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Clinical Training Agency Purchase Intentions 2009/10

Citation: Ministry of Health. 2009. Clinical Training Agency Purchase Intentions: 2009/10. Wellington: Ministry of Health.

Published in December 2009 by the Ministry of Health

PO Box 5013, Wellington, New Zealand

ISBN 978-0-478-33962-8 (online) HP 4976

This document is available on the Ministry of Health’s website: http://www.moh.govt.nz

Contents

Executive Summary v

Introduction 1

Purpose 1 Financial information 1 Sector consultation 2 Review of 2008/09 projects 3 Key projects planned for 2009/10 5

Portfolio Overviews 6

Medical portfolio 6 General practitioner vocational training 12 Nursing portfolio 14 Māori health portfolio 17 Pacific peoples health portfolio 19 Midwifery training 20 Pharmacy Intern training 22 Clinical rehabilitation training 23

Appendix 1: Explanatory Notes 25

Contracts structure 25 Reporting 25

Appendix 2: Sector Consultation for Purchase Intentions 26

Appendix 3: CTA Prioritisation Decisions 28

References 29

List of Figures Figure 1: CTA budget 2009/10 2

Clinical Training Agency Purchase Intentions 2009/10 iii

List of Tables Table 1: Subject areas of stakeholder submissions 3 Table 2: Projects progressed in 2008/09 4 Table 3: Projects to continue or commence in 2009/10 5 Table 4: Non-vocational medical training places 2007–2010 9 Table 5: Vocational medical training places 2007–2010 10 Table 6: Allied/technical training places 2007–2010 11 Table 7: Medical portfolio budgets 2007/08–2009/10 12 Table 8: GPEP1 training places 2007–2010 13 Table 9: GPEP2 training places 2007–2010 13 Table 10: PGY2 rural rotation training places 2007–2010 14 Table 11: General practice budgets 2007/08–2009/10 14 Table 12: NETP training places 2007–2010 15 Table 13: Postgraduate nursing training units 2007–2010 16 Table 14: NETP outcomes 2006–2008 16 Table 15: Postgraduate nursing outcomes 2007–2008 17 Table 16: Nursing portfolio budgets 2007/08–2009/10 17 Table 17: Māori health training units 2007–2010 18 Table 18: Māori support trainee numbers 2007–2010 19 Table 19: Māori health programme outcomes 2006–2008 19 Table 20: Māori health portfolio budget 2007/08–2009/10 19 Table 21: Pacific peoples support budget 2008/09–2009/10 20 Table 22: Midwifery first year of practice training places 2007–2010 21 Table 23: Complex care training places 2009–2010 21 Table 24: Midwifery budgets 2007/08–2009/10 22 Table 25: Pharmacy Intern training places 2007–2010 22 Table 26: Pharmacy intern training outcomes 2006–2008 23 Table 27: Pharmacy intern training budget 2007/08–2009/10 23 Table 28: Clinical rehabilitation training places 2007–2010 23 Table 29: Clinical rehabilitation training outcomes 2006–2008 24 Table 30: Clinical rehabilitation budget 2007/08–2009/10 24

iv Clinical Training Agency Purchase Intentions 2009/10

Executive Summary

CTA vision: ‘To facilitate development of a health and disability workforce which can meet the future requirements of health and disability services in New Zealand.’ This document summarises the purchasing and projects of the Clinical Training Agency (CTA) during 2008/09, details the anticipated purchases for 2009/10 and signals projects that the CTA will look to complete in the future. In the main the CTA purchases post-entry clinical training for doctors, nurses and midwives to the value of approximately $120 million per year. The new CTA Board will influence the CTA’s future purchasing decisions, funding priorities and work plans. Details are still being finalised. The CTA works closely with the Workforce Development Group of District Health Boards New Zealand (DHBNZ), as well as with the CTA Nursing Advisory Group, the wider Ministry of Health and various other groups to ensure its purchasing direction is consistent with national strategies and environmental changes. For example, a change in Government direction has led the CTA to increase funding in areas such as Surgery and Anaesthesia which will contribute to staffing the 20 new surgical theatres being planned. The CTA is also working with the Royal New Zealand College of General Practitioners to increase the number of first year General Practice trainees. There has been an increase in the number of medical graduates entering the system in 2009, and the number will increase further incrementally from 2016. Other changes in the New Zealand health sector will impact on training. On a profession by profession basis these changes are forecasted within the Health Workforce Information Programme (HWIP). Epidemiology, demographics, technology, service models, supply side characteristics and a raft of other ever-changing factors are analysed in order for HWIP to estimate various scenarios of future need. Over the next 12 months all registrar types and a significant number of nursing roles will have robust estimates of future supply and demand requirements. The guidance provided by these estimates will have a significant influence on the direction of future funding. The past year has seen the successful completion of the following projects:

Nursing Entry to Practice Expansion training programme – all District Health Boards (DHBs) now have their programmes approved by the Nursing Council

implementation of the new funding model for Māori health training – all DHBs now have access to Māori training funds

funding of five general practice training pilots in DHBs

new funding for rural hospital medicine places

new funding for postgraduate midwifery training in complex care

revision of surgeon training specification, revised costing and completed supply and demand estimates.

Clinical Training Agency Purchase Intentions 2009/10 v

In 2009 key projects include:

specifying and funding intensive care medical vocational training

revising the physician training specification and costing

specifying and funding five Accident and Medical Practitioner Association training positions

finalising the specification and costings for rural health medicine training

commencing the evaluation of the five general practice pilots

reviewing the specifications for general practice education programmes, including the associated bursary payments

specifying and funding the Mammography Postgraduate Certificate

reviewing postgraduate nursing training funding

reviewing the Nursing Entry to Practice programme

finalising the specification for complex care and other midwifery training

finalising the Midwifery First Year of Practice specification

incorporating HWIP estimates into CTA purchasing plans. The biggest issue regarding funding is the level of under-delivery. In some areas of high priority to the CTA, providers are unable to fill all contracted places. This issue is a key driver for CTA contracting strategies. As at 1 July 2009 the CTA was funding all places in 19 of 25 CTA-funded medical specialties (or other medical programmes) and all other CTA-funded training programmes except the General Practice Education Programme Stage 2. Based on analysis of previous years, the CTA expects an under-provision across all portfolios of $4,000,000 for the 2009/10 financial year. This under-spend will be set aside for an innovations fund. The Purchase Intentions consultation process yielded generally positive responses regarding CTA purchasing and identified many areas where CTA funding is desired. However, given the size of the CTA and budget constraints, not all requests are able to be met. As part of the CTA’s ongoing quality improvement, an updated funding decision model is planned to be developed in time for funding decisions on Purchase Intentions 2010/11.

