Professional development in primary care--who is responsible? Health professionals working in primary care need more opportunities for professional development and education, if the promise of the primary health care strategy is to be fulfilled.

THE ESTABLISHMENT of primary health organisations (PHOs) is well underway, with a majority of New Zealanders now enrolled. The PHOs are part of the Government's primary health care strategy. Further implementation of the strategy will depend on a stable, well-developed, well trained and well supported workforce. Effective ongoing professional development is central to successful recruitment and retention of a skilled workforce, and necessary for the provision of good quality primary health care.

Professional development for the primary care workforce--the past: It is well accepted that secondary care health professionals, and in particular nurses and doctors, must have appropriate vocational training in the years immediately following graduation, and effective ongoing professional development throughout their careers. Responsibility for ongoing education is undertaken not only at individual level through the membership and standard setting of professional colleges, but also at employer level, with the provision of financial assistance and study leave.

The development of vocational training and ongoing professional development for primary health care professionals has been different. Vocational training for GPs is now established, but effective ongoing professional development remains difficult to achieve in a fee for-service funded, small business environment.

Nurses have been working in general practices for nearly 30 years, but, as a group, practice nurses have lacked career structure and have had little incentive to undertake ongoing professional development, although many have built up a considerable body of experiential knowledge. They now have a professional body, the New Zealand College of Practice [Nurses.sup.NZNO], standards for practice and some skill-based training, including local nurse-led independent practice association education groups. However, the employer/employee relationship with GPs in an individual, fee-for-service funding model has not served nurses' vocational or practice needs well. (1)

Improved vocational education within disciplines has largely come from the different professional groups, working to improve provision, support and access to ongoing education and development. (2) Many tertiary education institutions can and do provide a range of uni-disciplinary postgraduate education for primary health care professionals and they have the capacity to further these in accordance with both new and existing workforce needs.

However to date, no one organisation of group of individuals has been able to carry any overall responsibility for integrated primary care workforce professional development.

Other barriers to further progress have been fragmentation of the workforce, lack of education-designated funding, no career advancement as a result of undertaking education, and increasing clinical, administration and accountability pressures in the workplace.

Professional development for the primary care workforce--current issues: With the advent of identified primary health care development and new organisation and funding arrangements, there is the potential to invest in human capital, ie the workforce. Just as in secondary care, training and development of primary health care workers needs to be regarded as a core investment rather than a cost, if best practice and quality standards of care are to be achieved and maintained. (3)

Primary care careers are the poor cousin to secondary careers in terms of structure, study assistance and protected time for ongoing professional development. Yet the responsibilities are as great, of greater. Patient volumes are high and the diversity of presenting problems and health promotion issues is broader than in secondary care.

Not only do primary care practitioners need new, updated and improved skills, they also need to learn to work together in new ways, with increased collaboration and effective teamwork. (4) The nature of primary care is changing and old isolated ways of working need to be replaced by new collaborative models. The focus is on the patient as the centre of care and particularly those groups of patients who are most in need of effective care to improve their health outcomes. Individual practitioners now cannot provide all the care available and necessary; teams have the potential to bring patients much better care. (5)

Interprofessional development for the primary care workforce: For both nurses and doctors, vocational training and continuing education opportunities have been largely uni-disciplinary. While initial promotion and development of professional development by the different professional groups has been and still is important, this "separate development" has not necessarily been an appropriate preparation for a primary care workforce now expected to work collaboratively in interdisciplinary teams.

