Specialty training in general practice. New roles and more responsibility for local authorities

A new scheme for specialty training in general practice was introduced on 1 March 2019. Before a doctor can apply to become a specialist in general practice, various criteria and recommended learning objectives need to be met. This includes five years of clinical practice, including a minimum of two years’ open, unselected general practice and a minimum of six months at an institution. One of the main changes in the new scheme is the local authorities’ responsibility to ensure that general practitioners (GPs) in training and GP trainees in other clinical positions in primary health care have the opportunity to achieve a number of specific learning objectives and complete their specialisation.

Fafo, the Norwegian Centre for Rural Medicine and Agenda Kaupang have followed the implementation of the new specialisation arrangements based on the experiences of local health leaders in the municipalities, GP trainees and other stakeholders during the process. A broad selection of local authorities in Norway were included in the follow-up study.

We have written several reports during the process, and this final report summarises the work. We present our findings based on the following questions

• What are the experiences from the implementation of the new scheme for specialty training in general practice to date?
• What can local authorities and national health authorities learn from the experience gained so far?

This is brief summary of some general experiences from the implementation work:

The transition to a new speciality training scheme has entailed additional work and increased administrative costs for local authorities. This is linked to the local authorities having to facilitate a comprehensive speciality training programme and the necessary learning activities, document how the specialist training is organised, distribute responsibilities and devise plans for the specialty training.

All the key stakeholders, including GP trainees, supervisors and local health leaders in the municipalities, have found it difficult to adapt to the new scheme, and have spent considerable time doing so. In particular, the local health leaders have called for better standard agreement templates and standardised routines for the new scheme.

The regulations state that at least two years of the new specialty training in general practice must take place in open, unselected general practice at a GP office. This requirement is automatically met for GP trainees doing the job of a GP (or locum GP), while those whose main job is in a nursing home or emergency clinic must transfer to a GP practice to satisfy this requirement. Providing open, unselected general practice places for primary care doctors who are not GPs is a particular challenge.

The new model for specialty training in general practice stipulates that much of the learning must be supervised by GP specialists. Local health leaders have expressed concern that recruiting formally qualified supervisors may be a challenge. It may therefore be necessary to develop models for inter-municipal cooperation on the supervision of GP trainees.

Many of the GP trainees in our study have changed jobs during their specialty training. The procedures for approving learning objectives differ between local authorities, which can create problems with documentation. To avoid such problems, the learning objectives should be approved as they are completed. However, many of the learning objectives require in-depth experience in a subject area before they can be approved.

A key element of the specialty training is learnings objectives gained by working in an institution (e.g., hospital). At the time of writing, several of the ‘first’ generation of GP trainees are approaching this point in their education. Different forms of cooperation have been established between local authorities and regional hospital trusts to facilitate this part of the training. From the local authorities’ perspective, recruiting locums to cover the period when GP trainees are working in an institution will be a challenge.

Based on the findings in this project, our recommendations to the local and national health authorities are as follows:

1. The research identifies challenges for GP trainees and local authorities when the former’s main position is not in a GP office. We recommend that the regulations and framework conditions are amended to facilitate flexible arrangements. Especially in the case of GP trainees who are not working as GPs, there seems to be a need to tailor the positions. We believe that the experiences of local authorities and GP trainees should continue to be collected and systematised until an efficient system is in place.
2. It is often difficult to find GP specialists to supervise GP trainees. Many local authorities have experienced GPs who are not GP specialists, but who are nevertheless competent to take on the role of supervisor. We recommend that the local authorities are given more responsibility for assessing which GPs have sufficient competence to supervise GP trainees. The health authorities should nevertheless monitor developments to ensure that local authorities impose sufficiently stringent requirements. We also recommend the further development of framework conditions, arrangements and agreement templates between local authorities and supervisors who work in other medical practices than the trainee, inter-municipal agreements on supervision, and, where relevant, the establishment of an inter-municipal pool of supervisors. The regional administration for the GP trainee scheme (ALIS-kontor) can no doubt offer useful advice to the local authorities on this.
3. We know from experience that changes take place in the GP trainees’ life and work trajectory during specialty training. A system should therefore be established that ensures documentation and approval of learning objectives during the training. We recommend that plans and framework conditions are sufficiently flexible to account for changes in the training that are due to both expected and unforeseen events in the life of the GP trainee. Questions are being raised as to how appropriate it is to expect all GP trainees to gain experience working in a hospital, which in many cases involves them moving to another municipality. It is true that requests can be made for municipal institutions to be approved as educational establishments on a par with hospitals, but this is currently only relevant for certain larger, municipal institutions. We recommend that more flexible and local alternatives are found for achieving learning objectives that can mainly be achieved through gaining experience in hospitals and other similar institutions.
4. Maintaining the necessary administrative expertise to serve their educational function is challenging for the local authorities. We recommend that, in the future, schemes are considered in which local authorities can enter locally tailored collaborations for safeguarding the role of education facilitator. This will also promote the cooperation on supervisor capacity, as described above. It would be practical for regional administration for the GP trainee scheme to be involved in this.
5. The design and administration of the national grant scheme for GP trainee agreements and supervision can have a major impact on the local authorities’ financial flexibility in this area. We recommend evaluation of the grant scheme after a few years, including an assessment of whether the scheme covers the local authorities’ total costs in connection with their new role as education facilitator, and of the impact of the grant scheme on the local authorities’ exercising of this role.