaid hours of teaching, inaddition to loss of income.Option 5.2: Other ratios of teachers to registrarsA variation on the one teacher to one registrar model is to change the ratio of registrars to teachersat the same stage of training, for example, one teacher supervising two or three GPEP Year 1registrars. There is likely to be an upper limit on the number of registrars that can realistically betrained by a single teacher and/or within a single practice.In this option, while each registrar would still be entitled to a predetermined number of formalteaching hours per week, not all of these hours would be one to one with their teacher.As teachers would be expected to provide some teaching in a group setting, the teacher may not bepaid the full number of formal teaching hours per registrar, but rather may have a discounted contractrate applied for their second and subsequent registrars. Where there are multiple teachers within apractice sharing the training of registrars, contract payments may be made to the practice rather thanthe individual teacher. An illustration of the possible costs for this model is shown below assumingthat there are sufficient practices able to accommodate more than one registrar at a time.NZ wide average ratioNumber ofteachersNumber ofpaid teachinghoursTeachingcosts for 52weeks trainingTeachingcosts perregistrarOne teacher to one registrar 170 1.5 $1,407,600 $8,300One teacher to 1.5 registrars 134 2.0 $1,094,800 $6,500One teacher to 2 registrars 85 2.5 $938,400 $5,500There is a risk that teachers may not be willing to take on multiple registrars as research shows thatteachers already spend more hours supervising and teaching per registrar than they currently getpaid for. This model may magnify that difference.Option 5.3: Vertically integrated teaching modelThis model assumes a practice with one or more teachers teaching trainees at multiple experiencelevels, for example undergraduates, PGY1/2 interns and GPEP registrars.The economics of this model are complex as the funding for different levels of training come fromdifferent sources. Until such time as there is certainty of the funding source for PGY1/2 interns withina practice setting, the training of PGY1/2 interns is not included in this model.Vertically integrated teaching therefore focuses on a practice teaching and supervising GPEPregistrars in Years 1, 2 and 3 and assumes each of these years would require immersion teachingand supervision.33

RNZCGP Review of the delivery of general practice vocational training August 2013Teachers would be expected to provide some teaching in a group setting and therefore wouldno longer be paid the full number of formal teaching hours per registrar, but rather would have adiscounted contract rate applied for their second and subsequent registrars (currently this is notfunded in GPEP Years 2 and 3).An illustration of the potential costs for this model is shown in the table below.Mix of registers assigned to asingle teacherNumber of paidteaching hoursTeaching costsfor 52 weekstrainingTeaching costsper registrarOne GPEP Year 1 and one GPEPYear 2One GPEP Year 1 and one GPEPYear 31.9 $10,490 $5,2441.8 $9,936 $4,968This model would enable senior registrars to take on mentoring roles to other trainees during groupsessions and in-corridor teaching situations. This should reduce the teaching and supervision load ofthe practice teacher.This model shifts the burden for training to practices or educators, for less income, and assumesthe status quo of “free training hours” being provided, therefore there is a risk that teachers will beunwilling to participate in this model.Option 5.4: Combination training modelThis is a combination of each of the three models above, depending on which model fits an individualpractice best. As far as possible, practices should be given flexibility to structure the training withintheir practices, while the College should ensure that education integrity is maintained.34

RNZCGP Review of the delivery of general practice vocational training August 2013Option 6: Workplace assessmentsPoints for consultation1. That the current workplace assessments continue but the format of these is adjusted to fit with thechanges in immersion teaching.2. A ‘pool’ of assessment resources is created for use by registrars requiring remedial assistance orwhere there is a break-down in the teacher/registrar relationship.3. That the feasibility of using video conferencing to complete workplace assessments be investigated,including the use of technology to observe patient consultations.The current format of a workplace assessment is based around consulting style, communicationskills, integration into a practice, educational activities and the learning portfolio of the registrar,and it provides a format for the future Fellowship assessment visit. If there is a wider spread of theworkshop/seminar delivery over the three years of training, registrars will initially have less contactwith their ME.If the 50:30:20 model educational delivery is adopted there would be potential for an increase in thenumber of visits during GPEP training, despite this being only 5% of the overall educational delivery.Option 6.1 (status quo): One registrar per visitCurrently an ME visits a single registrar within the registrar’s practice and consults with the registrar,in-practice supervisor, other practice staff and observes patient consultations.Option 6.2: Multiple registrars per visitIf there are several registrars in one practice, assessments could be combined on one day. Thework of reviewing the general practice setting and discussions with the in-practice teacher would beshared over several registrars and produce time and cost savings.Option 6.3: Virtual visitsFor registrars who are excelling in their practice setting, or who have been in the same practiceor group of practices for an extended period of time, there is the option to complete workplaceassessments virtually. This could occur where the visiting ME is comfortable that there is little to begained from physically visiting the practice, but that all objectives of the visit can be achieved bytalking to the teacher and the registrar online.Option 6.4: Remedial visitsTwo concerns are often addressed by external visitors - under-performing registrars anddysfunctional relationships between registrar and teacher. In such cases, there must be theopportunity for extra visits.While the allocation of hours between educational components allows a number of workplaceassessments per registrar, an option is required to allocate each registrar fewer visits and “pool” theremaining visits for use in these situations. Depending on the objectives of these visits, some visitscould be completed via an internet video conference.35

