The costs, barriers and enablers of providing PGY2 placements in general practice in Aotearoa New Zealand: a mixed-methods study

Design, study setting and sampling

For this mixed-methods study, we sought expressions of interest from general practices in Otago/Southland to: (i) host a PGY2 each quarter in 2022; (ii) record the time and financial costs associated with hosting the PGY2s over the term of their placement and (iii) be interviewed about their experience. WellSouth Primary Health Network funded each practice NZ$13 000 for hosting PGY2s for four quarters (ie $3250 per PGY2 per quarter) and provided ongoing medical educator training and support to GP supervisors. In addition, general practices across NZ that already hosted PGY2s were identified through the Primary Care Clinical Leaders Forum of General Practice New Zealand,¹⁰ and a purposive sample¹¹ of practice staff (geographic, rural and urban, small and large practice representation) were invited to be interviewed about their PGY2 hosting experiences. The Geographical Classification of Health¹² was used to define practice rural/urban status.

Data collection

Cost analysis

A cost analysis was undertaken (Fig. 1) using data from quarters 2 and 3 of 2022. To estimate the cost per placement of supervising and supporting a PGY2, the time spent by the GP, nurses and administrators outside of clinical consultation time was calculated for each practice and averaged across the two quarters. Time spent was calculated using the midpoint of each time category (eg if a GP selected 120–150 min, the midpoint of 135 min was used). The total time was multiplied by the associated hourly rates paid for each workforce using commonly used industry sources: the Medical Assurance Society’s median hourly rate for employed GPs ($103 per hour)¹³ and the mean collective agreement rates for primary care nurses¹⁴ ($30.83) and administrators ($22.10).¹⁴ These rates did not include associated costs of employment, such as annual leave and Kiwisaver. The costs for each category were summed across the practices and the means taken.

Fig. 1.

Cost analysis for PGY2 community based attachments.

The only direct practice cost included was for software. A PGY2 required a patient management system licence to use during their placement. The cost of a common software licence (MedTech Evolution)¹⁵ was applied, at a cost of $555 per licence for the 13 weeks.

To estimate the cost associated with a change in the number of consultations, the difference between the number of consultations provided by the GP and the PGY2 (b + c in Fig. 1) was subtracted from the baseline number of consultations provided by the GP prior to the PGY2 placement (a in Fig. 1) and multiplied by the average revenue per consultation. As consultations for children under 14 were free and part charges for adults were up to $50, an average revenue of $20 per consultation was used. The change in consultation costs were summed across the practices and the mean taken.

To calculate the opportunity cost of providing clinical space for PGY2s, the number of hours worked by PGY2s per quarter (8 h per day × 4.5 days per week × 13 weeks) was multiplied by the average hourly charge-out rate per room for that practice. One practice did not rent rooms externally. The mean charge-out rate was calculated using each practice’s hourly charge-out rates: $10 (practice 1), $0 (practice 2), $15 (practice 3), $50 (practice 4).

As well as producing a range of cost estimates including and excluding room rental costs, a conservative cost estimate was calculated using half of the mean GP supervision costs, double the mean revenue generated from the extra patients seen by the PGY2 and the mean room rental costs.

Subsequent to the study period, Health New Zealand | Te Whatu Ora Health Workforce Directorate (HWD) implemented a $3600 per placement subsidy for general practices hosting PGY2s in 2023.¹⁶ This was very similar to the funding provided by WellSouth for the study period. This funding is now ongoing, and so was included as revenue for the purposes of the cost analysis. All costs were calculated using NZ dollars.

Qualitative data analysis

All interviews were transcribed and combined with the field notes and thematically analysed.¹⁷ Themes and sub-themes were developed by JM. Initially these used the interview topic guide main headings and were modified as coding progressed. Two other authors (TS and CA) reviewed several transcripts to verify the appropriateness of the themes developed.

Ethics approval was obtained from the University of Otago’s Human Ethics Committee (D22/098).

Costs associated with hosting PGY2s

Three practices provided data for two quarters, and one practice provided data for one quarter only as the assigned PGY2 was unavailable. The mean hours spent by each practice supervising and supporting PGY2s together with the associated costs are presented in Table 2. When averaged over the four practices, GPs spent the most time and cost the most (85 h, $8797), followed by administrators (17 h, $369) and nurses (4 h, $136). Three out of the four practices experienced a gain in total consultations resulting from the PGY2 placement (Table 2). The mean change in consultations of 68 per placement (range −80 – 171) equated to a mean of $1350 in additional revenue at an assumed average revenue of $20 per consultation. The mean cost per placement, including the PGY2 HWD subsidy of $3600 but excluding room charge-out rates, ranged from $890 to $9183 across the four practices with an overall mean cost of $4907 per PGY2 placement.

