Flexible Training ICGP Policy Adopted by PGTC September Flexible Training ICGP Policy Adopted by PGTC September 2016

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1 Flexible Training ICGP Policy

2 Index Page No. Introduction 4 Part 1: ICGP Response to NDTP policy 5 Part 2: Accomodating flexible training in general 10 Appendix 1: Categories of Application 14 Appendix 2: Costs of Flexible Training 15

3 Members of the NCCT Task Group This report was prepared by Members of the National Co-ordinating Committee for Training (NCCT) Task Group on Flexible Training: Dr. John Brennan (Chair, GP Trainee) Dr. Sarah Maguire (Assistant Programme Director), Dr. Mary Teresa O Neill (GP Trainee), Dr. Nick Flynn (Trainer), Dr. Gerry Mansfield (National Director of Training), Ms. Martina McDonnell (ICGP) The report from the NCCT Task Group on Flexible Training was considered by: The National Co-ordinating Committee for Training (NCCT) on 1 st September 2016 The Accreditation Sub-Committee September 2016 The Postgraduate Training Committee on 27 th September The report is in two parts. Part I - ICGP response to NDTP National Flexible Training Scheme. Part II - Accommodating flexible training in general.

4 1. Introduction In 2013, The Strategic Review of Medical Training and Career Structure Working Group (McCraith Report) was tasked by the Minister for Health with examining and making high-level recommendations relating to training and career pathways for doctors with a view to: Improving graduate retention in the public health system; Planning for future service needs; Realising maximum benefit from investment in medical education and training. Recommendation 5 of this report pertains to flexibility in training and states: In view of the feedback from stakeholders and the emerging evidence from the Medical Council s Workforce Intelligence Report, the Working Group considers that more flexible and differentiated approaches and options during training that take account of family, research or other constraints should be explored by HSE-MET and the Forum of Irish Postgraduate Medical Training Bodies. In this regard, the Working Group suggests that HSE-MET and the Forum of Postgraduate Irish Medical Training Bodies explore the implementation of a couple matching/familyfriendly initiative for the July 2014 intake. In response to this recommendation, the HSE has established its own National Flexible Training Scheme. The HSE continues to expand this scheme and in 2016 there will be funding available for 32 trainees (from all postgraduate medical specialties). The HSE continues to accept applications for the scheme from GP trainees from year 2 onwards, however, to this point the HSE and ICGP have not examined how this Flexible Training Scheme will integrate into current GP Training structures. Flexible training has been an integrated option for trainees in General Practice in other international jurisdictions for many years. For example, the NHS adopted principles underpinning flexible training in 2005 with the following aims: To retain within the medical workforce doctors who are unable to continue their training on a full-time basis. To promote career development and work/life balance for doctors in training. To ensure continued training in programmes on a time equivalence (pro-rata) basis. To maintain a balance between less than full-time arrangements, educational requirements and service needs. Doctors in flexible training; Principles underpinning the new arrangements for flexible training, NHS 2005

5 At present, several GP training schemes in Ireland offer trainees individual methods of flexibility in their training by way of utilising parental and annual leave. This working group has been tasked by the National Coordinating Committee for Training (NCCT), a subgroup of the Post Graduate Training Committee of the ICGP, with the formal consideration and exploration of flexible training options in Irish General Practice training. This document presents the recommendations of this working group specifically in response to the HSE s National Flexible Training Scheme and also, more broadly, for the accommodation of greater flexibility in Irish GP Training overall. Methods Commencing in May of this year, this working group prepared a draft position paper informed by (i) consultation with representative Trainees, Trainers, Programme- Directing Teams and the GP Training Unit of the ICGP and (ii) review of international models of flexible postgraduate medical training. This document was circulated to these groups for further consultation in July. The feedback obtained has now been integrated to produce these recommendations. This document will set out recommendations specific to the HSE s National Flexible Training Scheme in the first instance and then to the broader issue of accommodating flexibility in GP Training. It will be seen that there are considerations which are common to both. Part 1. ICGP Response to HSE National Flexible Training Scheme Eligibility The guide to the HSE National Flexible Training Scheme states that applications may be made for flexible training: 1. By trainees who have been accepted onto the next immediate intake to BST2-4/HST/ST2-8. Such applicants may apply for flexible training prior to commencing their next stage of training; OR 2. Existing BST2-4/HST/ST2-8 trainees may apply for a position on the HSE National Flexible Training Scheme at any stage throughout his / her training but it is generally recommended that the final year of higher specialist training/streamline training be full time. Trainees must be enrolled in a specialist training programme under the auspices of one of the postgraduate medical training bodies recognised by the Medical Council in