vi Clinical Training Agency Purchase Intentions 2009/10

Clinical Training Agency Purchase Intentions 2009/10 1

Introduction

Purpose

The Clinical Training Agency Purchase Intentions 2009/10:

provides accountability information about the expenditure of health and disability clinical training funding

communicates intended activity for the upcoming financial year

indicates potential future funding directions and service developments. The next section is organised into portfolio areas to reflect the purchasing activity and contract management of the Clinical Training Agency (CTA). Each area contains a budget table that covers financial years (1 July to 30 June) and a table that details funded places which align with calendar years. The number of training places that the CTA intends to purchase, and that the provider hopes to deliver, can change for a number of reasons. A range of circumstances may cause a provider to be unable to deliver the training places contracted for with the CTA. For example, the provider may be unable to recruit the contracted number of trainees, or trainees may withdraw before completing the programme. This document is based on the information available at the time of preparation. Delivered trainee numbers for 2009 are based on those reported up until April 2009. There may be subsequent developments that will affect actual purchasing in 2009/10 and beyond. New directives from Government, results of reviews and other events can change purchasing in ways that cannot be predicted at the time of writing.

Financial information

Budgets are reported on a financial year basis. The financial year of the Ministry of Health and, therefore, the CTA runs from 1 July to 30 June. The CTA’s objective is to manage the actual expenditure as close to budget as is reasonably possible. Unspent budget is not transferable between financial years, unless there are exceptional circumstances. There is an increase in the CTA budget from $121,500,000 in 2008/09 to $125,000,000 in 2009/10 largely due to budget increases for General Practice, Postgraduate Midwifery and Nursing Entry to Practice (NETP) Expansion. Future Funding Track (FFT), the annual adjustment for providers to manage cost pressures, was not awarded to the CTA for 2009/10, nor was the demographic adjuster. The main changes between 2008/09 and 2009/10 are the increase in Vocational medical budget and decrease in the Non-vocational medical budget. This movement was required as a significant amount of Postgraduate Year 2 (PGY2) medical funding was unspent in 2008/09 and it is anticipated that this lower level of spending will continue in the foreseeable future.

Figure 1: CTA budget 2009/10

Non-Vocational Medical, $18,867,135

GP Training, $12,420,927

Psychiatry, $8,107,884

Nursing - Postgraduate, $12,182,760

Nursing - NETP, $6,653,420

Vocational Medical, $57,137,263

Public Health, $2,062,052

Midwifery, $2,564,558

Pharmacy, $915,735 Maori, $3,238,232

Disability Support, $311,724

Other, $320,177

Pacific People's Support, $135,133

Sector consultation

Prior to the preparation of this Purchase Intentions document, 140 sector stakeholders were sent an email invitation to contribute their views on CTA purchasing for the 2009/10 financial year. Attached to the email was the Purchase Intentions 2008/09 document with a letter outlining the points of difference between that document and the planned 2009/10 document. The stakeholder organisations contacted are listed in Appendix 2. Twenty-three submissions came from the following 18 organisations: Auckland District Health Board (DHB) Australian and New Zealand College of Anaesthetists Bay of Plenty DHB Canterbury DHB Capital Coast DHB College of Nurses Aotearoa Ltd Counties Manukau DHB Hutt Valley DHB Joint Faculty of Intensive Care Medicine Lakes DHB New Zealand Nurses Organisation Royal New Zealand Plunket Society Southland DHB Tairawhiti DHB Te Pou the Royal College of Pathologists of Australasia University of Otago Waikato DHB.

2 Clinical Training Agency Purchase Intentions 2009/10

Their submissions commented on the areas outlined in Table 1 below.

Table 1: Subject areas of stakeholder submissions

Workforce Number of submissions

Nursing 15

Medical 10

Midwifery 7

Māori and Pacific 5

Allied Health 4

Pharmacy 1

The majority of submissions suggested that for specified programmes the CTA:

increase the price per trainee

increase the number of funded places

broaden the funding into related areas that are currently excluded. No currently funded programmes were identified as low priority that could be stopped to allow funds to be reallocated. If all requests were met, it would cost tens of millions of dollars extra and the corresponding work would far outstrip the CTA’s workload capacity. Along with the additional requests, the CTA received a good proportion of positive comments. This positive response is also shown in the calls to expand funding in training areas, as the current funding is working well. There was particular support for the postgraduate nursing and hauora Māori purchasing approaches.

Review of 2008/09 projects

Table 2 below summarises the progress of projects with CTA funding in the 2008/09 financial year.


Table 2: Projects progressed in 2008/09

Project Progress Summary (reported for training year)

Implement NETP expansion Completed Programme was funded in 2009 training year. Contracts are in place with 20 DHBs.

Implement new funding model for Māori Health training

Completed The Hauora Māori funding model has been implemented and 20 DHBs applied for funding for 2009.

Implement outcomes of the surgery review

Completed A new specification and costings have been developed.

Fund general practice pilots Completed The CTA requested proposals for DHB-led general practice pilots in late 2008. Five pilots were chosen for 20 training places and training began in early 2009.

Fund rural hospital medicine training programme

Completed Six positions have been contracted in 2009.

Fund additional ophthalmology training

Completed Two extra training places were located and funded.

Implement postgraduate midwifery training (complex care)

Completed An interim specification and costings were developed for the 2009 training year. For 2009 there are 30 trainees in 12 DHBs with three education providers.

Review public health medicine Completed A final specification and costings will be in place for the 2010 training year.

Evaluate the Midwifery First Year of Practice pilot programme

Completed The pilot evaluation findings were generally positive.

Perform desk-audits of providers’ financial systems

In progress CTA funds are being checked as to whether they are being used exclusively for purposes detailed in the Head and Service Agreements.

Upgrade database In progress The CTA database is being modified to improve efficiency, ease of use and data integrity.