RNZCGP Review of the delivery of general practice vocational training August 2013Option 7: Workshop/seminar programmePoints for consultation1. That the syllabus currently being delivered via seminars and workshops is still required to be deliveredalthough some will now be presented using online channels.2. Other educational events should be investigated for delivery of the curriculum.3. The College implements the small group learning cluster models of workshop/seminar delivery.4. The College determines the feasibility of the virtual learning cluster delivery method.5. If the workshop programme is to be delivered using a cluster model, then registrar placements shouldalso be undertaken using a cluster method.Seminars and workshops play an important part in the current GP training delivery model.The current seminar programme provides opportunity for peer group development, case-basedlearning, video review, communication skills practice, reflection on learning and topic specificlearning. Currently practice teachers base their education mainly around case-based learning andrely on the seminar programme to deliver the specifics of a topic that needs to be dealt with in thegeneral practice setting. The seminar programme helps to convert hospital-based knowledge of atopic into the community setting.Seminars and workshops are also provided outside the training programme through a variety ofconferences and conventions throughout the year, including the College’s Conference for GeneralPractice. Agreement was unanimous that whatever configuration of the seminar and workshopcomponent of training was used, training should continue in all 11 regions.Four options are outlined below using the assumption that registrars in all three years could have thesame method of workshop delivery, and may attend the same workshops. A questionnaire for GPEPregistrars, MEs and other affected parties clearly showed that weekly training rather than blockcourses was preferred.Option 7.1 (status quo): Regional seminar programmeThis is a continuation of the current regional seminar delivery programme with GPEP Year 1seminars and workshops continuing in 11 regions, with each region delivering four regionalworkshops, with one day smaller groups meeting as required to meet the number of educationhours in each year group. Otago would continue to deliver their seminars in monthly block courses.Seminars and workshops are held during business hours.GPEP Years 2 and 3 would continue using small groups. Some groups would meet in person andhave between six and 12 registrars, while others use internet video conferencing, with five to eightmembers per group.36

RNZCGP Review of the delivery of general practice vocational training August 2013Option 7.2: Modified regional seminar programmeThis is a continuation of the current regional seminar delivery programme with two changes:Removal of GPEP Year 1 large group sessionThe four two-day regional seminars would be retained (i.e. orientation, communications and mockexaminations), but the weekly workshops would be reduced to a half-day per week (or one day perfortnight) focusing on small group learning.This change would reduce the number of seminar hours by approximately 45% but costs would notreduce by a similar magnitude and additional expenditure would be required to develop alternativedelivery mechanisms for speaker content.Increase small group sizeIncreasing the number of registrars in each small group workshop to between five and 10 is an optiondepending on the number of registrars within a region. There would be an educational trade off byhaving larger groups, especially for GPEP Year 1 registrars as the small group is an essential part ofthe entry to general practice and allows for more intensive learning and engagement from individuals.Groups could be combined to form larger GPEP Year 2 and 3 groups and this would ensure aseamless move between the years of GPEP training.Option 7.3: Hub seminar programmeProgramme delivery could occur in four hub locations (Auckland, Waikato, Wellington andChristchurch) through block courses interspersed with regular small group learning.The mix of block courses and small course work would vary across the years of the programme,although it would be possible for GPEP registrars from different years to attend in part, or in full, thesame block course depending on the course content.Block courses would provide a mix of communication and clinical skill workshops, ethics andprofessionalism. Small group learning would allow reflection of practice learning, role plays, casenote reviews, etc. Costs for travel and accommodation would need to be factored in if this optionwere taken.Option 7.4: Clustered small learning groupsCreating small learning groups around a geographic location is an option using clusters of betweensix and 12 registrars.Small group teaching would be provided to the clustered registrars on a regular basis by anindependent ME or in-practice teacher, the rotation of teachers providing registrars with a pool ofmentors, rather than one.As more registrars joined the GPEP programme more clusters would be created. For those registrarsin geographically isolated locations, virtual clusters could be created.While the large majority of teaching for this model would be completed in small groups, the four twodayregional seminars would be retained.37

