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A story without end.
The unrealised transfer of GP training may be considered in such exasperated terms.
Five years have passed since the HSE stated its intention to transfer management to the ICGP, but progress has been slow.
The College says it has made numerous efforts to clarify the proposed budget under the anticipated transfer. In recent years, the HSE has associated the delay with the complexity and variance of its employment arrangements for directing teams.
Nevertheless, with free GP care now extended to under-sixes (commencing July 1), and to all over-70s in August, and the need for more training places acknowledged by all parties, some manner of resolution is required. But there is not yet sign of a breakthrough.
Since April 2015, for example, the College says it has requested two meetings with the HSE to discuss a “comprehensive and structured process” whereby the governance and contractual issues involved in transferring GP training to the ICGP could be negotiated. The Medical Independent (MI) requested comment from the HSE on various aspects of GP training, but it had not responded by press time.
The HSE has been attempting to further increase the number of GP training places, which is a commitment of the Programme for Government 2011-2016
The evolution of GP training, whereby the College has responsibility for trainee selection and quality standards, while financial, structural and administrative aspects are managed by the HSE, is “reasonably unique” in the Irish medical system, says the ICGP.
Current and future resourcing of training, however, has long been a thorny issue. ICGP correspondence to the HSE on 10 March, obtained by MI under a Freedom of Information (FoI) request to the HSE, indicated that a sum of €6 million was suggested by the HSE for the management of GP training, once transferred to the ICGP. The College informed the HSE that this “wasn’t even remotely feasible”. MI understands current annual expenditure is approximately €20 million.
Separately, the College has publicly stated that while it would identify possible savings related to the current expenditure, in respect of taking over training, the quality of standards cannot be compromised.
The ICGP’s sense of unease is exacerbated by the experience of 2010, when the College and GP training schemes facilitated 37 new training places “without any additional financial resources” forthcoming from the HSE, it says. This brought first-year training places to 157 per annum, after many years of lobbying by the College for an increase in the numbers trained, to meet growing manpower issues.
The HSE itself has been attempting to further increase the number of GP training places, which is a commitment of the Programme for Government 2011-2016. This has met with resistance from the College, in the context of expressed concerns around resourcing and planning, as is clear from documentation seen by MI under FoI.
A briefing note on 30 March from the HSE National Doctors Training and Planning (NDTP/formerly MET) — marked for the attention of Minister for Health Leo Varadkar — described an “urgent need” to increase the numbers entering training this July.
Minister Leo Varadkar
According to the note, there was an “acute shortage” of GPs to deliver the “current” service. It said implementation of Government policy, such as free GP care for the under-sixes and over-70s, would result in the need for “even more GPs in the future”.
It stated that “funding was secured” for an additional 10 GP training places in 2014, but this was “turned down” by the ICGP. “Again, in 2015, funding for 12 additional places had been approved, but turned down by the ICGP,” it added.
Asked if the HSE briefed the Department of Health on reasons for the College’s reluctance to accept these requests, a Department spokesperson tells MI it “has been made aware of issues surrounding the filling of training places”.
ICGP CEO Mr Kieran Ryan strongly underlines to MI that the ICGP fully supports an increase in GP training numbers. However, he maintains the College requires earlier consultation and “proper commitment to resourcing” to expand the training schemes.
The requests from the HSE for increased places came at the tail-end of the recruitment processes in 2014 and 2015, he says.
The College has highlighted to the HSE, over a number of years, the “dwindling resources” in some of the 14 GP training schemes. Mr Ryan declines to name the particular schemes, but says some have been struggling to deliver training at the level required due to resourcing issues.
“There are some schemes that are just not suitable for expansion and are struggling to deliver the training at the level required, with existing resources. So additional trainees is not going to help,” he underlines.
Mr Ryan says that, in respect of the additional posts for 2014, the ICGP was informed the funding would come from “savings yet to be made on the transfer of training responsibilities and budget from the HSE to the College. And at that point, there were no formal negotiations: there has been no (formal) budget proposed and that remains the case.”