Implement new prioritisation model for training purchases

In progress The CTA is working on a new prioritisation model with which current and potential training programmes will be evaluated (see Appendix 3).

Review postgraduate nursing In progress Work has commenced; a revised specification and costings will be in place for the 2010 training year.


Key projects planned for 2009/10

In the 2009/10 financial year the CTA plans to undertake the projects set out in Table 3 below, either as a continuation from 2008/09 or as new projects.

Table 3: Projects to continue or commence in 2009/10

Project Progress Summary (reported for training year)

Implement new prioritisation model for training purchases

In progress The CTA is currently working on a new prioritisation model with which current and potential training programmes will be evaluated (see Appendix 3).

Review postgraduate nursing In progress A revised specification and costings will be in place for the 2010 training year.

Specify Midwifery First Year of Practice programme

In progress A final specification and costings will be in place for the 2010 training year.

Upgrade database. In progress The CTA database is being modified to improve efficiency, ease of use and data integrity.

Specify postgraduate midwifery complex care and other midwifery training

In progress A final specification and costings will be developed.

Fund trainees for 20 new theatres

In progress Workforces and volumes need to be agreed. The CTA has contracted for extra anaesthesia and surgery places.

Perform desk-audits of providers’ financial systems

In progress CTA funds are being checked as to whether they are being used exclusively for purposes detailed in the Head and Service Agreements.

Specify rural health medicine In progress Develop a final specification and costings.

Review General Practice Education Programme Stages 1 and 2 (GPEP1 and GPEP2) training

In progress Review training including bursary payments and scholarships.

Update specifications Ongoing All specifications will be scheduled for revision.

Evaluate general practice pilots

To commence A detailed evaluation of the General Practice pilots will commence to investigate whether DHB employment is a more attractive option for potential general practitioners.

Review NETP To commence A revised specification and costings will be in place for the 2011 training year.

Specify and cost Accident and Medical Practitioner Association (AMPA) training

To commence Specify and cost training.

Purchase Mammography Postgraduate Certificate

To commence The CTA is to investigate funding Postgraduate Certificates in Mammography.

Review physician training To commence Re-specify and re-cost training.

Specify and fund intensive care training

To commence Develop stand-alone specification and funding.


Portfolio Overviews

This section reports on the various portfolio areas in which the CTA is involved in purchasing activity and contract management. These areas cover: medical, general practice, nursing, Māori health, Pacific peoples health, midwifery, pharmacy internship, and clinical rehabilitation.

Medical portfolio

For the medical portfolio, the 2008/09 financial year showed evidence of shifting patterns in pre-vocational medical training. The number in training in the second postgraduate year (PGY2) has fallen from an expected 340 to approximately 170 reported eligible trainees in 2009 (see Table 4). This drop follows on from a significant decrease in the previous year. Potential PGY2 trainees are locuming or leaving the country. It remains to be seen if this shift will affect the number of trainees accepted into vocational training in 2010 and beyond. At the same time, an extra 40 first-year trainees have entered the system in the PGY1 training year, but it must now be uncertain how many will enter PGY2 for 2010. In 2008 the unspent PGY2 funding was returned to the sector to fund previously unfunded medical training. As a result of the Government initiative to provide 20 new operating theatres, the Portfolio will use some under-spend on increased vocational training associated with future staffing needs of the new theatres. In 2009, 149 unfilled PGY2 training places have been substituted to fund an additional 40 anaesthetist and 10 emergency medicine places. For 2009/10 the portfolio will continue to focus on the Ministry of Health’s priorities and ‘shortage’ specialties. It will also continue to shift funded numbers towards those indicated by the projections of the Health Workforce Information Programme (HWIP) as they become available. Intensive care training is now delivered separately from anaesthesia, and requires a stand-alone specification and price. The CTA has been directed by the Minister of Health to purchase AMPA training programmes. Further work on specifying and costing physician training will also be carried out.

Contracting

It has been noticeable that the medical portfolio must contract for more training places than will be filled in order to ultimately obtain a sufficient number of eligible trainees to meet budget projections. This necessity is a result of the difficulty DHBs experience in filling contracted places. The portfolio agreed to fund 3.1 percent more registrars for 2008, but training providers only managed a 0.2 percent increase in funded trainees. To minimise the financial uncertainty and loss of training funds resulting from the increasing vacancies, the portfolio intends to place some emphasis on substitution of contracted places that remain unfilled and diversion of funds to needed training places that can be occupied.


Health Workforce Information Programme

During 2009 significant progress was achieved with the HWIP and robust projections for five medical specialties were obtained, including surgery. HWIP reports are available at http://www.dhbnz.org.nz.

Surgery

The Royal Australasian College of Surgeons’ new Surgical Education and Training (SET) programme was specified for contracting. Based on HWIP projections, an expert advisory group established training numbers for New Zealand (for nine subspecialties).

Rural hospital medicine

During 2009 rural hospital medicine attained vocational status with the Medical Council of New Zealand and the CTA contracted to fund the first six trainees via the DHBs. The specification for this programme is close to complete and final costing will take place later in 2009. Ten places are anticipated for 2009/10.

Palliative medicine

Funding for palliative training also progressed with agreement to establish nine vocational training positions throughout New Zealand; three of these have already been contracted and funded in the Auckland region. The Ministry of Health has provided additional funding to the CTA to fund training in hospice settings, as these runs are required during training. The Central and Southern regions have yet to nominate trainees and the CTA has some concern that another year may pass before all training positions available are used. The portfolio has budgeted six vocational registrar positions for 2009/10, while funding of other registrar palliative runs will be provided to the limit of available funds.

Psychiatry

Psychiatry vocational training moved to contracting via the DHBs rather than independently through the ‘regions’ for the 2008 training year. There were some initial difficulties establishing trainee numbers, but the process has settled and is now functioning better. The CTA hopes to meet with the Royal Australian and New Zealand College of Psychiatrists during 2009/10 to discuss processes and training durations. The CTA continues to fund all available eligible trainees in psychiatry.

