Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

5.6 Impact of the RAHC on the NT health workforce

Evaluation of the Child Health Check Initiative and the Expanding Health Service Delivery Initiative - Final Report

Page last updated: 17 April 2012

5.6.1 Introduction
5.6.2 Data sources for the RAHC evaluation
5.6.3 Background
5.6.4 The performance of the RAHC model
5.6.5 The RAHC’s impact on meeting local needs
5.6.6 Suitability of RAHC practitioners
5.6.7 The RAHC’s impact on workforce capacity in the NT
5.6.8 Sustainability of the RAHC
5.6.9 Possible changes to the RAHC to better achieve its purpose
5.6.10 Conclusions

5.6.1 Introduction

This section gives a brief background on the RAHC, outlines the data sources used in the evaluation, and addresses the evaluation objective of the extent to which the RAHC has affected workforce availability and flexibility under the following headings:
  • the RAHC model’s record in deploying short-term staff to remote communities
  • the degree to which the RAHC has met local needs
  • the RAHC’s impact on quality and clinical governance
  • the RAHC’s impact on workforce capacity in remote NT communities
  • the sustainability of the RAHC model
  • possible changes to the RAHC
  • conclusions.

5.6.2 Data sources for the RAHC evaluation

Quantitative data sources

The main source of quantitative data was the RAHC’s database of deployments from December 2008 to 31 May 2010. Analyses based on data supplied by the RAHC to November 2010 have been included where possible and are identified in the text.

The RAHC database contains information about practitioner type (nurse, doctor, allied health or dental) and the place and dates of the deployment. Practitioners’ names were used to identify repeat visits to the same service and evidence of a longer-term relationship between practitioner and service. Names were not used for any other purpose and are not included in the reporting.

The RAHC data has been matched against a list of NT health services derived from information from NT Government websites and direct communications with the DHF and ACCHOs.

Further analysis of the RAHC deployment data is included in Appendix H.

Qualitative data sources

The evaluation uses data obtained from interviews with:
  • 10 individual health practitioners who had undertaken a RAHC placement (a 40 per cent response rate from a 10 per cent sample of practitioners chosen at random from each of the different practitioner types-no doctors responded to the request for interview)
  • 17 health service managers at various levels in DHF and ACCHOs (including some interviewed as part of the evaluation case studies)
  • the General Manager of the RAHC
  • DoHA personnel responsible for the RAHC Agreement.

The evaluation also considered written progress reports from the RAHC to the Australian Government and the funding agreement with the Australian Government.

The information concerning the RAHC was limited by the fact that no doctors responded to a request for an interview. The qualitative data is subject to the potential for biases to be introduced through the interview process. The characteristics and experiences of those who chose to be part of the sample may be different from those who did not accept the opportunity to participate.


5.6.3 Background

The NT faces significant difficulties recruiting health professionals. The high turnover of the population and the general workforce in the NT is reflected in the health workforce, particularly in smaller communities and more remote areas (Garnett et al 2008). The RAHC was established to supply health professionals for short-term deployments to fill temporary vacancies in the remote NT. Before the RAHC, the DHF and individual ACCHOs used a number of ways to fill short-term vacancies including:
  • using agency staff (staff recruited and placed by specialist recruitment firms)
  • recruiting directly from their own casual pool of temporary staff
  • filling positions through the use of overtime
  • short-term reassignment of health service staff to ‘backfill’ positions.
Alternatively, short-term vacancies were left unfilled until a permanent replacement could be recruited.
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Funding agreement for the RAHC

In August 2008 the Australian Government contracted Aspen Medical Pty 
Limited (Aspen Medical) to establish and operate the RAHC to supplement the recruitment efforts of ACCHOs and the DHF. The RAHC was designed to build on the willingness of urban-based health professionals to offer their services for short periods to remote NT Aboriginal communities as demonstrated during recruitment for the child health check component of the CHCI. The RAHC was designed to support the whole NT health sector, not solely the CHCI.

According to the Australian Government:

The RAHC is being established ... to recruit, culturally orientate, deploy and support health professionals, including doctors, nurses, and allied health professionals, to work in remote NT Indigenous communities. In undertaking these tasks the RAHC must have a focus on drawing recruits from urban based health professionals for short-term service.30

Initially the RAHC recruited and deployed doctors, nurses, and allied health professionals. From July 2009 it was extended to include dentists, dental therapists and dental assistants.