RNZCGP Review of the delivery of general practice vocational training August 2013Option 8: Online educationPoints for consultation1. Define the GPEP programme online education requirements and determine the feasibility of deliveringGP registrar education online.2. Begin discussions with funding providers to determine if funds can be made available to develop anonline education service.3. Online learning will include self-assessment and formative assessment tasks.At present, there is minimal educational content delivered online, and what there is provides staticinformation. Self-directed online learning is an option that can be delivered by speakers, specialists,local experts and allied health providers in any of the 38 topics covered over the current GPEP Year 1curriculum, replacing some of the large group learning.Online materials could be used by all GPEP registrars. The requirements and expected educationaloutcomes of using online material must first be defined and reflect the relationship between thelearning outcomes of the online models and the GPEP curriculum.Survey response on the use of an online channel for part of the trainingprogrammeNice Useful Important EssentialGPEP1 16 17 2 2GPEP2 15 17 10 2ME 17 10 2 8Other 7 13 5 9TOTAL 55 (34%) 57 (35%) 25 (15%) 21 (13%)Option 8.1: Access other providers’ materialsSeveral organisations provide online GP medical training and information, generally in one of twoformats. The first is information libraries which are repositories of news and articles related to variousmedical topics. The second is academic education, where the user interacts in a variety of ways withthe application to complete education exercises and formative assessment.The education materials available from some providers can be accessed free of charge while othersrequire payment for some, or all, of the services provided.These providers’ sites could be accessed via the College’s websites using hyperlinks. There wouldbe minimal web development required and no additional load would be placed on the College’s webinfrastructure. For example, the BMJ Learning materials are already available to members of theCollege.38

RNZCGP Review of the delivery of general practice vocational training August 2013Option 8.2: Create College specific materialsThe advantage of creating custom modules and libraries is that the materials created would meet all ofthe registrars’ requirements as the modules would be created to match the learning outcomes of GPEP.The costs and timing of such a development are unknown and difficult to quantify. There is potentiallyan issue with compatibility with, and capacity on, the College’s existing system.Option 8.3: Combination of development methodsThis option would involve sourcing as much material as possible from verified and validated sources,but using custom created modules and material to fill any gaps.Potential cost savings and return on investmentDepending on the model, it could be possible for the seminar delivery costs to be reduced, with anysavings retained and invested in the development and continuous improvement of online learning.39

RNZCGP Review of the delivery of general practice vocational training August 2013Option 9: e-portfolioPoints for consultation1. Determine if there are funds available for development of an e-portfolio.2. Determine and document the requirements for an e-portfolio application to meet the needs of registrarsand members.3. Once requirements and specifications have been determined, undertake a feasibility study of thedevelopment options.An e-portfolio is a collection of evidence assembled and managed by, and for, registrars online.When access is gained via the web, the portfolio becomes a self-service channel by which theregistrar can access and manage their information. It also allows appointed educational supervisorsand MEs to monitor and review the learning of these registrars. e-portfolios should log all theeducational components and work experience completed by an intern/registrar as they move throughthe programme.At present, administrative support is accessed via phone, email or mail. There is no face-tofaceaccess. OWL, the College’s online web learning site, provides access to static programmeinformation, forums and College surveys but there is no access to individual registrar information.Option 9.1 (status quo): No e-portfolioThis option would put the College ‘out of step’ with other health education providers, including MCNZfor PGY1/2 interns, as a number have already implemented such e-portfolios or are investigatingoptions.Option 9.2: Introduce an e-portfolioThis option involves the implementation of an e-portfolio to accommodate all aspects of a registrar’slearning. This includes the ability to accommodate PGY1/2 interns who undertake postgraduateplacements with the College. It must first be determined whether funding would be available for thedevelopment of an e-portfolio for the GPEP programme.The College’s e-portfolio needs to have the capability to interact with other e-portfolios being used inthe sector, such as at hubs, universities, DHBs and medical colleges.The introduction of a self-service channel such as an e-portfolio has the potential, in time, to reducethe workload of the GPEP administration team.40