Physicians

Little progress was made in 2008/09 with the organisation of specific trainee runs in diabetes, apart from the Royal Australasian College of Physicians (RACP) endocrinology trainees funded through the physician training line. The CTA will raise the issue with the RACP in forthcoming discussions in 2009 for advice on a way to obtain more practitioners with specific diabetes training. The physician training specification will be reviewed during 2009/10.


http://www.dhbnz.org.nz/

Cardiac physiologists

The portfolio was able to assist the Central Region to raise the training numbers of cardiac physiologists to meet the region’s projected needs. National funding requirements for technician training should become better understood as more HWIP projections become available during 2009/10. Until the overall requirements are known, technician funding will continue to be decided on a case-by-case basis, dependent on the availability of funding.

Didactic teaching

The examination of funding arrangements for didactic teaching by the medical schools at DHBs in 2008/09 raised some interesting questions. It led to an overall impression that the sector is uncertain of the mechanism or rationale for this funding (which is a fallout from the ‘unbundling exercise’ of the 1990s). This work should continue in 2009/10.

Public health

The CTA and public health medicine stakeholders have actively worked together to review the training specification for public health. An expert advisory group was set up in 2008 and a public consultation round on the training specification was completed in 2009. The volume of training positions to be funded in future will be influenced by a recent HWIP report that estimated the number of public health physicians needed. The HWIP forecasting included advice from experts who had been involved with the expert advisory group conducting the specification review. A number of scenarios were modelled in the report. Current purchasing is within the medium scenario projections. However, as is the case with a number of other medical specialty training programmes, the public health medicine programme has been offered CTA funding for more positions than it is currently able to fill.

Auditing

The CTA has recently commenced a round of desk-audits, requiring DHBs and other providers to demonstrate that all training funds provided are actually being assigned to the appropriate training areas and accessible by those departments. The CTA will carry out further provider audits in 2009/10.

Reporting

In end-of-year reporting for 2008, the number of programmes that reported trainee issues decreased slightly compared with 2007 and earlier years. Nearly two-thirds of programmes reported no trainee issues (64 percent) compared with 53–58 percent from 2004 to 2007. Among those trainees who reported issues, the most common complaint was that the clinical workload is too high and it applied to 15 percent of programmes (16–21 percent in previous years). Another issue reported was that clinical supervision is inadequate (for 7 percent of programmes). Programmes reported a similar incidence


of supervisor issues in 2008 to previous years (with 66 percent of programmes reporting no issues); those issues that arose were primarily due to inadequate time to provide clinical supervision (for 14 percent of programmes). Overall, 55 percent of programmes reported no issues from trainees or supervisors. One medical specialty had training issues reported in more than 70 percent of its programmes undertaken around the country. The CTA will continue to monitor the situation. Two of the remaining nine specialties had issues for more than half of their programmes.

Training places

The following tables show the number of contracted places for non-vocational (Table 4), vocational (Table 5) and allied/technical (Table 6) training between 2007 and 2009, the expected contracted places for 2010, the number of places that were delivered between 2007 and 2009 and the number of places that are expected to be delivered in 2010. The difference between contracted and delivered/expected is the level of over-contracting. As at 1 July 2009, the CTA was funding all eligible training places in 19 out of 25 CTA-funded medical specialities or programmes.

Table 4: Non-vocational medical training places 2007–2010

2007 2008 2009 2010

Year 1 house surgeons contracted places 284 275 322 322

Places delivered/expected 322 274 322 322

PGY2 contracted places 348 328 189 189


Diploma in paediatrics contracted places 32 28 21 21


Diploma in sexual health contracted places 14 14 8 8


Dentistry oral and maxillofacial surgery (OMS) contracted places

2 2 2 2


NZREX – overseas trained doctors contracted places 16 16 16 16


Total non-vocational contracted places 696 663 558 558



Table 5: Vocational medical training places 2007–2010

2007 2008 2009 2010

Anaesthesia contracted places(1) 122 119 166 166


Emergency medicine contracted places(1) 68 66 80 80


Physicians – adult contracted places(2) 194 198 201 201


Physicians – paediatric contracted places(2) 60 63 65 65


Physicians – diabetic medicine contracted places(3) 2 3 2 2


Physicians – palliative medicine contracted places(3) 6 8 8 8


Physicians – rehabilitation contracted places(3) 3 5 5 5


Physicians – other contracted places(3),(4) 9 10 8 8


Obstetrics and gynaecology contracted places 40 44 56 56


Ophthalmology contracted places(5) 15 15 19 23


Pathology contracted places 58 63 60 60


Psychiatry contracted places 167 155 149 149


Public health medicine contracted places(5) 35 35 35 35


Radiology contracted places 75 73 78 78


Radiation oncology contracted places(5) 17 17 17 19


Surgery contracted places(5),(6) 234 229 187 198


Rural hospital medicine contracted places 0 0 6 10


Total vocational contracted places 1105 1103 1141 1164



Notes

(1) 2009 contracted values include the following intended changes: –149 PGY2 positions +40 anaesthesia positions +10 emergency medicine positions

(2) Physician training is divided into adult and paediatric, although some positions are dedicated to specific subspecialties, listed separately in the table.

(3) These are dedicated positions; however there may be additional training in the subspecialty included under adult medicine or paediatrics.

(4) Includes sleep, sexual health, paediatric rheumatology, immunology, dermatology and infectious diseases, where listed explicitly in contracts.

(5) Intentions for 2010 are based on funding available. HWIP projections for these specialties differ and will be considered once all HWIP information is available.

(6) From July 2009 the CTA intends to fund only surgical registrars undertaking the SET programme.

Table 6: Allied/technical training places 2007–2010

2007 2008 2009 2010

Medical physics radiology and therapy contracted places

17 16 18 18


Ultrasonography contracted places 27 30 32 32


Anaesthetic technicians contracted places 52 63 70 70


Cardiopulmonary technicians contracted places 0 2 13 13


Physiology technicians contracted places 11 14 13 13


Postgraduate Certificate in Radiation Therapy contracted places

4 4 0 0


Cytology contracted places 2 3 2 2


Total allied/technical contracted places 113 132 148 148



Budgets

The substitution of PGY2 places for vocational training places has increased the Vocational budget and reduced the Non-vocational budget, as set out in Table 7.