In late 2009 Aspen Medical was able to demonstrate that, well before the end of its contract, the RAHC would exceed the maximum number of deployments (175) allowed for in its initial proposal. Aspen Medical successfully negotiated a funding extension to allow it to continue deployments to the end of the contracted period (30 June 2010). This extension was based on an average of 25 deployments each month from January to June 2010.31

How the RAHC operates

The RAHC uses a variety of marketing and promotional methods to let health practitioners know about the program. These include advertisements and a public-relations program through the national press and a range of specialist health publications, television and airport advertising, presentations at health-related conferences and expos and through its website and other internet promotion.

Interested health practitioners register their interest with RAHC. They can then decide whether to apply for deployment and complete the necessary paperwork so that the RAHC can check their credentials and complete the checks to ensure they are ready for deployment.

The RAHC works closely with both the DHF and with ACCHOs to establish requirements for short-term health practitioner deployments. Managers from the DHF regions and from a range of ACCHOs regularly contact the RAHC to notify them of upcoming vacancies over the coming one to two months. Services frequently contact the RAHC with requests to fill vacancies that occur at short notice.

The RAHC attempts to match the health service’s requirements with available practitioners on the RAHC database of ready to deploy practitioners. The RAHC sends a list of suitable CVs to the service.

Once an individual deployment is agreed the RAHC is responsible for arranging and funding:
  • travel to and from the remote health centre
  • training-typically for a new practitioner consisting of a two-day introductory training course with one day cultural and one day clinical training
  • clinical and pastoral support for the health practitioners during their placement.
In the case of dental practitioners the RAHC arranges one day of cultural training, while the clinical orientation is organised by the Helping Hands Child Oral Health Program team in DHF (see Box 4). This team also provides the clinical and pastoral support for the dental practitioners during their placement.
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RAHC governance and advisory structure

Under its funding agreement the RAHC was required to establish a workforce advisory committee made up of representatives of the key stakeholder agencies. The committee was established with the following membership:
  • AMSANT
  • Australian College of Rural and Remote Medicine
  • Australian General Practice Network
  • AIDA
  • AMA
  • Australian Rural Nurses and Midwives
  • Committee of Presidents of Medical Colleges
  • CRANAplus (Council Remote Area Nurses Australia)
  • DoHA (OATSIH)
  • General Practice Network NT
  • DHF
  • Royal Australian College of General Practitioners
  • Royal College of Nursing Australia
  • Rural Doctors Association
  • Rural Health Workforce Australia
  • Services for Australian Rural and Remote Allied Health.
Five meetings of this committee have taken place with some members attending in person and others joining by video-conference. Meetings have heard about and discussed the RAHC progress and have also had presentations and discussions on wider workforce developments in the NT and across Australia.
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5.6.4 The performance of the RAHC model

The Australian Government set the following expected outcomes for Aspen Medical’s delivery of the RAHC:
  • at least 40 health practitioners to be deployed in the 2008–09 year (starting December 2008) and at least 90 in the full year to 30 June 2010 based on average 21 day deployments
  • establish offices in Canberra and Darwin
  • use innovative approaches to skills transfer
  • establish longer-term relationships between recruited health practitioners and local NT providers
  • the RAHC to respond to all requests for practitioners from NT providers
  • the RAHC to ensure all health practitioners have full credentials
  • the RAHC to provide appropriate training, support and pastoral care.
This section looks at the RAHC’s performance against these contracted measures.

Short-term deployments to remote communities

There were a total of 439 individual deployments between 4 December 2008 
and 31 May 2010. By 31 May 2010, 1,597 weeks of deployment had been completed. By the time all deployments are completed, the total will be 1,777 weeks.32 As shown in Figure 11, the number of deployments was modest in the first six months of the program with an average of 11 deployments per four-week period between December 2008 and May 2009. Over the last 12 months there have been on average 28 deployments in each complete four-week period. 


Apart from quiet months over December and January, deployment numbers have stayed reasonably stable at around 28 deployments per four-week period since September 2009 until the end of the evaluation period.