Effective collaboration requires professionals from different disciplines to value each other's work, to communicate well and to work together to overcome difficulties, Internationally, interdisciplinary education has been shown to increase learning satisfaction and to result in improved collaborative working, especially where the learning is workplace related. (6,7,8,9)

Integrated programmes of study and professional development, including a range of knowledge, skills and values-based education, are also necessary to develop vision and leadership for improved and innovative ways of working; short, task-related updates and conferences on their own are not sufficient. (10)

An interface between health and education is seen as pivotal by the Health Workforce Advisory Committee (HWAC) in order to enhance professional development in the primary care sector. A specific recommendation is to "... strengthen working links with local and regional education and training providers to ensure health workforce education is aligned with health service delivery". (11)

Closer liaison between postgraduate education funders and providers and the health workforce, has the potential to greatly strengthen and expand interdisciplinary education and professional development. Education providers have the ability to bring health professionals of different disciplines together in ways which honour the important differences between disciplines, yet consolidate common ground and forge new ways of learning and working together.

Those who have undertaken such interdisciplinary study--usually experienced practitioners with a strong commitment to primary care--report increased understanding of their own, and each other's roles within workplace teams. (12)

Professional development for the primary care workforce--who is responsible? In its recommendations to the Minister of Health in 2003, HWAC emphasised the need for district health boards (DHBs) and District Health Board New Zealand (DHBNZ) to assume a role in leading workforce development. (11)

Currently, capitation payments to primary care providers include a modest provision for professional development but this money is not ring fenced for education. The current contract template between DHBs and PHOs does not specify a contractual requirement for the provision of professional development, although it states that it could be used as a quality requirement. (13) Rural health professionals can make a special case to apply for limited funding for professional development. (13) Generally, contract reporting requirements do not specifically include professional development; therefore there is no responsibility for DHBs to contractually support professional education or to audit uptake.

In contrast, doctors, nurses and other health professionals employed in secondary care have access to professional development funds and study time linked to performance through their employment agreements; (14) and this provision for staff is mandatory in the vertification requirements which all health and disability residential services must attain before October 1, 2004. (15)

Independent of DHBs, the Clinical Training Agency (CTA) holds a national budget for the provision of training for health professionals, but to date most of this funding has been tied closely to clinically focused, uni-disciplinary training, mainly for medical staff and those employed in secondary care settings. (16) With some important exceptions, eg support for first-year nurses in clinical practice, specialist postgraduate courses in child health and mental health, GP registrar training, and some nurse practitioner training, (17) little has been available to support generalist primary care education. Interdisciplinary postgraduate education or ongoing professional development for primary care sector health professionals has generally not been eligible for CTA funding.

Incomes in the primary care sector lag well behind those of the secondary sector, and dedicated funding for professional development is important to recruit and retain health professionals in the sector. Current salaries for practice nurses make the personal financing of professional development extremely difficult. Primary care doctors are in a somewhat better position than primary care nurses to fund the direct costs of their professional development, but funding for indirect costs, such as locum cover, and dedicated time for study within working hours, are just as difficult to achieve. For both groups, tangible career advantages such as promotion, increased job opportunities and financial reward, are difficult to identify.

Professional development for the primary care nursing workforce--a special case: Nurses constitute the largest professional group working in primary care, (11) yet their potential to work autonomously and effectively in multidisciplinary teams within the workforce is as yet unrealised. While there is a clear need to address ongoing professional development for the workforce as a whole, nursing needs are particularly acute. Further improvement and enhancement of nursing skills bring benefits, not only to nurses but to all health professionals and support staff working in primary care, as well as fostering innovation for improved delivery of patient care.

The new working environment, with a more towards population health and emphasis on a wider range of services in primary care, increases the need for well-trained primary health care nurses. (16,18) Practice nurses are now recognised in the legislation as providers and the current requirements for PHO reporting to the DHB requires numbers of nurse consultations, (13) but the roles of nurses currently working in primary care are diverse. Some work largely "under direction" (practice nurses), while others work more independently (Plunket and public health nurses).