The impact of including the cost to a general practice of providing the PGY2 with a consultation room is presented in Table 3. While only three practices charged out rooms, the mean cost (including $0 for practice 2) of hosting a PGY2 rose to $13 727 (range $5750–$24 715) per placement when space for the PGY2 was accounted for.

When the mean cost of GP supervision is halved, the revenue from extra patients seen by the PGY2 is doubled and the mean room charge-out rate of $8820 is used, the mean cost of hosting a PGY2 per placement is $7179 (range $2885–$11 001).

Practice interviews

Nine participants from the study practices in Otago/Southland (two female and three male GPs, one female GP/practice manager and three female practice managers) were interviewed. Four interviews with GPs and practice managers at each practice were conducted at the beginning of PGY2 placements, with follow-up interviews for three of the four practices. Seven interviews were also conducted with GPs from across NZ who were established PGY2 supervisors (four female and four male). Of these, one male and two female GPs were also practice managers. This study was conducted during health care reforms. We refer to district health boards (DHBs), with individual health boards responsible for ensuring the provision of health care services to 20 geographical districts, including district hospitals. From 1 July 2022, DHBs were replaced by a single national health organisation, Health New Zealand/Te Whatu Ora (TWO).

Four themes were identified (Fig. 2): working within in a small business model, general practice as a new learning environment, a positive PGY2 experience, and the relationship between general practices and DHBs. Illustrative participant quotes are presented.

Fig. 2.

Four themes identified by interviews with general practice teams across New Zealand.

Theme 1: working within a small business model

Due to pressures on clinical space and financial constraints, many practices were forced to prioritise the space required to host PGY2s. This was often driven by the impact of different types of employees and trainees on practice income. Overall, ‘space is money’ (P1), general practice is a business, and as one interviewee put it, ‘if the dollars don’t stack up, I’m not going to do it’ (P2). Several practices already hosted medical students, trainee interns and/or registrars and some also trained nurses and pharmacists towards further qualifications. They noted that medical students did not take up extra GP time or space so were considered cost neutral to the practice, and registrars generated an income for the practice which was a financial benefit. PGY2s on the other hand were perceived as an overall cost because of the supervision time required and limited revenue generation by the PGY2.

The PGY2s’ lack of real-world experience regarding the financial cost of health care was consistently recounted, stemming from lack of experience in primary care. PGY2s needed to learn that every procedure and intervention is costed to someone:

Every dressing we use either the practice covers it, or it gets put onto the patient. (P3).

While encouraging PGY2s to view medicine from a primary care perspective was important, this required considerable supervision. Supervising involved maturing a PGY2 in how the practice worked, teaching medicine in a community environment and modelling bedside manner and real-world ethics. While PGY2s had an invaluable learning experience because of such close supervision, concern was expressed about the detrimental impact on practice finances.

Theme 2: a new learning environment

The clinical environment of general practice was seen as unfamiliar and uncertain for PGY2s compared with previous hospital experience. Patients could present with anything, and consultations may cover social, emotional, mental or financial issues in addition to physical symptoms.

It is difficult to articulate the complexity of what we do and how uniquely challenging it is and there is still a perception, I’m sorry to say, amongst a lot of our colleagues that it is just coughs and colds and minor illnesses but it’s not, it’s incredibly complex, biopsychosocial, integrative care. (P3)

General practice was seen as a somewhat riskier environment to practise medicine in, compared with hospitals. Obtaining clinical investigations (such as blood tests and X-rays) and second opinions may not be immediately possible in primary care. This was particularly an issue for rural practices, but all practices required the ability to manage uncertainty that was not a feature of hospital care. The PGY2s were seen to benefit from being fully immersed in primary care. For example, in hospital settings, PGY2s often felt they had a predominantly clerking role, where they arrange patient care and referrals. In primary practice, however, they were expected to operate autonomously, with supervision. Interviewees reported their PGY2s feeling more empowered and experienced increased confidence in diagnosing and prescribing after their primary care experience. However, the responsibility for the PGY2s’ clinical decisions as they navigated managing this uncertainty and learning transition fell on the supervising GP and/or practice.

Another difference for PGY2s was the structured consultation templates within general practices. In the early stages of managing new PGY2s in practice, aligning the GP template with a less-structured approach for PGY2s, in addition to setting aside time to supervise, took some manoeuvring and required substantial time and experience.