The average length of deployment is 3.8 weeks (times include travel and training days-actual length of 
time in the community is usually one or two days shorter). This has not changed significantly since the second month.33 The longest deployment was a little over 17 weeks. The shortest was one day.34

The RAHC has well exceeded its contracted key output requirements of 40 deployments in the first year and 90 in the second year based on an average of 21 days. In the first year to July 2009, there were 100 deployments; in the second year to June 2010 there were 339 deployments. The extended funding agreement required an average of 25 deployments per month from January to June 2010 – the actual average was 34 per month to the end of May. It appears that in overall performance in placing practitioners, the RAHC model has been successful in at least temporarily increasing capacity in targeted areas; however, the deployment numbers do not tell the whole story of the impact of the deployments on health status.
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Figure 11: Number of deployments completed over four-week periods (December 2008–May 2010)

Figure 11: Number of deployments completed over four-week periods (December 2008–May 2010)

Source: Data supplied by the RAHC.

[D]

Deployments by type of practitioner

Of the 439 deployments in the period 4 December 2008 to 31 May 2010, 261 (59 per cent) were nurses, 46 (10 per cent) doctors, 50 (11 per cent) allied health and 82 (19 per cent) dental practitioners.35 From 1 July 2009 to 31 May 2010, when dental practitioners were included, their numbers make up 22 per cent of deployments. Deployment length is discussed further in Section 5.6.5 below.

The deployment by type of practitioner reflects the shape of the permanent NT health professional workforce, which is comprised of more nurses than doctors (probably by a factor of three or more).36 The number of allied health and dental workers is very high compared to the permanent workforce of these professionals. As discussed below, most RAHC allied health and dental practitioners are deployed for particular programs rather than as short-term replacements for permanent staff. The high use of allied health staff may also indicate a gap in recruitment of these personnel, as other locum agencies generally focus on the recruitment of doctors and nurses.

Figure 12 (which excludes placements with the two regional mental health services based in Darwin and Alice Springs) shows relatively steady numbers of deployments of nurses and doctors to remote centres, illustrating the difference between these professions and the program-focused allied health placements.
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Figure 12: Number of deployments of nurses and doctors to remote centres (December 2008–April 2010)

Figure 12: Number of deployments of nurses and doctors to remote centres (December 2008–April 2010)

Source: Data supplied by the RAHC.

[D]

5.6.5 The RAHC’s impact on meeting local needs

We examined deployment length, type of practitioner, location and number of communities served and 
repeat deployments, and considered RAHC’s responsiveness against the four ways it has been used:
  • to fill short-term planned study or annual leave vacancies-usually up to four weeks placement 
and often with a month or more notice of vacancy
  • to fill short-term unplanned vacancies-such as longer sickness leave often needing to be filled at short notice (shorter periods of sickness or bereavement leave can usually be filled by redeploying other staff)
  • to fill vacant permanent positions until permanent staff can be recruited-these can be for 
several months
  • for particular programs or visiting services-such as dental teams for the Closing the Gap Child Oral Health Program or allied health workers such as podiatrists or physiotherapists for three to four weeks visiting service to a community.
The RAHC does not capture data about how practitioners are used-the purpose of the deployment-so it is not possible to give definitive numbers for each of these categories of use. Some indications about likely use can be derived from the deployment database and from the interviews.

We were able to ascertain that of the 82 dental practitioner deployments, 68 were two-practitioner teams (a dentist or dental therapist along with a dental assistant) deployed to communities as part of the DHF’s Child Oral Health Program. The remaining 14 deployments were single practitioners deployed mainly to ACCHOs where there is a dental service.

The 50 allied health deployments were generally used to provide a short period of service in a community rather than relieving a permanent service (of which there are few, if any, in NT remote Aboriginal communities).

Deployment length

As can be seen from Figure 13, the majority of deployments were for two to four weeks. Only 16 per cent of all deployments were for periods longer than six weeks. These deployments are likely to be for unfilled permanent positions and are more common for nurse deployments. Almost a quarter of nurse deployments are for longer than six weeks. This aligns with information received from those managers responsible for recruitment.
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Figure 13: Deployment by length (December 2008–May 2010)

Figure 13: Deployment by length (December 2008–May 2010)

Source: Data supplied by the RAHC.