RNZCGP Review of the delivery of general practice vocational training August 2013Option 10: College/DHB interactionPoints for consultation1. That the College explores the placement of GPEP intern supervisors within all DHBs. Discussions withDHBs need to ensure these representatives have access to interns within hospitals.2. Begin discussions with funding providers to determine if funds can be made available for theemployment of GPEP intern supervisors.Option 10.1: Additional information and training for GP liaison officersThis option involves the College, via the GPEP Clinical Leaders and regional MEs, providingadditional information and training to GP liaison officers to ensure they can champion the GPEPprogramme for PGY1/2 interns. The current GP liaison role varies considerably from one DHB toanother. In the smaller provincial regions there is already some involvement of these people in GPEPtraining.This low cost option would require minimal implementation. However the effectiveness of thisapproach may also be low, especially in the larger DHBs where the GP liaison role has a broaderscope and may not have time to focus on GP training or interact with the larger number of PGY1/2interns within the DHB.Option 10.2: GPEP intern supervisor assigned to hospitalsThis option involves the College engaging GPEP supervisors, either full- or part-time, to work in theDHBs to provide a direct link between the College and PGY1/2 interns. These representatives wouldideally be based at all teaching hospitals. There is currently a designated GPEP liaison person ineach training region, however they are not providing any training within the DHB to PGY1/2. Thisproposal could be an extension of their role and enable them to hold equivalent status to that of othersupervisors.The main objective of these positions would be to promote general practice to interns, providegeneral practice-related education within the DHB and promote community training in generalpractice (refer below). These representatives would also be able to assist interns in the preparationof their professional development plans and career planning.This option would require acceptance from the DHBs before implementation could occur and theDHB would need to agree to a College representative having a direct relationship with their internemployees.Option extension 10.2.1: There is the opportunity for the College to expand the responsibilities ofthe GPEP representative to cover undergraduate students at medical school.Option extension 10.2.2: The GPEP representative could provide mentoring support to registrarswho are undertaking other vocational scope training within the DHB and any other “in DHB” GPEPtraining that may occur in the future.Option extension 10.2.3: The GPEP representative could facilitate vertical integration of PGY1/2placements in practices where feasible, as well as helping to ensure suitable practices are used forplacements.41

RNZCGP Review of the delivery of general practice vocational training August 2013Option 11: Community-based pre-vocational trainingPoints for consultation1. That the College engages with MCNZ to help develop the definitions of community-based training andplacement.2. That the College (in the first year) expands the current PGGP programme to 170 placements perannum, with placements occurring in all practice settings, but promoting rural placements. If there isdemand from PGY1/2 interns, the programme should be expanded to 300 placements over the nextthree to five years.3. To achieve this, additional funds will be required from HWNZ or other sources (potentially allocatedbetween DHBs and the College), along with agreement with the DHBs for consistent employmentterms and treatment of all interns as they move into, and out of, the PGGP programme.4. The College begins discussions with HWNZ and DHBs as soon as possible to ensure implementationcan be achieved prior to the MCNZ community-based training requirements beginning.5. That interns involved in the PGGP programme be offered provisional membership to the College.6. Depending on numbers of interns entering the programme, and MCNZ’s definition of community-basedtraining, the feasibility of a generalist primary care-focused placement programme be explored.In New Zealand, PGY1 and PGY2 training is completed in a hospital without any, or minimal, inputfrom, or contact with, GPs or the College. If the College is to increase the profile of a career pathwayin general practice, more interaction is required between the College and the PGY1/2 interns.MCNZ has proposed introducing the requirement for PGY1/2 interns to complete three monthscommunity-based training. This training will not need to be completed as a single block, nor does thistraining need to be in a general practice setting. The College endorses this proposition as a focuson generalist training that can be provided in a community based setting will help upskill the PGY1/2trainees so they are more ‘fit for purpose’ on entering GPEP. The current PGGP programme isrurally-based and the College would like to preserve the value this adds to generalist training.The College currently provides a three month rural general practice-based placement programme(PGGP) for PGY2/3 interns with funding 50 PGGP placements per annum.Current numbers indicate that 350 PGY1/2 interns will complete community-based training eachyear with a number wishing to complete this in a general practice setting. However it is likely thatcommunity-based training will also be provided by up to nine other vocational scopes for exampleaccident and medical practice, palliative medicine or sexual health medicine etc.One scenario is that the programme offered by the College, that is already established and hasan excellent reputation, is positioned as the programme of choice for interns. Assuming the otherscopes have five interns/placements each, that would leave approximately 300 interns on the PGGPprogramme (see table opposite).Another scenario is that the other vocational scopes establish programmes that gain reputations ofexcellence. In this scenario, it could be assumed that the 10 vocational scopes share the internsevenly and therefore attract 35 each to their programmes. The middle ground is that the 170 interns,who are likely to choose general practice as their registered vocational scope, will join the PGGPprogramme.42