Table 7: Medical portfolio budgets 2007/08–2009/10

Financial year 2007/08 actual

2008/09 budget

2009/10 budget

Vocational budget $49,737,680 $55,737,355 $57,137,263

Non-vocational budget (including allied/technical)

$18,631,824 $19,546,543 $18,867,135

Psychiatry budget $9,241,416 $8,107,884 $8,107,884

Public health budget $1,502,532 $2,062,052 $2,062,052

General practitioner vocational training

General Practice Education Programme Stage 1

GPEP1 is the first year of intensive, vocational training for general practice medicine. Trainees are placed in general practice training practices throughout New Zealand and receive clinical training and supervision. Table 8 presents the number of contracted places for GPEP1 and the number delivered or expected to be delivered between 2007 and 2010. The Government’s intention to fund an additional 50 GPEP1 training places (from 2010 onwards), combined with the additional number of training placements required for undergraduate medical students, means that the capacity of general practice to provide these clinical training placements is likely to be stretched in the near future. The Royal New Zealand College of General Practitioners (RNZCGP) has appointed a clinical co-ordinator and is doing work to address this issue. In previous years the RNZCGP offered a ‘seminar-only’ training programme (not funded by the CTA) for doctors working in general practice. In 2009 it closed this programme and encouraged all registrars to undertake the full GPEP1 training. This approach was supported by the CTA and an additional 25 places for GPEP1 training are funded for 2009. During 2009 the effect of diverting the seminar-only applicants into the full GPEP1 programme will be evaluated and the findings will inform future purchasing decisions. The GPEP1 trainee bursary will also be reviewed in 2009 as part of this work.


Table 8: GPEP1 training places 2007–2010

2007 2008 2009 2010

Contracted places 69 104 129(1) 154


Māori and Pasifika scholarships available 4 10 10 10

Actual Māori and Pasifika scholarships awarded/expected 2.5 10 10 10

Rural Scholarships available 15 20 20 20

Actual Rural scholarships awarded/expected 15 19.3 18 20

Note

(1) One-off funding increase from 104.

General Practice Education Programme Stage 2

General practice trainees continue their training with two years in GPEP2. Table 9 presents the number of contracted places for GPEP2 and the number delivered or expected to be delivered between 2007 and 2010. The RNZCGP is currently revising the training syllabus for GPEP2. Once the syllabus review is finalised the CTA will review the GPEP2 specification in partnership with the RNZCGP in 2009. Once the specification has been completed the CTA will review the level of funding for GPEP2.

Table 9: GPEP2 training places 2007–2010

2007 2008 2009 2010

Contracted training places 100 100 100 100

Training places delivered/expected 100 100 100 100

General practice pilots

Requests for proposals were called for from the DHBs to provide general practice training pilot programmes from a base of trainee-employment within the DHBs. Supported by the RNZCGP the pilots are designed to determine whether more GP trainees will be recruited if the normal DHB employment benefits and support are available to them. Although all pilots are based on the RNZCGP teaching programme, five differing pilots were selected with a view to determining the best national training format. The intention is to evaluate them in detail over several years together with existing training methods.

Postgraduate rural rotation

There is currently a widely acknowledged shortage of GPs in rural practice. Information collected by the RNZCGP shows that 65–70 percent of doctors who undertake a Postgraduate Rural Rotation (PGRR) go on to GPEP1 training. Table 10 presents the number of contracted places for Rural Rotation in PGY2 and the number delivered or expected to be delivered between 2007 and 2010.


The rural placement in PGY2 and PGY3 years is clinically based, with trainees working in rural general practices for three months. In 2008 the RNZCGP was unable to fill all of the contracted places for this training. Towards the end of 2008 the RNZCGP and the CTA reviewed the allocation of these training funds in order to find a more effective way to use them. The intention was to offer some provincial and urban rotations to utilise the funding for the unused rural rotations. This work will continue in 2009 with a view to achieving more effective use of the funding and value for money.

Table 10: PGY2 rural rotation training places 2007–2010

2007 2008 2009 2010

Contracted places 24 50 50 50


Budgets

As Table 11 shows, the budget for GPEP1 has increased for 2009/10 due to the addition of 50 new training places. The rural rotations budget has been reduced by a small amount but this will not affect the number of training places.

Table 11: General practice budgets 2007/08–2009/10

Financial year 2007/08 actual 2008/09 budget 2009/10 budget

GPEP1 budget $6,015,122 $8,043,098 $10,627,527

GPEP2 budget $235,000 $235,000 $235,000

Rural rotations budget $1,520,016 $1,602,004 $1,558,400

Total general practice budget $7,770,138 $9,880,102 $12,420,927

Nursing portfolio

The nursing portfolio continues to experience growth in trainee numbers due to an increase in demand for training and the introduction of the Nursing Entry to Practice (NETP) Expansion programme and Long Term Conditions Management (Postgraduate Certificate) funding. The CTA offered one-off funding during 2008/09 for initiatives to develop programme co-ordination for both NETP expansion and ring-fenced postgraduate nursing funding. The CTA in partnership with District Health Boards of New Zealand (DHBNZ) has commenced an HWIP nursing project to model and forecast the nursing workforce in New Zealand to provide a robust basis for workforce planning. More information is available from http://www.dhbnz.org.nz.


http://www.dhbnz.org.nz/

The Nursing Advisory Group to the CTA continues to meet on a regular basis. It has provided support for the introduction of the NETP expansion programme and for the postgraduate nursing training funding review.

Nursing Entry to Practice

The NETP programme is being expanded to include new graduate nurses employed by a health service that is funded by a DHB non-provider arm or the Ministry of Health. The Nursing Council of New Zealand (NCNZ) has approved the NETP Expansion programmes of all DHBs so they can now offer programmes during 2009. The CTA has commissioned an evaluation of the extent to which the NETP programme has achieved its intended outcomes. The final report is expected December 2009. The NETP training programme as a whole will be reviewed in 2010. Table 12 shows the number of contracted places for NETP training and the number delivered or expected to be delivered between 2007 and 2010. In 2009 all eligible NETP trainees are CTA funded.