The concept of primary health care nursing has been considered (19) but needs further development, with clarification of the appropriate capabilities, responsibilities, competencies, areas of practice, educational and career frameworks, remuneration and suitable employment arrangements. It has been acknowledged that "... primary health cure nursing will be crucial to the implementation of the Strategy", and there has been expressed intention to "address this at the national level". (5)

The Ministry of Health (MOH) has begun by providing two national initiatives: a nursing innovations fund, which is currently supporting 11 nursing innovations projects; and money for nursing scholarships to undertake clinically focused postgraduate papers to complete their masters degree and then apply to Nursing Council to become NPs. However, while useful for a number, these uni-disciplinary initiatives have not so far met the needs of the majority of nurses currently working in primary care. (16)

Many nurses, especially practice nurses currently in general practice, do not wish to become NPs or attain a clinical masters degree. They want educational support to enable them to gain the knowledge required to enable them to be recognised as a fundamental group in the primary health care workforce, providing a unique service in line with the overall vision of the primary health care strategy. This may mean undertaking vocationally based courses, as well as engaging in interdisciplinary postgraduate education with doctors and other primary care health professionals. Nurses want to develop skills in governance to effectively work on PHO and DHB boards. (20,21) They want to explore new interdisciplinary ways of working with patients and families, focusing on holistic needs, care over the lifespan and care of those with long-term illnesses. (22) Some of these new ways will be through nurse-led initiatives; (23) some within traditional GP teams; (24,25,26) and some within wider primary care interdisciplinary teams. (27,28,29,30)

Conclusion

To ensure quality primary health care delivery in accordance with the primary health care strategy, there must be a commitment to ongoing professional development for all primary care health professionals, at individual and team levels. However, commitment must also come from health funders to support effective professional development. Clear expectations for workforce development, and ear-marked financial support for health professionals is necessary; it is the role of the health funders to provide this lead. The MOH and CTA, DHBs and PHOs now have a responsibility for interdisciplinary and collaborative primary health care workforce development; investment is needed to ensure quality care from well trained, up-to-date primary health care professionals.

Existing education providers are keen to work with funders and health professionals to support primary health care professional development. Aligning the vision of the primary health care strategy in relation to the expanded and integrated role of practice nurses, with the strategic direction of the CTA would help target primary care nurse workforce development across a number of funding boundaries.

The new focus on population health, interdisciplinary team care and enhanced nursing roles has created demands on the existing workforce which are not being effectively addressed by funders of health care, it is the responsibility of all funding stakeholders to respond to these key questions and formally report their answers to the primary care workforce: How will integrated professional development for the existing primary care workforce be improved and supported? How will interdisciplinary learning and teamwork be further developed?; How will links between education providers and health care funders be strengthened and maintained? And how will new and existing primary care and practice nurses be trained and supported to assume expanded roles?

Health care practitioners are keen to work within the strategy, and many acknowledge the need for enhanced skills to implement these changes. Enhanced professional development has the capacity to create innovation and vision, solve many of the retention and recruitment issues currently facing primary care, and improve and sustain high quality patient care. If funders ignore this need, the integrity of the primary care workforce will be compromised, along with the vision of the primary health care strategy.

* We acknowledge the wise advice of our colleagues in preparing this paper and in particular: Gill Regan, nurse team leader, Newtown Union Health Service, Wellington; Jill Lowrey, practice nurse, Johnsonville Medical Centre, Wellington; Rosemary Minto, chair of the New Zealand College of Practice [Nurses.sup.NZNO]; Tony Dowell, professor, Department of General Practice, Wellington School of Medicine and Health Sciences, University of Otago; and Pam Hyde, national director of general practice education programme, Stage 1, Royal New Zealand College of General Practitioners.

--This article is jointly published with the journal of the Royal New Zealand College of General Practitioners, New Zealand Family Physician, it will appear in the August issue of that journal.

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--Eileen McKinlay, RCpN, MA (App), AD N, is a lecturer in the Department of General Practice, Wellington School of Medicine and Health Sciences, University of Otago.

--Sue Pullon, MBChB, FRNZCGP, PGDipGP, is a senior lecturer in the Department of General Practice, Wellington School of Medicine and Health Sciences, University of Otago.