A lead-in of around five months would be required to plan new posts, says Mr Ryan, who refers to the quality standards that the ICGP is responsible for upholding.
A GP with first-hand knowledge of training on-the-ground, speaking to MI on condition of anonymity, confirms that resource issues are negatively affecting GP training delivery. A lack of GP trainers, contracted by the HSE, is particularly concerning, he contends. It has been difficult to gain Executive approval for new trainers, and if recruited, they are contracted on a short-term basis, he says.
According to the GP, the trainer has a “crucial” role in the formation of GP trainees. “They are the ones most likely to see how the trainee performs in action. And obviously, the quality of training in practice is crucial as to how the trainee will perform in practice in the long term.”
When it comes to requested resources, there appears to be an element of “brinkmanship”. He says schemes may get resources at the last minute — and on a short-term basis. Some Programme Directors have had to spend “an awful amount of time” pursuing these issues, and this impacts on capacity to focus on education delivery. He says GPs feel there is “distrust” within the HSE regarding their views on resource issues.
Certainly, the question of resourcing of GP training is the recurrent theme of communications between the ICGP and various sections of the HSE over the last number of months.
In January 2015, a HSE official contacted Mr Ryan, requesting “a draft proposal as to how you envisage the delivery of GP training once ICGP assumes responsibility for same”.
Mr Ryan replied that a business plan “would be near impossible until the HSE fully discloses the budget intended for transfer and legal constraints in respect of the employees”.
He outlined his understanding that, to date, there had been no formal discussion with HSE staff employed in the GP training schemes as to their terms/conditions and entitlements, against the background of the proposed transfer.
“The legal and regulatory matters around the transfer need to be underpinned by a collaborative agreement between the ICGP and HSE in relation to the commitment to the project and its successful transfer,” wrote Mr Ryan. “If we are to go at a serious project such as this without a commitment to working together, then the risks of failure, breakdown of trust and relationships will send this opportunity for significantly positive change back to the Stone Age.”
He called on the HSE to sign a formal agreement with the ICGP to enact the transfer “under a set of binding principles which are in accordance with our roles under the MPA [Medical Practitioners Act] 2007 and good practices, as required by employment legislation”.
On 10 March 2015, a letter from Mr Ryan to Mr Brian Murphy, Head of Planning, Performance and Programme Management, Primary Care Division, HSE, stated that one of the primary obstacles to transfer of training delivery was defining the budget to be allocated to the ICGP to manage training.
Some Programme Directors have had to spend ‘an awful amount of time’ pursuing these issues, and this impacts on capacity to focus on education delivery
The most recent estimate from the HSE was €6 million, stated Mr Ryan’s letter. He wrote that delivery of the programme involved infrastructure including directing teams, administration, ICT, physical locations, the network of GP trainers and local governance through steering committees and local trainer workshops. “The vast majority of the budget expenditure of the HSE on the delivery of training (outside of the salaries of the trainees themselves) is for this delivery structure,” wrote Mr Ryan.
His letter stated that, from previous discussions as far back as 2011, the estimated expenditure of the HSE on the delivery infrastructure was in the region of €10.5 million, “which only covers the salary costs of the programme directing team and tutors and the GP trainer costs (based on current rates),” wrote Mr Ryan.
“There would also need to be consideration given to issues such as employers’ PRSI, pension entitlements and insurance costs,” he wrote. “This estimate is also not inclusive of costs such as premises and ICT. Therefore, as we have previously outlined on numerous occasions, the HSE needs to consider a realistic budget which the College could consider. The notion of delivering a national GP training programme at the level of trainee numbers currently is not even remotely feasible for €6 million.”
Mr Ryan stated that the ICGP Board believed the HSE should bring this matter to a conclusion “one way or the other” no later than June 2015.
“The current situation where proper resourcing of training schemes is being delayed pending the transfer can no longer continue.”