Table 12: NETP training places 2007–2010

2007 2008 2009 2010

NETP contracted places 815 960 939 950

NETP places delivered/expected 704 786 779 800

NETP expansion contracted places – – 145 134

NETP expansion places delivered/expected – – 100 100

Postgraduate nursing

The Long Term Conditions Management Postgraduate Certificate programme was evaluated by an independent evaluator in 2008. Generally the programme has been well received. However, uptake of the programme has been much lower than expected. The CTA is exploring options to increase the number of trainees in this programme. The postgraduate nursing training funding review is underway. Feedback from the sector has been extremely positive and only minor adjustments need to be made. A revised specification will be in place for 2010. The costing for this programme is being reviewed, in conjunction with the DHBs. In 2009 all eligible postgraduate nursing training places are CTA funded. As reflected in Table 13, the expected training units for 2010 are expected to be same as 2009 because funding has not increased.


Table 13: Postgraduate nursing training units 2007–2010

2007 2008 2009 2010

Postgraduate contracted training units 1195 1602 1927 1927

Postgraduate training units delivered/expected 890 1400 1670 1670

Postgraduate trainee headcount 1597 2342 2130(1) 2130

Note

(1) Does not include second semester intake.

Audits

NCNZ has completed first year audits of NETP programmes. All of the DHBs were successfully assessed as meeting the requirements of the NCNZ standards and the CTA NETP specification. The CTA has now carried out eight audits of the use of the Postgraduate Nursing funding and expects to complete all DHBs by the end of 2010. DHBs have generally met the criteria for the funding.

Reporting

Table 14 presents the trends over the first three years of the NETP programme. Although data are incomplete for 2008, there would appear to be a steady increase in the percentage of trainees who successfully completed it. During 2006 and 2007, the completion rates for NETP were above 90 percent and a similar rate is expected for the graduates who commenced in 2008. Over the same period there has been a decrease in the percentage of those who withdrew and a slight increase in the percentage who failed.

Table 14: NETP outcomes 2006–2008

2006 2007 2008

Successfully completed 93.7% 94.4% 67.7%(1)

Still in training – 0.1% 25.6%

Break in training – 0.1% 0.5%

Withdrew 5.2% 4.4% 3.3%

Failed 1.1% 1.0% 2.9%

Note

(1) As at 1 May 2008, 25.6% of trainees who started the programme in 2008 were still in training and the outcomes are yet to be confirmed. These data will be updated in next year’s document.

The number of NETP programmes with trainees who found the teaching not directly applicable to the clinical setting has decreased substantially from 14.3 percent in 2007 to 3.8 percent to date in 2008. The issue of theoretical workload has shown great fluctuation but is still viewed as a problem, as reported by 38.5 percent of programmes in 2008 to date. The NETP programme is currently being evaluated and will cover theoretical content in the report.


As Table 15 shows, in the first two years of the postgraduate nursing funding model a high rate of trainees have successfully completed their papers, while failure and withdrawal rates are small. At the time of writing there were still a number of trainees awaiting results from semester two.

Table 15: Postgraduate nursing outcomes 2007–2008

Postgraduate Certificate

Postgraduate Diploma

3rd Year Masters

Final Year Masters

Masters with Prescribing Practicum

Qualification

2007 2008 2007 2008 2007 2008 2007 2008 2007 2008

Successfully completed

94.5%

89.8%

97.3%

95.2%

96.0%

89.0%

94.7%

88.3%

100% 95.8%

Still in training 0.1% 4.2% – 2.2% – 10.0%

5.3% 11.1%

– 2.8%

Withdrew 4.3% 5.2% 2.0% 2.4% 3.2% 1.0% – 0.6% – 1.4%

Failed 1.1% 0.8% 0.7% 0.2% 0.8% – – – – –

Budgets

Table 16 presents the specific budgets under the nursing portfolio from 2007/08 to 2009/10.

Table 16: Nursing portfolio budgets 2007/08–2009/10


NETP budget $5,999,323(1) $5,880,020 $5,993,420

NETP expansion budget $42,188 $360,000 $660,000

Postgraduate budget $10,600,503 $12,296,160 $12,182,760

Total nursing budget $16,642,014 $18,536,180 $18,836,180

Note

(1) Inflated due to ‘carry forward’.

Māori health portfolio

The review of the Māori Health Portfolio was completed in August 2008. An expert advisory group consisting of DHB Māori general managers and Ministry of Health officials assisted with the development of a new funding model and a draft specification. After these documents went out for consultation, the CTA received 22 submissions from a range of organisations. The submissions were positive about the move to a DHB-centred funding model and generally supportive of the specification. The expert advisory group considered the feedback and incorporated several changes into the final specification (which is available on the CTA website: http://www.moh.govt.nz/cta).


http://www.moh.govt.nz/cta

Hauora Māori funding

The hauora Māori training funding enables the Māori health workers employed by either a DHB (or a health service funded by the DHB non-provider arm) or the Ministry of Health to access funding for certificates, diplomas and graduate diplomas from levels 3 to 7 on the New Zealand Qualifications Authority (NZQA) framework (degrees excluded). The funding covers tuition fees, travel and accommodation costs (subsidised), clinical release, clinical supervision and programme co-ordination. District Health Boards are responsible for prioritising appropriate training programmes to support the Māori health workforce. The new funding model will assist DHBs to develop their Māori health workforce according to their planned needs in response to Government policy. It is intended that a review of hauora Māori training funding be undertaken once the new funding model has been fully implemented for two years. The new specification and funding model replace the national Māori health training programmes previously funded by the CTA. The new funding model will allow more trainees to be funded through hauora Māori training funds. Between 2006 and 2008 the number of trainees entering the national programmes fell steadily. In 2009 all eligible trainees are CTA-funded and the number of trainees is expected to rise significantly in 2010, as Table 17 indicates.

Table 17: Māori health training units 2007–2010

2007(1) 2008(1) 2009 2010

Māori contracted training units 203 187 237 360

Māori training units delivered/expected 177 141 150 273

Māori training head count 177 141 178(2) 300

Note

(1) Previous funding model.


Māori support

Māori health workforce development continues to be supported in mainstream post-entry clinical training through the Māori support grant. The purpose of the Māori support grant is to enhance the likelihood that Māori trainees will successfully complete CTA-funded training programmes such as postgraduate nursing and Nursing Entry to Practice. There is also targeted funding for general practice trainees committed to Māori health. Table 18 presents the number of trainees funded or expected to be funded under Māori support from 2007 to 2010. In 2009 all eligible Māori support applications received CTA funding.


