Master of Primary Health Care degree: who wants it and why?

In 2001 the New Zealand Government released the Primary Health Care Strategy (PHCS).¹ The stated aim of this strategy was to provide a clear direction for the development of primary health care in New Zealand, and to enable primary care to play a central role in the health system.¹ There are no postgraduate programmes in New Zealand whose aims are aligned to the PHCS.

In New Zealand the University of Otago offers both a Master of General Practice (MGP) and a Master of Primary Health Care (MPHC) from its Dunedin and Wellington campuses respectively. The MGP (120 points) is open to general practitioners, while the MPHC (120 points) is open to all primary health care professionals. Prerequisites include completion of the post-graduate diploma in general practice and primary health care respectively, completion of a research methods paper, and for the MGP the Nature paper, for the MPHC the New Zealand Primary Health Care (PHC) paper. Both degrees can be by thesis or by research portfolio and can be completed by distance and part time. There have been few MGP graduates in recent years and small on-going numbers of MPHC graduates.

Internationally there is a variety of postgraduate programmes in Public Health, General Practice, and Evidence Based Medicine but few that focus on primary health care. We could find only seven taught masters programmes in primary health care or Community Care, four primary health care research masters, and two International primary health care masters. Most of these programmes have a modular structure with core papers, elective courses, and a research project. Some programmes are designed to launch academic careers alongside clinical careers, while others seek to develop students’ research and literature appraisal skills. Many programmes promote lifelong learning, and include clinical leadership and management, health policy, and the changing agenda of primary health care in their aims.^2–20 Most university postgraduate programmes are targeted towards a single professional group.^21,22 We could find only six interdisciplinary masters programmes.^{4,7,11,14,15,19}

A major problem for the primary care workforce is the flat or static career structure; once established in practice there are few opportunities for promotion or advancement. While some students may embark on masters study for reasons of personal interest or fulfilment, masters study is a huge commitment in terms of time and money and few primary care practitioners may be in a position to afford such a luxury. Most students who embark on masters study do so with a goal in mind; with the hope that the qualification may lead them somewhere in their career or life. To be successful then, any new masters programme must serve a purpose and enhance the career options of primary care practitioners.

The Department of General Practice and Primary Health Care at The University of Auckland is considering developing and introducing an MPHC programme. The introduction of a new masters programme is a considerable endeavour. University programmes that do not help clinical students move into new roles or add value to their practice struggle to maintain student numbers. For example, the Diploma in Obstetrics and Gynaecology all but faded away following the introduction of the Lead Maternity Carer model in New Zealand and the subsequent exit of general practitioners from providing intrapartum care.^23,24 For the proposed MPHC to attract and maintain student numbers it is critical the programme provides value to potential students and employers.

The aim of this project was to discover the views of PHC stakeholders on the proposed MPHC programme to establish whether there is a demand for such a programme and to inform its development.

Potential primary health care stakeholder and practitioner participants from throughout New Zealand were identified through initial purposive sampling followed by snowball sampling. Participants were recruited by email invitation followed up with phone calls. Twenty-five semi-structured interviews were conducted between November and December 2014, exploring participant opinions about student learning needs, motivation, graduate skills, possible research projects, funding, and course structure. The individual interview process was modified to include one focus group to accommodate a group of participants from the School of Nursing who declined individual interviews. Interviews were digitally recorded and transcribed verbatim. Transcripts were checked for accuracy and coded by participant occupation to protect anonymity.

A general inductive method was used to analyse the data and identify emerging themes.²⁵ Sections of text were independently coded according to theme by two researchers (AA, KW) and discrepancies were resolved through adjudication. Codes were collapsed into thematic groups to develop the final list of themes and sub-themes.

Ethics approval for the research was given by The University of Auckland Human Participants Ethics Committee on 7 November 2014 for three years, Reference Number 013061.

There were 30 participants from throughout New Zealand. Participant characteristics are shown in Table 1. Most were from Auckland but the sample included some participants from elsewhere in both the South and North Islands. Although most participants came from organisations that might employ future MPHC graduates, few identified themselves as potential students.

