HWNZ and the future funding of vocational medical training

1. HWNZ and the future funding of vocational medical training CMC Chair Dr Derek Sherwood

2. Council of Medical Colleges in NZ • Represent 15 NZ Medical Colleges or their NZ Branches and more than 14,000 Doctors • A collective voice for the Colleges • Vocational Training • Continuing Professional Development/Education • Promoting Professionalism • Advocacy re Protecting and Promoting Public Health • Conduit for information flow to and from HWNZ

3. Medical Training in NZ • Undergraduate • Med Schools/Universities • Pre vocational • MCNZ/DHBs • Vocational • MCNZ/Colleges

5. History of Vocational Training in New Zealand • Colleges began being formed from Specialist societies from the 1920 onwards modelled on British Colleges • Some were bi-national from the onset eg RACS • Some became bi-national as education and qualification requirements became more onerous • A register of specialists only after the 1968 Act • Many still trained in the UK until the 1970s.

6. Vocational Training recent years • New Colleges as new specialities have developed • New “craft groups” within Colleges as sub specialisation has increased • Increasing requirements of Colleges from AMC and MCNZ • College accreditation standards • MOUs between MCNZ and Colleges • Still a high reliance on overseas trained vocationally registered doctors • Note no planning/funding for the increased grads

7. How is Vocational training funded at present • HWNZ has contracts for the provision of postgraduate training with DHBs and other Health Provider Orgs • Money allocated for about 2/3 trainees to recompense the cost of training and any “service slow down”. • The amount per trainee is different for each speciality based on a historic formula • In General Practice the contract is now with the RNZCGP

8. Current Funding • $102 million; vocational trainees, prevocational trainees and allied • $62 million Vocational Training • $18.5 million Pre Vocational Training • $21.6 million RNZCGP • 1730 Vocational Trainees 1146 are funded

9. Other workforces training funded by HWNZ • Nursing • Dental • Allied • Mental Health • Disability support • Midwifery • Some funding of unregulated or Kaiawhina workforce

10. What are the problems from a College perspective? • The money allocated does not correlate with actual costs • The funding goes directly to DHBs so is an income stream not directly linked to training • The number of training positions is only very loosely based on future needs • There has been no additional funding to meet the training needs of the increased number of medical graduates

11. What are the problems from a HWNZ perspective • A variable correlation between investment and HWNZ priorities • A bias toward post graduate medical training • Bias toward training in hospital settings • Limited community based health work force with educational capacity • There is a subsidy of the trainee workforce needed to meet service needs rather than “targeted” investment • There is a disconnect between NZ Health Strategy and DHB annual plans

12. Other challenges in health that might be addressed through changes to vocational training • There are shortages in some specialities • There are some small subspecialities that have vulnerable workforces • There are problems with geographic maldistribution • There are inequalities in healthcare delivery

13. HWNZ • Established in 2009 • To Achieve Governments Health Targets by providing a capable and well distributed supply of health professionals • Chair Prof Des Gorman

14. What have they done 1 • Initially resisted developing a Health Workforce plan but rather promoted the development of a flexible workforce. • Review of Specialities promoting new models of care • Review of regulations to remove barriers to role substitution

15. What have they done 2 • In 2014/15 worked with Colleges to determine criticality and vulnerability of specialities • Funding to be allocated on • Vulnerability ranking • Age distribution of SMOs • Dependence on general registrants • Dependence on IMGs • Contribution to government priorities

16. What have they done 3 • Now have access to MCNZ APC application workforce data which has allowed them to develop • Health of The Health Workforce Report • Health Workforce Calculator • Have worked with Colleges to provide better career information to Students and RMOs • But they wanted to develop a new funding model to have more influence on training despite constrained budget

17. Funding and implementation Principles Agreed • The right workforce for the communities needs • Address geographic mal distribution • Diversity in workforce to reflect community • Increased primary care workforce • Aligned with the Health Strategy • Engagement with Stakeholders • Current trainees supported until end of training • Transition over 3-5 years

18. What Colleges would like • All stakeholders need to be engaged DHBs, Colleges, MOH, RDA NZMA, NZMSA, ASMS and Med Schools • DHBs need to be accountable for use of training funding and to collaborate regionally and nationally • HWNZ to engage with Colleges to get best intelligence re workforce needs and consult on ideal trainee numbers • HWNZ to be transparent and collaborative • To continue to accredit training positions or sites • A commitment to adequately funding training positions

19. Initial proposals • Status quo but some reduction on subsidy to create a fund that could be targeted at areas of training need • Subsidy attached to trainee rather than position • Reduced subsidy and surplus “invested in the pipeline” • Or a mixture of the above • These were all only considered for medical training

20. The Models of Care problem Role Delegation/substitution New Roles New treatments Use of Technology An Investment Model the solution?

21. 2016 The Grand Unified Theory • A pure Return on Investment approach • The entire health workforce considered • Incorporates Models of Care • Great in theory but how would it work? • Practically a “Pharmac” type approach preferred

22. What are the potential benefits of the ROI approach • Opens up the possibility of a redesign of services with community involvement and input from all stakeholders • Better match of workers to service needs • Better geographical coverage of services • Services more aligned with Health Strategy

23. What are the potential risks of the ROI approach • Paralysis due to the complexity • New orphan health workforces • Qualifications that are not recognised overseas • Loss of critical mass of specialists to provide acute care in provincial centres • Services and training based on costs not quality

24. To summarise • The present system of funding has delivered high quality vocationally trained doctors but • There has been on overall under supply • They are geographically mal distributed • There has been a lack of diversity • They may not be ideal for future models of care • There are shortages in some specialities • Vocational Training takes time and considerable investment and any change needs to take into account the impact on present trainees and SMOs

25. The HWNZ ROI Model offers; • A complete approach to service models of care and the work forces required but; • One of the drivers is clearly cost saving • There are considerable risks • It will be a complex and potentially costly process

26. The Colleges would favour • Adequate funding of the current model and new ways of funding some specialities • Better engagement to inform decisions re trainee numbers • Investigating areas of shortage and mal distribution to find solutions which might include; • New models of Care • Incentivising training and SMO retention • Better career information for students and RMOs

27. Questions?