[D]

Location of deployments

Different regions have used RAHC practitioners to various extents, but there is no clear pattern to 
explain the variability.

The RAHC was used by almost 75 per cent of services, though less so by DHF and smaller centres. We compared RAHC deployment data to a list of 92 health centres or services across the NT. The list includes nine services where RAHC practitioners have been placed but which are not health centres or communities and excludes six health centres that would not be expected to use RAHC practitioners since they do not have at least one full-time nurse position. Of these 92 centres, 66 (72 per cent) have had at least one RAHC deployment. The real proportion may be a little higher since a few centres or communities may have received services from RAHC personnel based in a larger centre.

Over the lifetime of the RAHC, the number of health centres using the program has gradually increased, therefore increasing the number of deployment sites. This growth has been almost linear since the program began, but since already more than 70 per cent of centres have used the RAHC, the rate of increase could be expected to slow.

Number of deployments by type of health service

The number of deployments per health centre ranges from nil to 43, with an average deployment of 
4.8 and a median of two. Distribution was not even (Figure 14). Eight centres (8.7 per cent) in the NT have received almost half (46 per cent) of all placements while 43 centres (46.7 per cent) have received 
3.9 per cent of all placements.

Our analysis also showed that ACCHOs use RAHC nurses more frequently 
than DHF centres. The extent to which each type of service (ACCHOs or DHF services) uses the RAHC varies, as shown in Table 55. It shows that similar proportions of both ACCHOs (28 per cent) and DHF centres (31 per cent) have never used RAHC practitioners. Six of the 10 ACCHO centres that have not used the RAHC belong to one regional health service. The manager of that regional health service explained at interview that since December 2009 the service has made its own internal arrangements to cover short-term vacancies without using staff from an agency. Previously they have used the RAHC and would do so again if needed.
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Figure 14: Frequency of the RAHC placements per centre (December 2008–May 2010)

Figure 14: Frequency of the RAHC placements per centre (December 2008–May 2010)

Source: Data supplied by the RAHC.

[D]


Table 55: RAHC deployment by type of service provider and deployment duration (December 2008–May 2010)
Service organisation
Number of centres
Number of centres not using RAHC
Per cent not using RAHC
Total RAHC deployments
Total RAHC weeks
Average number if do use
Average weeks if do use
ACCHO
36
10
28
256
1,045
9.8
40.2
ACCHO/DHF
2
0
0
22
84
11.0
42.0
DHF
52
16
31
152
517
4.2
14.4
Other
2
0
0
9
35
4.5
17.5
Total
92
26
28
439
1,681
6.7
25.5

Source: Data supplied by DHF (number of centres) and the RAHC.


Interviews with health service managers suggested that many RAHC nurses were thought to be less experienced and skilled in operating as nurses in small, remote Aboriginal communities and so would not readily be deployed there. To analyse this, deployments were compared according to the size of the clinic. When adjustment is made for the fact that larger clinics have more vacancies in a given period than smaller clinics, the data does not demonstrate that the RAHC is used less in smaller clinics. Little difference can be shown according to clinic size.

ACCHO clinics used significantly more RAHC practitioners than DHF clinics, with averages of 9.8 placements and 4.2 placements respectively. The average length of deployment also differs. ACCHO clinics that use the RAHC had an average of 40.2 weeks of deployments each compared to 14.4 for DHF clinics.

As would be expected given the data above, ACCHO clinics received more frequent deployments of nurses and doctors than DHF clinics-two and a half times and four times as often, respectively. DHF clinics have made more use of RAHC allied health and dental practitioners. This is likely to be due to deployments for particular programs, rather than short-term replacements for existing permanent staff.

These differences are greater if the type of RAHC practitioner is considered (Table 56).
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Table 56: Number of RAHC deployments by type of practitioner and organisational type (December 2008–May 2010)
Total RAHC deployments
Nurse 
deployments
Doctor deployments
Allied health deployments
Dental 
deployments
Number
Per cent
Number
Per cent
Number
Per cent
Number
Per cent
Number
Per cent
ACCHO2565817266327022443037
ACCHO/ DHF2251147150045
DHF15235692671528564859
Other9293000000
Total439100261100461005010082100

Source: Data supplied by the RAHC.