6 Ireland at the time of commencement of flexible training and throughout their flexible training post. All applicants must have well founded individual reasons for flexible training. Applications for flexible training in order to pursue other paid work, paid nonmedical interests or to engage in research will not be considered by NDTP. The most common reasons to date for individual higher specialist trainees making an application to the National Flexible Training Scheme include Responsibility for caring for others (e.g. children or elderly relatives) and Personal family circumstances. HSE Guide to HSE National Flexible Training Scheme 2016 Further important eligibility points to note as part of the HSE Flexible Training Scheme include: The number of available flexible training posts is limited. Each approved flexible training post will be approved for 12 months, and will commence in July each year, in line with the training year. Any trainee appointed to a flexible training post and who wishes to continue in flexible training after this period will be required to re-apply. No preference will be given to trainees already on the flexible training scheme for subsequent periods on the scheme. Participation on the flexible training scheme will be restricted to a maximum of two years and will only be extended by NDTP in exceptional circumstances. This is to provide as many trainees as possible with the option to train flexibly. Prospective applicants should note that deferral of flexible training places is not permitted. An applicant who cannot take up a flexible training post on the specified date of commencement must re-apply. HSE Guide to HSE National Flexible Training Scheme 2016 This working group believes that all trainees, male and female, should be eligible to apply for flexible training provided they have a well-founded individual reason. While HSE/NDTP have defined their own criteria for eligibility for accessing the HSE National Flexible Training Scheme, the working group broadly supports categorised eligibility similar to the model used by the NHS, as demonstrated below, to assess eligibility and provide prioritisation for applicants on certain grounds We recommend the implementation of two categories of eligibility: Category 1 includes doctors in training with needs related to disability, health or caring for others;

7 Category 2 includes other well-founded reasons for requesting flexibility in training. Applications under category 1 would be treated as a priority while those under category 2 would be considered on a case-by-case basis. (See Appendix (i) for further recommendations on category details) While it is recognised that the HSE Flexible Training Scheme is open to all trainees from 2 nd year onwards, it is felt that the ability to work in full time general practice on completion of the training scheme is essential and that this proficiency must be protected in training. This working group recommends a minimum period of 6 continuous months of full time training in the general practice setting as a means of ensuring this capability. At present, training in General Practice in Ireland must be completed within 6 years of commencement. Exemptions from this stipulation are assessed on an individual basis by the Post Graduate Training Committee. Flexible training may prolong the duration of training beyond the six-year mark in some cases. Early recognition and flagging of this possibility at the time of application will aid progression towards satisfactory completion of training. We feel it is in the best interests of the trainee and GP training that the ICGP would play an ongoing role in assessing the eligibility of candidates for flexible training. However, we believe that if a situation arises whereby the number of applicants deemed eligible for Flexible Training exceeds the number of available positions, prioritisation of these applicants should remain the responsibility of the HSE National Flexible Training Scheme as employer and administrator of this scheme. Application Process This working group recommends that the ICGP support the HSE in managing applications for the HSE National Flexible Training Scheme. The guide to the HSE National Flexible Training Scheme outlines the application process. The application process for the National Flexible Training Scheme is a two-step process. Each step is outlined below. Application Stage 1: Expression of Interest The purpose of this stage is to allow the trainee to formally register their interest in the National Flexible Training Scheme with NDTP and to provide information to NDTP which will enable the HSE to make an initial assessment of the application.