Table 1. Participants

Potential MPHC students were identified by participants as nurses, community pharmacists, allied health professionals, general practitioners (GPs), primary health care administrative/management staff GPs, international students, Maori health providers and other community based providers:

’I think you are going to pick up those people who don’t particularly want to go through the nurse practitioner’s scope of practice’ (PCP-NL2)

’People who have a bigger view about what their nursing role is... those are the people who want to reach out across sectors...to be able to influence preventable healthcare... [they are] your target.’ (PCP/M-NL2)

Some participants felt that existing courses already catered to this educational need.

’I think if a nurse wanted to do a Masters she would do a clinical nursing masters or a research nursing masters, not a generic masters in public health, and if they wanted to do a generic masters then they would do an MBA or something like that.’ (M-NZNO2)

Three key themes were identified: primary health care practitioners might study for a MPHC to help move into management and leadership positions; to develop clinical and practical skills to add value to practice; or to move into academia.

1. Health management and leadership

Many participants suggested the MPHC could help clinicians move into health leadership and management positions:

’You know very often clinicians don’t make good managers, and managers don’t understand clinicians... so if there’s some way of bridging that gap, that would be great, I’d be really supportive of that.’ (M-PHO4)

Desired content included health policy, population health, health promotion, information services and technology, models for improvement, business management, health economics, practice management, harm, vulnerable populations, equity, the aging population, whānau ora, and the broad context of primary health care in New Zealand and internationally.

There was concern over attracting sufficient international student numbers:

’I think it’s a challenge to get an appropriate number of international students into the course... that wouldn’t poach the students perhaps out of the Health Leadership programme.’ (Uni-I1)

Participants suggested that important graduate skills included practice management, information services/technology, business management, clinical leadership and knowledge of health policy/strategy:

’We have four practice advisors: one is clinical, one does the register management, one is the IT side... If the person had more of a broader scope then they would be a one-stop shop for that practice ... So the nurse would be her core skill, but she would have enough of the whole practice management side... I think that is very valuable, particularly for PHOs to support their practices.’ (M-PHO1)

1. 2.

2. Clinical and practical skills, pathway to fellowship

Participants suggested the MPHC programme should be structured to align with the requirements of professional bodies and that the programme could be used as a pathway to fellowship:

’Public Health physicians, their College requires them to do the MPH and that’s their Stage 1 equivalent. So one of the ways of approaching it with the College [RNZCGP] is that this will become their stage 1 ...’ (Uni-F2)

’...what you will find is those people who take the course up will be looking for a greater wage, so they’ll be looking to see what the payoff for their investment is.’ (PCP/M-NL2)

However, some considered the post-graduate learning needs of GPs were best satisfied by short courses and continuing professional education providers:

’...quick, short, is good for working people.’ (M-PHO1)

While some participants suggested specific content for nurses, others felt a MPHC would not fit with nurse training/funding pathways:

’What [nurses] want is one that leads to a clinical nursing Masters ... with them being able to attract the Health Workforce New Zealand (HWFNZ) funding.’ (M-NZNO1)

One participant considered masters level study superfluous for the primary care workforce and identified the competing interests of educators and employers as problematic. This included the issue of pitching training programmes to a higher level than necessary for most of New Zealand’s primary health care workforce needs:

’In my view master level training is almost completely irrelevant to the vast majority of the workforce in primary care.’ (M-HWFNZ1)

’I think universities ... we have a terrible habit of following our interests and creating courses which we think are enjoyable, that we think the subject matter is important or interesting, but in fact the market place, the employers, have no interest whatsoever. The other thing we do is we tend to overshoot.’ (M-HWFNZ1)

The clinical topics that participants would like covered included brief intervention tools, motivational interviewing, management of long-term conditions, prevention, elderly care, self-management, risk assessments, prescribing, mental health, immunisation, practical skills and special interest areas:

’family planning, travel medicine, adolescent health... things which GPs often have a special interest in. Elderly health, with special reference to nursing homes might appeal to some people, because they’re practical things that they do.’ (PCP-GP1)

The breadth of clinical skills suggested ranged from generalist to specialist:

’...the role of the nurse working in the PHC setting is a generalist... So it’s about having a programme that allows them to... increase their capability and their knowledge and skills across all... areas. If we keep specialising in little bits, then we don’t actually grow our workforce.’ (M-DHB2)

The art of consultation was another desirable skill for potential nursing students:

’... the art of consulting with a patient, that’s the piece of skill development that nursing doesn’t have per se ... that should absolutely be a core part of any primary healthcare clinician’s education.’ (PCP/M-NL2)

1. 3.