Meanwhile, in parallel to this was another HSE attempt to increase the number of GP trainees. On 28 October, 2014, Prof Eilis McGovern, Director of the NDTP, had written to HSE National Director of Primary Care Mr John Hennessy on the issue of GP training numbers.
Prof McGovern noted the agreement reached with the GP Western Training Scheme, in that, from 2016, its trainees would start each July. This meant there would be no recruitment for the Western scheme in 2015, with the Scheme’s 15 trainees commencing in April 2015, having already been recruited. Therefore, although 157 trainees would commence training in 2015, only 142 would be appointed through the 2015 recruitment process.
Prof McGovern informed Mr Hennessy that the NDTP wished to propose that 157 appointments be made. One of the cited advantages was helping to address GP shortages, while there was also the possibility of targeting specific region(s) to locate the additional trainees, “as there is strong evidence internationally that trainees tend to settle and locate their practice in the region where they trained”.
The NDTP Director outlined very little cost implication for years one and two as the trainees are employed as SHOs in the acute hospital system. The add-on training costs in this respect would be “marginal” and borne by the NDTP.
“There is potentially a significant cost implication in years three and four (2017-2019), due to trainee salary and training programme costs kicking-in,” she added. “However, by that stage, GP training should be located within the ICGP under a SLA [service level agreement] with MET, with considerable savings achieved.”
Mr Kieran Ryan, ICGP CEO
Further correspondence obtained under FoI shows that, on 2 March 2015, Prof McGovern emailed Mr Ryan and ICGP Director of Specialist Training Dr Gerry Mansfield, referring to news of approval by the Department of Health for an additional 12 places in July.
The short time-frame was acknowledged by Prof McGovern. However, she underlined potential benefits. She noted that less training posts were appointable for the 2015 cohort, due to the realignment of the Western Training Scheme.
This email also referred to an additional proposal to fill three vacant second-year posts for 2015, following the drop-out of three trainees in first year. This particular proposal, formally communicated in writing to the College on 13 February 2015, could be achieved via a pilot programme recognising prior training (see panel), it was suggested.
“There is a very tight timeline now as the lists for training places will be locked down in the next three-to-four weeks,” wrote Prof McGovern. She said she had heard anecdotal evidence of many disappointed applicants for the GP training programme.
A few days later, in a letter dated 6 March, Mr Ryan informed Prof McGovern of the substantial time and resources expended by the ICGP to meet new NDTP requirements, under which recruitment for 2015 was undertaken.
The required changes “represented the very first time that a national rank order list was utilised to make offers to candidates for GP training based on agreed available training places confirmed at the commencement of the recruitment process. It is regrettable that this positive decision to expand training places by 12 has been made too late for this to work within the constraints inherent in our new recruitment process”.
Nevertheless, an administrative error within the ICGP during its 2015 recruitment process led to the College agreeing to four more places. Correspondence seen by MI shows that the HSE again applied pressure as regards fulfilling all 12 additional places, but this was resisted by the ICGP during a particularly tense period.
The Department of Health had also advocated that the 12 new trainee posts be implemented. An official in its Workforce Planning Unit informed the NDTP on 30 March that it would be “desirable” for the posts to be filled, “from a medical workforce planning perspective”.
On April 28 this year, Mr Ryan informed Mr John Hennessy, HSE National Director of Primary Care, that the ICGP board agreed it is “still committed in principle to taking on the responsibilities for the delivery of GP training from the HSE”.
However, the Board wanted to ensure that “due diligence” is applied to the transfer, and that the appropriate “structure, resources and funding are put in place to enable it to effectively exercise its accountability”.
Mr Ryan wrote: “This approach will ensure that, on transfer to the ICGP, we can deliver GP training that meets the standards set by the Medical Council and train sufficient general practitioners for our health service needs.”
The College suggested the use of a “structured, collaborative approach to delivering a fit-for-purpose solution” acceptable to both parties.
This would include, but not be limited to, jointly drawing-up a memorandum of understanding on how both parties would engage on the transfer process, agreeing on the scope of the issues to be addressed.