Table 18: Māori support trainee numbers 2007–2010

2007 2008 2009 2010

Funded trainees 136 155 216(1) 340

Note


Reporting

Between 2006 and 2008, 398 trainees passed a CTA-funded Māori health training programme. Table 19 presents the outcomes in percentage terms. The pass rate was above 70 percent each year and the withdrawal rate reduced from 13 percent in 2006 to 7.1 percent in 2008. The only issue that presented itself frequently in end-of-year reporting was that the trainees’ workload was too high to allow time to attend formal training components.

Table 19: Māori health programme outcomes 2006–2008

2006 2007 2008

Successfully completed 70.0% 86% 79.4%

Withdrew 13.0% 7.3% 7.1%

Failed 17.2% 6.8% 13.5%

Feedback from end-of-year reporting for Māori support was generally positive. The main issue raised concerned rushed timeframes involved in organising mentors and support plans.

Budget

Table 20 presents the budget for the Māori health portfolio from 2007/08 to 2009/10.

Table 20: Māori health portfolio budget 2007/08–2009/10


Māori Health budget $2,518,546 $3,238,232 $3,238,232

Pacific peoples health portfolio

The development of the Pacific health workforce is supported in mainstream post-entry clinical training through the Pacific peoples support grant. The purpose of the Pacific peoples support grant is to enhance the likelihood that Pacific trainees will successfully complete CTA-funded training programmes. There is also targeted funding available for general practice trainees committed to the health of Pacific peoples. In 2009 all eligible Pacific peoples support applications received CTA funding.


Reporting

In 2008 there were eight Pacific peoples support programmes with 56 trainees participating. Feedback from end-of-year evaluations was positive.

Budget

Table 21 presents the budget for the Pacific peoples support grant for 2008/09 and 2009/10.

Table 21: Pacific peoples support budget 2008/09–2009/10

Financial year 2008/09 budget 2009/10 budget

Pacific peoples support budget $135,133 $135,133

Midwifery training

The CTA currently funds two midwifery training programmes: the Midwifery First Year of Practice programme for new graduates; and postgraduate clinical training on midwifery complex care.

Midwifery first year of practice

The Midwifery First Year of Practice (MFYP) programme is now its third year of operation and ongoing funding has been secured for this training (see Table 24). The main aim of the programme is to support new graduate midwives in their first year in the workplace to:

develop the necessary skills and knowledge to practise safely and competently

contribute to better outcomes of consumer and maternity services

improve the job satisfaction and retention of new midwives. The provider of the programme is the New Zealand College of Midwives. The 12-month programme is available to all new graduate midwives and includes mentor development, training courses, mentor support time, trainee clinical release and national co-ordination. The pilot evaluation findings were positive overall. The CTA and the MFYP Expert Advisory Group took account of them when reviewing the pilot specifications in 2008 and finalising the interim specification. In March and April 2009 the CTA consulted with the wider sector on the interim specification. The consultation results will be considered by the MFYP Expert Advisory Group and the CTA in 2009. The interim specification and the level of funding for the training will be reviewed as part of this process.


Table 22 shows the number of contracted places for MFYP training and the number delivered or expected to be delivered between 2007 and 2010. In 2009 all eligible graduate midwives received CTA funding.

Table 22: Midwifery first year of practice training places 2007–2010

2007 2008 2009 2010



Midwifery postgraduate education

In 2008 the Ministry of Health identified a budget for postgraduate midwifery education and the CTA Midwifery Postgraduate Expert Advisory Group was set up. The Expert Advisory Group prioritised clinical training on midwifery complex care for these training funds for 2009, due to the increasing number of women and babies with complex care needs. The main aims for the training are to enhance the skills and increase the number of midwives who can proficiently work as members of the multidisciplinary care team that cares for women and babies with complex care needs. Three tertiary education providers offer midwifery postgraduate education: Otago Polytechnic; Auckland University of Technology and Victoria University. All three were part of the Expert Advisory Group, and as a result of a concerted effort have been able to offer (in 2009) a postgraduate certificate that includes a clinical training programme in conjunction with an academic course. The clinical training programme includes clinical training hours, clinical placements, and precepting. As indicated in Table 23, in 2009 the CTA provided funding for 33 midwives working in secondary and tertiary settings to undertake this training. In 2009 and 2010 the pilot training will be evaluated and the preliminary findings considered when setting the funding priorities for 2010. In 2009 the sector will also be consulted regarding its midwifery postgraduate education needs and priorities so that support may be made available for midwives to undertake other postgraduate education. Depending on the consultation findings, in 2010 the budget for midwifery postgraduate education may be divided between complex care clinical training and other postgraduate education.

Table 23: Complex care training places 2009–2010

2009 2010

Contracted places 33 33

Places delivered/expected 30 30


Budgets

From the 2008/09 financial year onwards, funding has been secured. Table 24 presents the specific budgets within midwifery training for 2007/08 to 2009/10.

Table 24: Midwifery budgets 2007/08–2009/10


MFYP budget $2,000,004 $1,556,467 $1,564,558

Complex care budget – $350,000 $1,000,000

Pharmacy intern training

Pharmacists have an important role in meeting local health needs at the primary care level. In the future this role is likely to be further utilised with the implementation of the Primary Health Care Strategy (Minister of Health 2001). Developing closer integration between primary care practitioners and working with local communities are two key areas of the strategy that will require pharmacists’ involvement. The CTA provides a funding contribution for the pharmacy internship year. This year is completed immediately after the undergraduate pharmacy degree and is a compulsory requirement for graduates wanting to practise as a pharmacist in New Zealand. The pharmacy internship year consists of practical training in a pharmacy setting approved by the Pharmaceutical Society of New Zealand and the completion of the society’s pre-registration programme. The practical training is carried out under the supervision of a registered practising pharmacist. In 2009 the intern training programme was reviewed externally by a Canadian expert who rated the programme highly overall. The Pharmacy Council of New Zealand is currently reviewing its accreditation criteria for the intern training programme (in conjunction with the Australian Pharmacy Council) and will be consulting on them in mid-2009. The Pharmacy Council of New Zealand then intends to invite other training providers to submit a programme for consideration for accreditation in 2011, when the new accreditation criteria must be met. In 2009 the CTA made a one-off increase in the number of eligible trainees it part-funds from 170 to 196, as reflected in Table 25. It will commence a review of the pharmacy training specification in 2010.