8 NDTP will consider the application and will contact the applicant, advising them whether: 1. A post is expected to be available and the trainee may proceed to stage 2 of the process, OR 2. A post is not available but the application is appropriate for inclusion on the reserve list for vacancies. The applicant will be informed of their position on the reserve list. Vacancies will be filled in the order of the placement of applicants on the reserve list, which in turn is based on the order in which applications are received OR 3. The application is not appropriate for a flexible training post. All decisions made by NDTP at Stage One will be notified directly to the relevant training body representative (Dean/ National Specialty Director/ Programme Director) to ensure that all parties are aware of the status of applications for flexible training. All decisions by the NDTP on each application received are final. Application Stage 2 Detailed Application Form If an applicant is advised by NDTP that they may proceed to Stage Two of the application process, the applicant must complete and submit to NDTP the Detailed Application Form. The purpose of this stage is to provide NDTP with both the training details and the employment details of the proposed flexible training post. The Detailed Application Form must be signed by: 1. The applicant, 2. The relevant training body representative (Dean/National Speciality Director/ Programme Director) and 3. The employer (HR Manager/ Medical Manpower Manager/ Hospital Manager). It is the responsibility of the applicant to ensure that the necessary approval is obtained from both the training body and the employer in a timely manner. HSE Guide to HSE National Flexible Training Scheme 2016 The working group strongly supports a well-structured and robust application process administered by the HSE NDTP. We strongly recommend that early liaison takes place with those directly responsible for training (Trainer /Consultant and programme directing team) prior to a trainee commencing stage one of the application. This would allow all relevant parties to plan for educational continuity and training needs. We believe that all requests for flexible training should be treated constructively and without prejudice. However, the overall training capacity of a training programme and service commitment must be taken into consideration. Early liaison between the educational stakeholders will help to remove potential barriers which may arise later in the application process through advanced planning and consultation.

9 Appeals This working group recommends the implementation of an integrated appeals process for applicants declined flexible training. This appeals process should involve representation from both the HSE and ICGP as well as an independent arbiter, and should be processed in a transparent and fair manner. Role of the Training Body The working group believes that the ICGP should have a role in assessing the eligibility of trainees and capacity for Flexible Training. It is also essential that the ICGP continue to have a role with the HSE in the administration and governance of the HSE National Flexible Training Scheme. We recommend that the ICGP be formally involved in assessing eligibility and capacity for HSE National Flexible Training posts. This is in addition to advocating for the educational and training requirements and standards for trainees, trainers and programme directing teams. Role of the Training Scheme It is envisaged that individual training schemes will continue to organise and oversee the individual training requirements of trainees participating in the National Flexible Training Scheme, in consultation with the employer and local fund holder (HSE). Funding Trainees training in a hospital post approved for flexible training will have their post backfilled. The trainee s flexible training post will become a supernumerary hospital post and will be funded from the HSE National Flexible Training Scheme budget. The trainee will be paid pro rata for time worked. Trainees training in General Practice are already operating in a supernumerary capacity, therefore the HSE will provide no funding in addition to existing Trainers Grants to backfill these positions. However, where a trainee s duration of training is extended as a result of flexible training and further time in practice is required, financing of the additional trainer time will be ringfenced from the HSE National Flexible Training budget. In order to facilitate the timely resourcing of flexible training posts, this group recommends close communication and planning at local scheme level with HSE NDTP as administrators of the National Flexible Training Scheme. Appointment of trainers and their payment would remain the remit of the local fund holder. Coordination, administration and supervision of trainees training flexibly is currently not resourced as part of the HSE s National Flexible Training Scheme. This group recommends that the additional resources required both nationally and locally be addressed as part of the ongoing Service Level Agreement process between the ICGP and HSE.

10 As an essential component of the governance of Flexible Training within General Practice, this group recommends the development of a post of National Director for Flexible GP Training (through the HSE National Flexible Training Scheme and by other means, see below) with responsibility for monitoring and audit of flexible training pathways, data gathering to inform improvement, trainee support and quality assurance. The HSE/NDTP has stated that no additional resources will be made available for trainees in need of remediation as a direct result of training flexibly. Trainees in need of remediation for other reasons may be able to access the necessary resources locally, as is standard practice currently. All feasible means to identify training concerns early, and to engage in ongoing remediation through the course of training must be utilised. This should be taken into account by all stakeholders in training prior to submission of an application for flexible training. Please also see recommendations in the section on Educational Continuity, below. (For further notes on costs as they apply to each training stakeholder, please see Appendix (ii) below.) Structure of Working Time Where a trainee is successful in their application to the HSE National Flexible Training Scheme and is in the hospital portion of their training they would be subject to the Structure of Flexible Training on the National Flexible Training Scheme. This states that: Applicants may propose the structure of flexible training posts within certain parameters. Each flexible training post must be 50% of full time. The working pattern of a flexible trainee must be managed over a maximum of a two week reference period, meaning that of every two week period at least 50% of time must be worked, with the exception of approved leave in line with the NCHD Contract Examples of acceptable flexible training working arrangements are Three days one week, 2 the next; 2.5 days on, 2.5 days off per working week; 5 mornings per week; or One week on, one week off. It is important that a flexible trainee has similar exposure to learning and experience including on-call duties as their full-time colleagues. Therefore, trainees on the National Flexible Training Scheme will be expected to partake in on-call duties / oncall rotas on a pro-rata basis. HSE Guide to HSE National Flexible Training Scheme 2016 Where a trainee is successful in their application to the HSE National Flexible Training Scheme and is in the general practice portion of their training, this working