Additionally, it would involve adoption of a “bottom-up approach” to fully understand the funding necessary to deliver the agreed level of service, “using an independent reviewer (if necessary) to examine the current funding of GP training”.
Mr Ryan’s letter also proposed a joint steering group and project team to “oversee the smooth transfer of responsibilities”.
On 20 May 2015, in another letter to Mr Hennessy, Mr Ryan pointed out the ICGP’s formal accreditation with the Medical Council, as the body responsible for oversight of specialist GP training.
He also referred to a stipulation in the Medical Practitioners Act that medical education and training be developed and co-ordinated in cooperation and in consultation with medical training bodies. He referred to the requests to expand recruitment for 2014 and 2015 without prior consultation.
The other significant issue highlighted was lack of progress on the SLA. “The decision of the HSE to devolve their responsibilities for the delivery of GP training to the ICGP for nearly five years without implementing the decision has contributed adversely to the resource and standards deterioration in many of our GP training schemes,” Mr Ryan wrote. “It is our firm view that the sooner the HSE begins the negotiation process with the ICGP, the sooner the deficits and challenges in our training programme can be addressed.”
Mr Ryan requested a meeting with Mr Hennessy and Prof McGovern to discuss GP training posts for 2016, how they will be resourced and where exactly they will be placed, in addition to discussing the SLA.
The ICGP CEO confirms to MI that this is where matters currently stand. “We would love to have more involvement in the allocation of the resourcing side of things… it could give us more flexibility, we could get more efficiencies and so on, but not necessarily to the extent that the HSE are expecting. But that is what we would like to negotiate on.”
The current situation cannot continue much longer, as some schemes have been “severely hit” by the resource issues.
As of June 2015, there is a possibility training places may have to reduce next year, if resourcing issues are not addressed.
“It is a possibility, yes,” confirms Mr Ryan. However, he emphasises that no-one wants this to happen.
“We are seeking the advice of the Medical Council on what are the options, what the best approach is. But ultimately, we know the best approach is for all parties — the HSE, College and the Medical Council — to sit down together and work something out.”
HSE proposed accelerated training pilot for 2015
The HSE NDTP proposed that three places be included in second-year GP training commencing 2015, for doctors with prior training experience in other specialties.
This is outlined in correspondence to the ICGP obtained by MI following an FoI application to the HSE.
Prof Eilis McGovern, Director of the NDTP
NDTP Director Prof Eilis McGovern informed ICGP CEO Mr Kieran Ryan on 2 March last that the Department of Health had approved three posts “for an accelerated programme,” ideally commencing in July. This would address three drop-outs in the first year of training and ensure the graduating class of 2018 remained at 157, rather than 154.
Prof McGovern wrote: “I would strongly encourage the ICGP to pilot the accelerated programme for three trainees this year… psychiatry and emergency medicine already have reciprocal recognition of previous training in place. Progressing this as a pilot introduces the flexibility required with such a short lead-in time.
“As the trainees would be in hospital posts until 2016, there is time to develop the proposal in a more detailed way during the coming year. It might be possible to apply some principles from the Alternative Route to College Membership, which is already in operation.”
‘Psychiatry and emergency medicine already have reciprocal recognition of previous training in place’
A HSE letter to the ICGP on 13 February, which had formally outlined the proposal, referred to the shortage of GPs in Ireland and the need to “collectively explore all opportunities to address this deficit”.
In this letter, Mr Murphy and Prof McGovern wrote that evidence from the UK Medical Careers Research Group suggested that a significant number of trainees change training programmes in the early years post-graduation, and the specialty training programme to which they are most likely to transfer is general practice. “NDTP will provide the necessary resources to support these three posts,” it stated.
Asked by MI why the College was not in a position to implement this proposal, Mr Ryan indicates that it was made too late, from a planning perspective, for 2015 recruitment.
The College supports the need to develop recognition of prior training, which requires a planning infrastructure in itself, he said. In recent years, the ICGP had submitted a proposal to the HSE on this matter, he added.