Theme 3: providing a positive PGY2 experience

All participants emphasised that they wanted PGY2s to have a positive experience of general practice:

We want to showcase them without frightening them. (P4)

Balancing supervision versus autonomy was required for each PGY2, to be safe for patients as well as empowering for PGY2s. The expectation was that GPs supervised most or all the PGY2s’ patients in the early phase of placements, and then adapted templates based on the competence and confidence of the PGY2. Experience and trust in the PGY2 were the drivers for increased autonomy, however, safety for the patient and the clinical decisions made about their care were at the core of this process. Adapting templates on an individual basis was challenging. One doctor described how organising their schedule to align with PGY2 needs, supervising and rostering staff and fine tuning, was a time-consuming process that required careful assessment for the first few weeks (at least) of placement.

Every three months it’s a new puzzle. It’s a different approach, a different personality, different view on medicine, or on life. (P5)

The expectations of medical students, trainee interns and registrars were well-established, but the role of PGY2s was unclear in practices beginning CBAs. While experienced PGY2 teaching practices had built a clear process, there were no guidelines for practices beginning to host PGY2s to follow.

Building a positive experience for PGY2s had an added challenge for rural practices. DHBs were less willing to take responsibility for finding accommodation for PGY2s in rural practices, thus the onus fell on the practice. Solutions ranged from informal arrangements with local people to use spare accommodation for placements, to buying and converting a house into a multi-bedroomed lodge for all health professional undergraduates and new graduates. GPs in rural practices also provided pastoral support and had more involvement in PGY2s’ overall wellbeing:

The whole process is more than GP clinical and teaching. GPs also provide accommodation and pastoral care as they [the PGY2s] are away from home. (P6)

Theme 4: relationship between practices and DHBs

All practices recounted the strained relationship between the practice staff and the DHBs. One interviewee put it succinctly:

The DHB is a barrier to success. (P6)

Participants considered that a career in primary care is viewed by DHB staff as an easy option. It was felt that DHB staff assumed the PGY2s would provide extra (and free) manpower and practices should be grateful.

A lack of communication from the registered medical officer (RMO) units at DHBs who oversaw PGY2 placements further added to frustration within the practices. Many practices were not given information about the PGY2 prior to their arrival which hampered much of the preparation for induction. There was little understanding of the numerous and cumbersome administration processes and logins (eg ACC, Practice Management Systems, HealthOne, etc) to arrange at the beginning of placement. When placement start dates fell during school holidays, fewer GPs and practice staff were available, and this meant that induction programmes were fragmented or inadequate.

The lack of an ongoing relationship or even knowledge of a contact person, between the RMO units and practices throughout placements was most concerning. This was particularly frustrating for practices when RMO units made unilateral decisions granting PGY2s annual leave with little or no consultation with the practices. There was no formal process in which the DHBs were required to inform practices of these decisions. Some practices experienced PGY2s returning to their employing hospital to provide cover for a shortage of junior doctors during the placement. This was not expected, or at times communicated, to the practices.

The difference in funding and salary between the DHBs and practices was a source of contention. PGY2s received a lower salary by choosing a general practice placement. An equivalent doctor in a hospital setting had the capacity to earn more on after hours shifts and weekend work. As GPs provide out-of-hours care, it was suggested that the PGY2 CBA placements could be set at a higher salary band and include general practice out-of-hours experience.

Practices felt that they were not adequately funded for their time and commitment to training PGY2s. In some cases, the funding covered the start-up costs but did not cover ongoing costs and expenses. Practices were frequently left out-of-pocket for training PGY2s. Adequate funding for practices was vital for the continuation of the PGY2 initiative. One interviewee put it succinctly by saying ‘my devotion to the project would dip and I would have to look at other options’ (P2) if current funding issues were not addressed.

Differences between Otago/Southland practices and wider New Zealand practices

Experienced practices had developed efficient processes and had standardised systems in place for working with PGY2s. All staff knew the role PGY2s performed, and their own roles to facilitate positive PGY2 experiences. Indeed, the wider NZ practices described their reliance on having PGY2s in practice: ‘[the] worst fear is that they [the DHB] don’t have anyone now’ or the DHB wish to ‘give you guys a break [from hosting PGY2s]’ (P5). In contrast, Otago and Southland practices who were new to hosting PGY2s lacked clarity regarding the optimal time to begin reducing supervision while incrementally increasing the PGY2s’ autonomy. They expressed the overwhelming amount of work required to adequately supervise PGY2s, ‘I think that the DHB thinks they have taken a huge chunk of workload off us and made our lives lighter. I don’t think they realise how much extra work it actually is’ (P2). Some were reluctant to participate in hosting again.