Table 57 shows the average number of RAHC nurses by the size and organisational type of the clinic. As expected, because small clinics have fewer nursing vacancies they used fewer RAHC nurses than medium and large centres; however, small and medium DHF clinics have used many fewer RAHC nurses than have similar sized ACCHO clinics.
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Table 57: Average number of RAHC nurse deployments per clinic according to size and organisational type (December 2008–May 2010)
Health service organisation(a)
Large(b)
Medium
Small
ACCHO
7.0
7.8
3.4
DHF
10.5
1.5
0.9
Total
8.0
5.1
1.8

(a) Table excludes clinics with no permanent nurse positions, services that span a complete region and those that are joint DHF and ACCHO services.
(b) The size of clinics is based on the number of nurse positions. Small clinics had three or fewer, medium clinics had four to seven, and large clinics had eight or more nurse positions. Source: Data supplied by the RAHC.


The RAHC explanation for the lower DHF use of RAHC nurses is that DHF clinics (particularly in Central Australia) are more likely to be small one or two-nurse stations. For these posts, DHF operational managers look for nurses with remote experience which, by and large, RAHC staff do not have because the RAHC mandate is to recruit practitioners who are new to this work. DHF managers put the same rationale forward in interviews. ACCHO recruitment managers had a slightly different emphasis, saying that they prefer to use the RAHC because the costs are significantly lower than for agency staff (travel costs are covered, for example) and their organisations have no leeway to exceed budgeted funding. One ACCHO service manager said that if practitioners indicate that they are interested in future short-term placements, managers suggest that they organise this through the RAHC to save costs.

DoHA reported that DHF has its own systems for filling short-term placements and that, from the outset of the program, DoHA never expected DHF to use RAHC to the same extent as ACCHOs.

Repeat deployments

Many practitioners have had more than one deployment with the RAHC. 
To 31 May 2010, 48 per cent of all deployments37 involved practitioners who had done at least one previous RAHC deployment. Repeat deployments have become more common over time as shown in Figure 15.
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Figure 15: Proportion of repeat deployments over time (December 2008–May 2010)

Figure 15: Proportion of repeat deployments over time (December 2008–May 2010)

Source: Data supplied by the RAHC.

[D]

There are few differences between practitioner types in terms of the proportion of repeat deployments (Table 58).

Repeat deployments are not surprising considering the nature of the deployments and the likelihood that practitioners would want to return to communities and services where they have existing relationships with the staff and the community. While difficult to quantify, repeat deployments may be more beneficial to the community (providing continuity of care) and less disruptive to the services as deployed practitioners are already familiar with the health status of the community and the systems and processes used by the service they are working in.


Table 58: Repeat deployments by practitioner type (December 2008–May 2010)
Nurse (%)
Doctor (%)
Allied health (%)
Dental (%)
First deployment
51
54
41
58
Repeat deployment
49
46
59
42
Repeat deployment to the same community/service
31
34
70
23

Source: Data supplied by the RAHC.


5.6.6 Suitability of RAHC practitioners

ACCHO and DHF managers differed significantly when commenting on the suitability of staff that the RAHC recommended. The general response was positive from ACCHOs and negative from DHF managers. This is consistent with their responses to the RAHC in general.
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Training and support for RAHC practitioners

Participants generally acknowledged that if a practitioner had not had previous experience in a remote Aboriginal community there was always a significant element of ‘culture shock’ and that this could have a big impact in a short attachment. They generally needed initial orientation, induction and support. Several practitioners remarked positively on the support they received from other staff in orienting them toward working in an Aboriginal community.

The RAHC contract requires that it provide ‘appropriate training, support and pastoral care to recruited health professionals prior to, during and after their deployment’.38 As well as meeting contractual obligations, it is highly likely that RAHC practitioners will be more effective and have a greater positive impact if they are well-trained, well-supported and have realistic expectations.

The RAHC arranges for new practitioners to receive training (with the exception of clinical orientation for dental practitioners as noted in Section 5.6.3) including a one-day cultural training course. The RAHC has also developed an online cultural training resource. Training was generally well received by practitioners and thought to be useful preparation, with some practitioners noting that it was really just a short introduction. Where managers had experience of RAHC practitioners both ACCHO and DHF managers agreed that the cultural training they received was good and there had been very few cases of complaints or problems because of culturally inappropriate behaviour.