2. Academic career: teaching and research skills

The topics suggested for using an MPHC to move towards an acadaemic career included the philosophy of primary health care, ethics, culture, health beliefs, and teaching/learning theories. There was some support for the MPHC helping to develop those able to contribute to the primary care literature base, but others felt this was not the purpose of any proposed MPHC:

’it needs to be practice based rather than a research based qualification. We’re not talking about producing researchers ... maybe people who are able to interpret the literature and apply it, but not actually necessarily adding to the body of literature through research’ (Uni-F1)

Participants agreed that primary health care theory is important, but many felt there is little demand in New Zealand for this type of Masters:

’I don’t think there’s enough demand... anecdotally there’s not a lot of [nurses] that do the Research Masters...’ (M-NZNO1)

1. 4.

2. Personal interest

Participants pointed out that masters level study was not enough to move into academia, and not likely to add value to a GP’s practice. They suggested personal interest might be the sole motivating factor:

’...if you look at the GPs, why would I do a MPHC? It doesn’t get me into the academic community, it doesn’t give me access to a funded line of work, so the only reason why I might do it is out of interest.’ (M-HWFNZ1)

Many participants thought the course should be inter-disciplinary:

’... if I was that nurse I’d do the Masters in Primary Healthcare probably because it would be inter-professional. If you do a Masters of Nursing... you’ll only have nurses in the class, and that’s good for some things... But it doesn’t have that wider perspective’ (Uni-N1)

’when you’ve got inter-professionals training together they’ve got more understanding around the capability of those health care professionals... and if they’re working as peers in an education setting then hopefully that translates into the workplace.’ (M-DHB2)

However, some said inter-disciplinary study had been tried unsuccessfully in the past:

’Doctors don’t like studying with other people, unless they’ve stopped being doctors and become managers...the gerontology course that used to be here... because a lot of the students were nurses, doctors stopped coming, and then eventually it was taken over by the nurses...’ (Uni-F2)

Participants preferred a flexible structure with broad entry and exit pathways. Most favoured distance taught courses:

’[online delivery] is fantastic, certainly for our networks which are, you know we’re spread far and wide and geographically a lot of our... clinicians are... isolated in rural areas...Anything... they could do from a distance would have an added bonus, definitely.’ (M-PHO4)

’I think that [distance learning] will fit into people’s lifestyles much better.’ (PCP/M-NL2)

However, face-to-face learning and group work was also considered important for peer support and in helping to overcome isolation providing students with an opportunity to meet like-minded others. There was some enthusiasm for online group discussion. Some said international students might prefer on-site learning:

’many international students are looking for the Western education experience’ (Uni-I2)

Participants considered the time required for masters level study would be a barrier to most GPs. The costs associated with masters level study, including enrolment fees, unpaid leave and locum fees, would also be a barrier:

’You know the biggest thing I think is the time off work and the shortage of doctors. Then there’s the funding thing as well... if you don’t come to work you don’t get paid.’ (PCP-GP2)

’finance is always potentially a barrier... if you are in the workforce then reducing your income or increasing your costs by studying, it can be much more of a barrier.’ (M-PHO2)

’There wouldn’t be any point in developing a programme unless we’re going to get 100 [international] students into this course because the government limits the number of domestic EFTS students they can fund so... [The university] can grow the postgraduate taught numbers internationally exponentially ... there’s no limit. But we cannot grow the postgraduate taught students we recruit into this faculty.’ (Uni-F1)