RNZCGP Review of the delivery of general practice vocational training August 2013Option 11.1 (status quo): PGGP placements retained at 50 per annumThe College would not extend its current PGGP programme and would not attempt to attract anyadditional interns to the general practice environment. This is viable if the other community-basedvocational scopes are able to provide training for an equal proportion of the PGY1/2 interns, or thatPGY1/2 interns are able to undertake their training through a variety of scopes within the DHB.Option 11.2: Expand existing PGGP programmeThe College would increase the number of PGGP placements to cater for some, or all, interns whowish to complete their community-based training in a rural practice.There are three potential challenges with the implementation of this option.1. Finding rural practices that are able to accommodate additional placements. While there may berural practices willing to take interns for a three-month placement, there is unlikely to be capacityto find between 120 and 250 additional placements per annum (over and above the current50 PGGP placements) even if there is flexibility in placement timeframes. There are currentlyapproximately 400 rural practices nationwide.2. This can be addressed by expanding the PGGP to all general practices willing to take an internfor a placement regardless of their physical location. It is possible that from this increased poolthe College could source the required placements, however this would detract from the ruralaspect of PGGP and may reduce the number of interns exposed to rural practice.3. Funding would need to be obtained for any additional placements. HWNZ provides the Collegewith funding of $30,000 per placement for the current PGGP placements and an administrationfund of $58,400 to support the 50 PGGP placements. If the number of placements increases, thenfunding for administration will also need to increase. The PGGP programme is a specialised ruralbasedprogramme and is funded as such. At the current level of funding 300 placements wouldrequire funding of more than $9,000,000 per annum, an unsustainable amount.But there is an option. Currently DHBs receive $31,000 and $18,000 per annum for PGY1 and PGY2training respectively. If this funding was directed towards community-based placements then prorated,the following funding (assuming a 50:50 split of PGY1 and PGY2) would be provided to thecommunity-based training providers.Total placements 35 170 300Funding $430,000 $2,080,000 $3,675,000Responsibility for intern salaries while they are on the programme would need to be determined.DHBs currently take inconsistent approaches to the PGGP programme. Some interns are requiredto resign from their DHB posts and reapply for their DHB positions on completion of the PGGPplacement while others are permitted by their DHB to take three months unpaid leave during theirPGGP placement.Presently interns on the programme are paid a bursary via the College. Agreement must be reachedwith all DHBs to ensure consistent employment terms. The bursary component of the PGGP fundingcould be used by the DHBs towards employee payments subject to agreement by all affected parties.IMPLEMENTATIONIf the challenges noted above can be addressed, implementation of the expanded PGGP programmecould begin, including reviewing PGGP syllabus material, in line with the MCNZ’s proposedcurriculum changes, training new practices and teachers, increasing support staff numbers and theestablishment of an e-portfolio.43

RNZCGP Review of the delivery of general practice vocational training August 2013ATTACHMENT TO A VOCATIONAL SCOPERegistrars who complete a PGGP placement in PGY2 or PGY3 can count this time towards their timein traditional general practice in GPEP. This would continue.To enhance MCNZ’s objective of attaching training doctors to vocational scopes, interns whoundertake a PGGP placement could be offered provisional membership of the College, allowing themto have input and support from the proposed DHB GPEP supervisor, and be engaged in generalpractice earlier in their career.Option 11.3: Develop a new generalist focused PGY placement programmeThe College would supplement, or replace, the current PGGP programme with a generalised primarycare-focused placement programme, with general practices being the ‘home’ of the placement,although not necessarily delivering all aspects of training in the practice setting. Relationships wouldbe built with other community-based health care providers to deliver the required experience andteaching for the intern. This would introduce interns to the concepts of ‘whole of patient care’ andworking within teams across different areas of care.Development of such a programme would require source funding, curriculum development, training,agreement with DHBs regarding employment, the establishment of an e-portfolio and increasedadministrative support.44