Reshaping Medical Education and Training to Meet the Challenges of the 21st Century
A Report to the Ministers of Health and for Tertiary Education from the Workforce Taskforce
March 2007
Acknowledgements
The Workforce Taskforce would like to acknowledge and thank the following organisations and individuals for their contributions and helpful comments in the preparation of this report.
Organisations
Association of Salaried Medical Specialists
Australian and New Zealand College of Anaesthetists
Clinical Training Agency
Council of Medical Colleges in New Zealand
DHB Chief Medical Advisors
DHBNZ Medical Workforce Strategy Group
Hutt Valley DHB junior doctors, physicians
Medical Council of New Zealand
New Zealand Medical Association
New Zealand Medical Students’ Association
New Zealand Resident Doctors’ Association
RoyalAustralasianCollege of Physicians
RoyalAustralasianCollege of Surgeons
RoyalNew ZealandCollege of General Practitioners
Individuals
Dr Stephen Child – Clinical Director, Clinical Education and Training, Auckland DHB
Joanne Griffin – Clinical Nurse Specialist – Paediatrics, Capital and Coast DHB
Associate Professor Annette Huntington – MasseyUniversity
Mrs Anne Kolbe – Deputy Chief Medical Officer, Waitemata DHB
Margot Mains – Chief Executive, Capital and Coast DHB
Stephen McKernan – Director-General of Health
Dr Garry Nixon – Chair, Rural Hospital Doctors Working Party
Susan Shipley – Director, Policy Advice and Government Services, Tertiary Education Commission
Dr Iwona Stolarek – Intern Supervisor, Hutt Valley DHB
Helen Weston – Junior Doctor Roster Co-ordinator, Hutt Valley DHB
Dr Robin Youngson – Intern Supervisor, Waitemata DHB
The Taskforce would particularly like to acknowledge the contribution from officials at the Tertiary Education Commission and thank them for their participation.
The Taskforce would like to gratefully acknowledge the work of Marilyn Goddard who led the Workforce Taskforce Secretariat at the Ministry of Health. She was supported by Amanda Burgess.
Citation: Workforce Taskforce. 2007. Reshaping Medical Education and Training to Meet the Challenges of the 21st Century: A Report to the Ministers of Health and for Tertiary Education from the Workforce Taskforce. Wellington: Ministry of Health.
Published in May 2007 by theMinistry of Health, PO Box 5013, Wellington
ISBN 978-0-478-19114-1 (Online)
HP4393
This document is available on the Ministry of Health website:
Reshaping Medical Education and Training to Meet the Needs of the 21st Century:1
A report by the Workforce Taskforce
Contents
List of Recommendations
Recommendation 1a
Recommendation 1b
Recommendation 2
Recommendation 3
Recommendation 4a
Recommendation 4b
Recommendation 5a
Recommendation 5b
Background
Introduction
Desire for change
Leadership of change
What needs to be done
Oversight and implications of the continuum of learning
Undergraduate years
Transition years
Vocational training
Funding
The way forward
Oversight body
Implications for registration
Outcome monitoring
Implications for other professions
Recommendation 1a
Recommendation 1b
A commitment to ongoing self-sufficiency for the medical workforce
Recommendation 2
New roles and inter-professional collaboration
Recommendation 3
Accountability for clinical training
Interdependence of training and service delivery
DHB responsibilities
Funding
Use of other providers
Recommendation 4a
Recommendation 4b
An increasing focus on generalism
General practitioner numbers and training
The way forward
Recommendation 5a
Recommendation 5b
Conclusion
Appendices
Appendix 1: Investment in medical education and training
Appendix 2: Workforce taskforce membership
Appendix 3: Workforce taskforce – terms of reference
Appendix 4: List of submitters
Reshaping Medical Education and Training to Meet the Needs of the 21st Century:1
A report by the Workforce Taskforce
List of Recommendations
Recommendation 1a
That a body to be known as the Medical Training Board, involving providers of education and training and health care, be established to oversee medical education and training in New Zealand. It is proposed that the Board be jointly accountable to the Minister of Health and the Minister for Tertiary Education, and be required to:
ensure effective oversight and co-ordination of the continuum of medical education and training in New Zealand; from entry to medical school to registration in a vocational scope of practice
develop an educational framework for the transition years between the university environment and clinical practice
receive advice from the District Health Boards (DHBs) and other providers of health care on the number and mix of medical practitioners required to meet future health care needs
develop a national view on the appropriate number of training positions required to allow all trainees to complete their requirements to graduate MBChB, achieve general registration and, subsequently, registration in a vocational scope of practice with the Medical Council of New Zealand. The numbers must focus on meeting the projected health care needs of the New Zealand population
approve clinical training specifications and funding intentions
promote the recruitment and retention of medical trainees to meet the predicted future demand for the provision of health care services in New Zealand by vocationally registered medical practitioners, and take steps to ensure that the available programmes meet this demand
develop mechanisms to collect appropriate data including regular longitudinal surveys of cohorts of students, trainees and medical practitioners, which will facilitate medical workforce development.