11 group supports an approach to working time which best balances the needs for flexibility with continuity in the learning environment. This balance should recognise the context of individual trainee circumstances. Where a trainee opts to train flexibly during the general practice element of their training, it is recognised that this may cause disruption to the normal flow of work within the training practice. It is expected that structured flexible training could allow greater planning and predictability of trainee absences from the training practice, and less short term variation in service provision at an individual practice level. Where two or more trainees wish to avail of the HSE National Flexible Training Scheme during the General Practice component of their training and a trainer is amenable, job sharing is recommended where possible to maximise use of training resources and to minimise the disruption of workflow within the training practice. This may also be feasible across different schemes to allow more trainees avail of flexible training, and to minimise disturbance to the training practice. We support work at a minimum of 50% of full time, as is set out in legislation. However, we strongly encourage trainees, trainers and programme directing teams to liaise closely to plan day release attendence in advance in order to preserve the continuity of the Day Release curriculum where possible. This mapped attendance will also allow for clearer recognition of potential areas of learning deficit throughout and on completion of a period of flexible training, facilitating timely remediation. In addition, working at 50% of full time would provide the best opportunity for a job sharing arrangement and continuity within the training practice. While maximising efficiency, it could also obviate the need for additional funding for trainers in some cases. This approach would also allow more trainees to avail of flexible training, and would reduce the administrative burden in facilitating completion of training. In addition to time in the training practice, trainees would also be expected to complete the other prerequisites for the completion of training on a pro-rata basis (e.g. on-call and out of hours duties). The working group recognises the experience and expertise that training schemes have in facilitating all the necessary components of satisfactory completion of GP training. This group recommends supporting training schemes to adopt individual mechanisms for facilitating flexible training while ensuring educational standards in line with scheme reaccreditation requirements and maintaining stakeholder satisfaction. The working group feels that this will prove the most effective approach in order to maintain standards while helping to realise the aims of the McCraith report. Please see the following section for further detail.

12 Part 2. Accommodating flexible training in general This group recommend that the Postgraduate Training Committee of the ICGP advocates all schemes to accommodate applications for flexible training in General Practice where possible (via the HSE National Flexible Training Programme or by other reasonable means within each scheme). However, in assessing and processing requests for flexibility, training capacity, service commitment, mandatory rotations, criteria for satisfactory completion of training and overall competence must be taken into consideration. While the HSE s National Flexible Training Scheme provides one means by which trainees can avail of flexibility in training (with the constraint of one annual intake), it is recognised that requests for flexibility in training are often made at short-notice and for a shorter-duration than this scheme accommodates. This working group recommends supporting training schemes to further develop local options to facilitate flexible training, where educational and service capacity allows. We encourage trainees, trainers and programme directing teams to build on the good work already being done to explore all available options to facilitate flexible training when the need arises. To this end, this group recommend that the PGTC endorse the following specific approaches to flexible training at scheme level, which may be considered on a case-by-case basis 1 : Post Reassignment in the case where a trainee s placements are mapped out in advance and a circumstance arises necessitating flexibility in training, this trainee may be allocated another post in order to obviate the need for less than full time training and to reduce the personal and professional burden on the trainee as a result. Post Reassignment may also refer to a situation where a post becomes vacant (e.g. as a result of a maternity leave), and a trainee is allocated to this post in order to maximise use of training resources where a need for a post arises. This is in addition to trainee needs as outlined above. Job Sharing the situation where two trainees working less than full time share one post making up a total of 100% of one full time working equivalent. 1 It is recommended that these means of achieving flexibility in training be permitted where no other trainee is disadvantaged, where quality and educational composition of overall training will not be compromised, and overall training capacity of a training scheme, service commitment and minimum period required in mandatory rotations permit.