Table 25: Pharmacy intern training places 2007–2010

2007 2008 2009 2010

Places contracted 170 170 196 170



Reporting

Over the past three years, the completion rate for the programme has been around 90 percent, as reported in Table 26.

Table 26: Pharmacy intern training outcomes 2006–2008

2006 2007 2008

Successfully completed 92.4% 88.0% 87.4%

Break from training 0.6% 0.5% –

Withdrew 0.6% – 2.2%

Failed 6.4% 11.4% 10.4%

Budget

Table 27 presents the budget for the pharmacy intern training programme from 2007/08 to 2009/10.

Table 27: Pharmacy intern training budget 2007/08–2009/10


Pharmacy budget $890,808 $915,735 $915,735

Clinical rehabilitation training

The CTA has a very limited budget available for disability-related training needs. It purchases one postgraduate certificate programme which is provided by the University of Otago. The programme focuses on effecting quality improvements in rehabilitation services and in improving the culture and environments in which rehabilitation services are provided. Over time this programme is increasing the knowledge, skills and capacity of the multidisciplinary workforce to provide quality rehabilitation services. This training is open to all rehabilitation health professionals and is one of the few inter-professional education programmes that the CTA funds. Table 28 shows that the number of clinical rehabilitation places delivered has fluctuated between 2007 and 2009. In 2008 only nine of the 18 training places were filled. However, 15 of the 18 places have been filled in 2009. The contracted amount is expected to remain at 18 places.

Table 28: Clinical rehabilitation training places 2007–2010

2007 2008 2009 2010




Reporting

Over three years there has been a steady rise in the completion rate for the programme from 86.7 percent in 2006 up to 100 percent in 2008, as Table 29 shows.

Table 29: Clinical rehabilitation training outcomes 2006–2008

2006 2007 2008

Successfully completed 86.7% 94.4% 100%

Withdrew 13.3% 5.6% –

Budget

Table 30 presents the budget for the clinical rehabilitation training programme from 2007/08 to 2009/10.

Table 30: Clinical rehabilitation budget 2007/08–2009/10


Clinical rehabilitation budget $303,534 $319,815 $311,724


Appendix 1: Explanatory Notes

Contracts structure

The CTA contracts consist of a Head Agreement, Service Agreement and a Programme Specification. CTA standard terms and conditions are evergreen, and only one Head Agreement is required for each organisation that the CTA contracts with for the provision of training services. Individual service agreements are negotiated with each training provider organisation to determine the detail of training to be purchased. These service agreements sit beneath a Head Agreement, and are small, easy-to-read documents, detailing price, quantity, the training to be delivered and any additional programme- or provider-specific clauses. Training programme specifications are in place to provide detailed descriptions of programmes and can be viewed at http://www.moh.govt.nz/moh.nsf/indexmh/cta-specifications. Specifications reduce the detail required in service agreements, are uniform across providers and are transparent.

Reporting

The CTA makes payments to training providers based on reports of who is in training on the 15th of each month. At the end of each training year, providers complete reports on trainee progress, including whether the programme was completed or is continuing, or whether the trainee left the programme or failed. These outcomes are summarised so that trends can be analysed. Training providers also send the CTA an end-of-year report based on their own monitoring of programme issues, including the perspectives of trainees and supervisors. Again, these responses are summarised nationally. When the CTA prepares these reports, it places them on its website http://www.moh.govt/cta.


http://www.moh.govt.nz/moh.nsf/indexmh/cta-specifications

http://www.moh.govt.nz/moh.nsf/indexmh/cta-specifications

http://www.moh.govt/cta

Appendix 2: Sector Consultation for Purchase Intentions

The following 58 organisations had at least one representative receive an email copy of the Purchase Intentions 2008/09 document for consultation. The 140 representatives contacted in this way were invited to forward the document on to others.

Auckland District Health Board Australian and New Zealand College of Anaesthetists Bay of Plenty District Health Board Canterbury District Health Board Capital and Coast District Health Board College of Nurses Aotearoa (NZ) Inc Counties Manukau District Health Board Diagnostic Medical Laboratory Ltd District Health Boards New Zealand (DHBNZ) Eastern Institute of Technology Family Planning Association of New Zealand Fulford Radiology Services Ltd Hauora.com Hawke’s Bay District Health Board Healthcare Providers NZ Hutt Valley District Health Board Joint Faculty of Intensive Care Medicine Lakes District Health Board Massey University Mauri Ora Associates Medlab Central MidCentral District Health Board Midwifery Council of New Zealand Ministry of Health (eight directorates) National Association of Nurse Education in the Tertiary Sector Nelson Marlborough District Health Board New Zealand Blood Service New Zealand College of Midwives New Zealand Nurses Organisation New Zealand Population Health Charitable Trust New Zealand Private Surgical Hospitals Northland District Health Board Nursing Council of New Zealand Otago District Health Board Queen Elizabeth Hospital Royal Australasian College of Physicians


Royal Australasian College of Surgeons Royal Australian and New Zealand College of Obstetricians and Gynaecologists Royal Australian and New Zealand College of Ophthalmologists Royal Australian and New Zealand College of Psychiatrists Royal Australian and New Zealand College of Radiologists Royal College of Pathologists of Australasia Royal New Zealand College of General Practitioners South Canterbury District Health Board Southland District Health Board Tairawhiti District Health Board Taranaki District Health Board Te Pou Te Wānanga-o-Raukawa Tipu Ora Trust UNITEC Institute of Technology University of Auckland University of Otago Waikato District Health Board Wairarapa District Health Board Waitemata District Health Board West Coast District Health Board Whanganui District Health Board Whitireia Community Polytechnic


Appendix 3: CTA Prioritisation Decisions

The CTA is in the process of creating a new prioritisation model. This model will be aligned with the joint DHB and Ministry of Health paper The Best Use of Available Resources: An approach to prioritisation (Ministry of Health 2005). The principles for prioritisation are:

Government policy

effectiveness

equity

efficiency

whānau ora

constraints. The model will be phased in during 2009/10 and the results will affect the purchasing decisions for 2010/11.



References

Minister of Health. 2001. The Primary Health Care Strategy. Wellington: Ministry of Health.

Ministry of Health. 2005. The Best Use of Available Resources: An approach to prioritisation. Wellington: Ministry of Health.

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