That:
the Minister of Health and the Minister for Tertiary Education appoint the Medical Training Board
the Medical Training Board be jointly serviced by the Ministry of Health and the Tertiary Education Commission.
Recommendation 1b
That the Medical Council of New Zealand:
be asked to develop a process for limited registration for trainee interns
work with the Medical Training Board to develop a process for competency-based assessment and progression to general registration.
Recommendation 2
That:
the number of medical graduates produced by the training system be increased to ensure that New Zealand moves towards achieving ongoing self-sufficiency for its medical workforce
the Medical Training Board review no less frequently than every five years the number of medical training places, both undergraduate and graduate, that should be funded by the government.
Recommendation 3
That:
the Medical Training Board, in consultation with health care providers and consumers, consider the need for new roles to support medical practitioners and advises the Medical Council and education providers accordingly
inter-professional collaboration and care, communication and teamwork be taught and assessed by universities as part of the medical undergraduate curriculum and throughout the continuum of learning, and that the same principles be reflected in work environments within DHBs and other health care providers.
Recommendation 4a
That:
through their district annual plans, DHBs be required to demonstrate and reporton their commitment to the education and training of their present and future workforce. This should include the development of an appropriate culture and environment for training, inter-professional collaboration and taking responsibility for providing both the necessary facilities and adequate supervision and guidance for doctors in training.
Recommendation 4b
That, to support clinical training:
a national curriculum be developed by the Medical Training Board for the transition years, which clearly defines the standards and competencies required for entry to vocational training
specific contracts for training be developed by the Medical Training Board to ensure and demonstrate the allocated funding is spent on training
employers of doctors in training be made accountable for ensuring that the funds received are used to the best advantage
DHBs ensure that senior doctors are trained and supported to deliver training for trainee doctors
DHBs appoint Directors of Clinical Training
working with the DHBs, the Medical Training Board should ensure all providers of training have appropriate standards and external accreditation of their training programmes
hospital and community settings for training include both private and public providers of health care.
Recommendation 5a
That the Medical Training Board work with educational and training organisations to ensure that:
all medical practitioners acquire a broad general foundation, which includes community and regional hospital experience, before entering vocational training
the training system produces sufficient numbers of doctors entering the New Zealand workforce with training in general vocational scopes of practice.
Recommendation 5b
That, in relation to general practitioners in particular:
universities be invited to bring forward proposals to the Medical Training Board for a primary care based undergraduate programme which is targeted to areas of need such as rural, Māori and high deprivation populations and is linked to postgraduate training for general practitioners
further work be undertaken to submit an education and training programme for general practice to meet New Zealand’s needs, taking into account experience of innovative programmes overseas
those factors both educational and non-educational that influence the choice of students and trainees for general practice as a career be identified and addressed.
Background
As its first task, the Workforce Taskforce was charged by the Minister of Health with advising on how to streamline the current New Zealand medical education and clinical training arrangements to produce medical practitioners who are fit for purpose and for practice in the minimum time period. The full terms of reference are in Appendix 3.
The Taskforce has received submissions and invited presentations from a range of interested parties on the specific issues detailed in its terms of reference.
In formulating its recommendations for action, the Taskforce has sought to connect all background information and current streams of work to ensure a consistent approach to the development of the medical workforce into the future and its education and training. However, the Taskforce recognises that further work needs to be done in some areas, such as consulting with Māori and Pacific medical groups, and in the areas of primary health care and overseas trained doctors.
In previous years there have been a number of reviews of the health workforce for New Zealand. In particular, during 2005/06, an extensive amount of work on the medical profession was undertaken by the Medical Reference Group of the Health Workforce Advisory Committee and the Doctors in Training Workforce Roundtable, culminating in two reports to the Minister of Health, Fit for Purpose and for Practice and Training the Medical Workforce 2006 and Beyond.
Key points from the latter two reports are outlined below:
There is an overall shortage of medical practitioners, evidenced by the use of locums and reliance on overseas-trained doctors, which will be exacerbated in the future as the population ages and competition for medical practitioners increases in the international market.
There is a ‘maldistribution’ of the available medical workforce, with rural and non-metropolitan areas finding it increasingly difficult to recruit and retain doctors. Māori and Pacific peoples are currently under-represented in the medical profession in New Zealand. Those from lower socioeconomic backgrounds are also under-represented. There is a need for strategies to increase recruitment into medical schools from these groups.
New Zealand needs to train more medical practitioners locally to meet the demand. To achieve this, the level of the cap on funded undergraduate medical places should be raised and further clinical training positions made available.
The quality and relevance of medical education and training could be improved by greater continuity between undergraduate medical education and subsequent clinical training and increased responsiveness of the whole system to the needs of the health sector.
The health sector is complex, and there are many players involved in educating and training medical practitioners – there is a need for a central body to co-ordinate and oversee medical education and training.