13 Post Swap the situation where two trainees, with mutual agreement, swap posts in order to obviate the need for less than full time training and to reduce a personal or professional burden on the trainee as a result of a circumstance requiring flexibility in training. Parental/Annual/Unpaid Leave refers to a circumstance whereby a trainee takes leave as a contractual entitlement in order to access flexibility in their training. This leave is often spread across a period of training to allow a trainee to train on a less than full time basis. At present, initiatives such as these are supported and funded locally by HSE Primary Care, and do not fall under the remit of HSE National Doctor s Training and Planning Unit. Educational Continuity and Quality during all Flexible Training The introduction of formalised flexible training in General Practice training will have implications for educational continuity and quality for individual trainees. To safeguard quality and continuity in training, the working group recommends close mentorship and communication between trainees, trainers and programme directing teams prior to application, and at regular structured individual reviews (3 monthly) throughout the period of flexible training. This is necessary to protect the progress of the trainee and to highlight and address deficiencies and areas of difficulty. Where a trainee elects to train flexibly, by whatever means, they should remain cognisant, together with their trainer and programme directing team, that the primary role of General Practice training is to attain proficiency in routine general practice. Flexible training may result in disjointed and interrupted time spent in routine practice, and consequently may mean that more overall training time needs to be dedicated to routine clinical practice at the expense of discretionary study leave or special interest time in order to achieve this competence. This will depend on the competence of the individual trainee and must be taken on a case by case basis. As is custom and practice currently, granting of study leave and special interest time rests between the trainee, trainer and programme directing team in accordance with the individual needs of the trainee and current local variation. Trainees engaged in flexible training are expected to fully complete (and must attend a minimum of 75% of) training posts and educational components required to achieve Satisfactory Completion of Training as per the ICGP Criteria Document Training time will not be accelerated as a result of flexible training. The development of further mechanisms and initiatives by individual schemes for the protection of quality and continuity of training for trainees engaged in flexible training is encouraged (e.g. Flexible Training Pilot developed by the Donegal Scheme).

14 Accreditation during all Flexible Training The working group acknowledges that the introduction of flexible training will have significant implications for how training schemes are accredited and suggests early input from the ICGP Accreditation Group in the development and implementation of flexible training in general practice. Monitoring of Flexible Training As the introduction of formalised flexible training is new to General Practice in Ireland, this working group proposes a monitoring process be implemented at its inception to gather data on applications, the training pathway for successful applicants and overall outcomes for these trainees. This data may be used in future to inform revision and improvement of the flexible training pathway. 4. Moving Forward This document will now be submitted for consideration at the meeting of the National Coordinating Committee for training on September 1 st, This group recognises that changes in the structure and process of GP Training as a result of flexible training arrangements have the potential to impact on quality and standards in training. In order to safeguard against any negative impact, this group recommends formal consultation with the ICGP Accreditation Subcommittee as the group that executes the ICGP's accreditation function, as recognised by the Medical Council..

15 Appendix 1. Categories of application (i) Category 1 Those doctors in training with: disability or ill health (this may include those on in vitro fertility programmes) responsibility for caring (men and women) for children responsibility for caring for ill/disabled partner, relative or other dependant. Category 2 Those doctors in training with: unique opportunities for their own personal/professional development, for example training for elite national/international sporting events, or short- term extraordinary responsibility, for example a national committee non-medical professional development such as management courses, or other higher qualifications which have the potential to contribute positively towards a career in General Practice. Other well-founded reasons may be considered but it would be dependent on the particular situation and the needs of General Practice training. Category 1 applicants have priority and schemes will support all Category 1 applicants. In general, nonmedical interests will be treated on their individual merits. Access to Category 2 is dependent on individual circumstances and the availability of funding.

16 Appendix 2 Costs of Flexible Training The costs related to the implementation of the HSE National Flexible Training Scheme are envisaged as follows Trainee no total additional salary cost and paid in accordance with time working/training Trainer cost for additional trainer time as required will be provided for by the HSE NDTP Flexible Training budget. Trainer grants will remain the remit of the local fund holder. Scheme coordination, administration and supervision of trainees training flexibly is currently not included in additional costs, however, this working group proposes that this role (in the form of a National Director for Flexible Training) be planned and budgeted for through the SLA process. This aspect of training will constitute a considerable workload including monitoring of flexible training pathways and data gathering to inform improvement, trainee support and quality assurance. It is likely that flexible training will expand further requiring significant additional resourcing and will likely require national coordination in the future