Possible sources of funding for potential students were identified as Primary Health Organisation (PHO) professional development budgets and educational scholarships; Health Workforce New Zealand (HWFNZ) funding; the Royal New Zealand College of General Practitioners (RNZCGP) Contestable Fund and research/education trust; the Nightingale Grant; multi-employer collective agreement (MECA) funding in rural hospitals; New Zealand Nursing Organisation Nursing Education Research Foundation (NERF) grants; College of Primary Health Care Nurses funds; and District Health Board (DHB) continuing professional education packages. DHBs already pay for some nurses to do the nursing 240 point masters degree. The proposed 180 point MPHC could be more affordable for DHBs:

’DHBs have got commercial interests. They’re going to have interests in spending less money... for a 180 point.’ (FG1)

Participants in this study suggested that primary care practitioners might embark on MPHC studies if the degree added value to their practice, for example by developing special interest skills; or if the degree helped in their career development, for example by helping them transition into clinical leadership positions or into an academic career; or students might embark on masters study for personal interest reasons. However, many of these identified learning needs are satisfied by pre-existing courses and programmes, university post-graduate study is expensive and there is only a small market of primary health care practitioners in New Zealand who might want to embark on masters study for personal interest. Short courses and continuing professional education meetings better serve the continuing professional development needs of primary care practitioners. Auckland’s planned masters in health management and leadership may better serve the needs of practitioners wanting to move into leadership and management positions, and a masters degree is no longer sufficient for an academic career (a doctorate is required).

Participants suggested the core content of any masters programme needed to be consistent with purpose. Some participants emphasised the need for knowledge around management, policy and health economics. Others suggested practical and clinical skills, while others suggested primary health care philosophy, ethics, research methods and teaching theory.

The preferred delivery format for participants was interdisciplinary and flexible with mainly online options. They suggested that busy primary care practitioners, and especially rural practitioners, would benefit from online course delivery. This is consistent with previous research identifying that online platforms enhance the social presence of both teachers and peers, increasing student satisfaction with courses.²⁶ Posting online messages during the modules has also been found to increase interaction and engagement of postgraduate students.²⁷ This is important when considering target students who may be working while studying, and who would benefit from tools which increase engagement in the course.

Participants agreed with previous research identifying workload, other commitments, workplace support, cost, and the availability of funding as influencing the decision to undertake masters level study.²⁸

Possible funding streams for students were identified to be DHB and PHO professional development funds, professional bodies such as the New Zealand Nursing Organisation (NZNO) and the RNZCGP. While HWFNZ was identified as a potential source of funding for nurses, securing this funding may prove difficult as it is generally reserved for clinical nursing masters.

Our findings are in agreement with international literature which found successful masters programmes have flexibility in the course structure, effective small group work, online peer discussion, clearly transferable graduate skills, and foster workplace support.^26,28–32 Motivation to study included career development, increased job satisfaction, personal development, inter-professional networking, and job security or increased income.^29,30,33,34

Strengths of this study include the range of participants from throughout New Zealand, from both urban and rural backgrounds, and participants with knowledge of the international student market. We also reached saturation in participant responses.

A limitation was that few participants identified themselves as potential future students. Most participants were from organisations that might employ future MPHC graduates. The time constraints of this summer student project provided a barrier to interviewing potential students who were primary care practitioners. It is possible that practitioners might want something else from MPHC study, for example an opportunity to reflect on their practice or to explore the meaning of health and illness through literature, art or music.³⁵

Any successful MPHC programme will need to be carefully targeted to serve the unmet postgraduate educational needs of PHC practitioners and be distinct from any other pre-existing programmes. While practitioners might embark on masters study for reasons of career development or personal interest, masters level study requires a substantial investment in terms of both time and money and most PHC practitioners are already busy or, if early career, loaded with debt.

Future research could seek to clarify what the unmet post-graduate educational needs of primary care practitioners, if any, are. Further discussion is needed to determine how universities could best contribute to post-graduate GP training. It would also be helpful to discover whether the Nursing Council would endorse a MPHC and then whether such a masters could attract HWFNZ funding for nursing students.

This study was funded by SoMF Clinical Education, The University of Auckland.

Dr Katharine Wallis is the Postgraduate Director and Prof Felicity Goodyear-Smith is the Goodfellow Postgraduate Chair of the Department of General Practice and Primary Health Care, The University of Auckland.