The difficulties for training in clinical settings created by the inherent tension between service delivery and training needs, the changing service delivery patterns in public hospitals and the implications of industrial agreements over the last 20 years, are putting pressure on the current apprenticeship model.
The Taskforce is also aware that a considerable amount of work relating to the medical profession has been, or is being, undertaken by other groups, notably the District Health Boards New Zealand’s (DHBNZ) medical workforce strategy group, the Tertiary Education Commission (TEC) on the funding of undergraduate medical programmes and the Clinical Training Agency (CTA) on vocational training for general practitioners. Also of relevance are the findings of the New Zealand Institute for Economic Research (NZIER) in its report prepared for the Ministry of Health Ageing New Zealand Health and Disability Services: Demand projections and workforce implications, 2001–2021and The Treasury’s statement on New Zealand’s Long Term Fiscal Position June 2006, both of which highlight the pressures that will be brought to bear on the health and disability system over the next 20 years as a result of New Zealand’s ageing population and an increasing demand for services.
This Taskforce report in considering all the previous reports and submissions, now strongly advises the establishment of an implementation plan based on the recommendations of this report.
Introduction
The Taskforce began by considering the recommendations of the reports from the Medical Reference Group[1] and the Doctors in Training Workforce Roundtable[2] to the Minister of Health. Comments received from key organisations and individuals delivering medical services and medical education and training proved to be consistent with those of the reports and also the outcomes of previous reviews commissioned by governments over the last 20 years. Most of the problems identified by the Taskforce are not new. They are, however, becoming more apparent, and the need to address them more urgent, as pressures on the health system increase. Collectively, they have resulted in an inability to produce the best outcomes from the taxpayers’ investment in medical education and training at both undergraduate and postgraduate levels.
The question that must be addressed is why, given the consistency of expert advice, there have been no effective changes? This report, therefore, identifies the barriers to change and makes recommendations for overcoming them.
Desire for change
The Taskforce’s consultation has revealed a widespread desire for change initially focused on the transition years from completion of undergraduate studies to practice as a doctor. However, effective change will be achieved only by a national, systematic, integrated and collaborative approach that recognises the uniqueness of New Zealand’s health needs and the importance of linking workforce training, in this case medical, to meeting them.
Of particular importance will be the issue of sustainability. The system must be flexible enough to react to change, reward improved productivity, produce the number and mix of doctors to match the needs of the health care system and be affordable. In addition, the environment in which medical practitioners work must be supportive, including such features as acceptable rosters, collegial support and access to appropriate professional development.
Leadership of change
Fragmented innovation reduces the ability of the system as a whole to learn and, as a consequence, gains in effectiveness and productivity are diminished. The introduction of leadership of the whole medical training system is required to give coherence and balance to the provision of training, while retaining the vigour that individual components variously bring. It will ensure that the cumulative effect of the changes made by those involved have a sustainable impact on increasing the productivity of health services.
In the absence of any oversight of the medical training system there is a tendency for individual participants to respond to changing circumstances in ways that reinforce or sustain the value of their own roles, rather than considering the needs of the system as a whole.
What needs to be done
Faced with the uncertainties inherent in long-term workforce development, it is important to have effective and responsive leadership. The Taskforce considers that enhancements could be made within the existing structural arrangements that will ensure that the value of the government’s investment in medical education and training is maximised, improve accountability, meet the objectives of the Tertiary Education Strategy and meet the needs of the health sector.
This report makes five recommendations as the first step toward making changes that will result in a sustainable medical education and training system to produce medical practitioners who are fit for purpose and for practice in the minimum time period. The recommendations cover the following areas:
1.Oversight and implications of the continuum of learning
2.A commitment to ongoing self-sufficiency for the medical workforce
3.New roles and inter-professional collaboration
4.Accountability for clinical training
5.An increasing focus on generalism.
Oversight and implications of the continuum of learning
Medical training is a continuum from the levels of novice to expert that includes acquisition of knowledge and basic skills with increasing clinical confidence and competence. Initially, this is directed at meeting the Medical Council’s requirements for general registration and, thereafter, vocational training and maintenance of competence through a lifetime of practice.
The undergraduate curriculum is funded by the TEC, and postgraduate clinical training, including vocational training, is funded by the CTA and the District Health Boards (DHBs). Learning, however, is seen less as a continuum but rather as a series of poorly co-ordinated steps. Currently, steps taken in isolation at one point in the continuum may be inconsistent with desired outcomes at another point. The lack of oversight and co-ordination of the medical training continuum means that the current funding arrangements are not achieving the best outcomes from investment in medical education and training.
New Zealand is part of a global market for health care professionals and, accordingly, any changes to our current systems and content of training must continue to meet international accreditation standards. New Zealand and Australia have many accreditation standards and governance processes in common for undergraduate and vocational training. These may not uniquely reflect the needs of the New Zealand health care system but they enable a higher degree of global relevance for New Zealand qualifications than we mightotherwise be able to ensure from our resources alone.