Some practitioners thought they needed to have more practical and detailed information about living in the communities such as dealing with camp dogs, accommodation arrangements, finding various facilities and so on. One suggestion was that the RAHC should build a detailed database of this sort of information for each of the communities. The RAHC has responded by developing profiles on the communities where it places practitioners39 and has responded to specific requests such as four-wheel drive training.

In the opinion of practitioners and managers, the clinical training that the RAHC gave was useful but limited and both groups thought practitioners needed local orientation and introduction to systems.

Those practitioners who were interviewed had little need for contact from the RAHC while in placements. Most felt that if medical staff are well matched to the job they do not need particular support. One DHF manager commented that the commercial recruitment agencies seemed to offer closer and more appropriate support, often by people who have themselves been remote-centre clinicians, whereas this is not always the case with the RAHC.
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Suitability of practitioners recommended and deployed by the RAHC

ACCHO managers thought the RAHC was generally able to recommend 
suitable practitioners to fill vacancies and that, with only rare exceptions, the program improved over time. ACCHO managers reported that in the early days of the program, RAHC recommended practitioners who were too inexperienced for the work, leaving permanent staff with extra work orienting, supporting and training RAHC practitioners for remote Indigenous practice. The data tends to support these comments. In the early months of the program, RAHC deployments to ACCHO centres were mostly to larger centres where less experienced practitioners would have more support, whereas over recent months there have been more deployments to smaller centres.

DHF managers, on the other hand, all thought that most RAHC-recommended nurses and doctors did not have suitable experience and qualifications. For example, small and isolated clinics required nurses to take a high degree of clinical responsibility (for example situations such as a major road injury or a complicated pregnancy), as well as being able to manage a range of PHC services such as immunisations and preventive care. Managers of such clinics (which are the rule, particularly in DHF services in the Central Australia region) were only prepared to accept nurses who had significant previous experience in remote Aboriginal communities. Several commented that the RAHC thought that a couple of weeks’ experience as part of a team during the CHCI counted as significant experience, whereas this was inadequate preparation 
for the role of a remote clinic nurse.

Unlike ACCHO managers, DHF managers did not note significant improvements over time in the suitability of RAHC recommended practitioners. In the case of one region, the DHF seemed only to have approached the RAHC once in the early phase of the program. The recruitment manager was put off by what was seen as an overly bureaucratic system compared to other agencies. This, and the shared experience of nurse recruiters who found the RAHC nurses were not well suited to the environment, meant that the RAHC had not been approached again to fill medical vacancies in that region.

There is a notable exception to the apparent lack of matching between the RAHC and the DHF. The Child Oral Health Program, funded by the Australian Government and delivered by DHF, has been running since 2008. Up to July 2009 DHF recruited and employed dental practitioners directly. In 2009 the RAHC’s scope was broadened to include dental practitioners and the RAHC took over staff recruitment for this project.

The DHF Child Oral Health manager commented that initially when the RAHC took over staff deployment, the DHF still needed to work very closely with the RAHC to ensure that placements were managed properly. In the early days of the changeover, there were a number of problems with logistics and a lack of local support for the teams. These have become less common over time as the RAHC has learned from these early issues. In future the DHF is going to spell out its expectations of the RAHC in a detailed agreement to try and reduce the level of oversight needed from DHF.

Concerns and issues with RAHC placements

Interviews with practitioners and health service managers highlighted that introducing a new practitioner to a clinic inevitably involved existing staff spending time orienting the practitioner with the relative burden being greater for short-term deployments. The burden is much greater if the practitioner has never worked in a similar setting before and greater again if the practitioner does not have the experience or skills needed for work in remote Aboriginal health services. If a practitioner placement occurs in these circumstances, it is unlikely that the benefits to the community will match the costs and negative impacts on the practitioner and other staff.

The ability of clinic staff to respond to the demands that come with a RAHC placement depends on the size of the clinic, how busy it is and how clinical staff are organised and governed. DHF managers commonly cited these extra demands on existing staff as one reason why they preferred to use more experienced practitioners from commercial recruitment agencies rather than accept a practitioner from the RAHC who had not previously worked in a remote NT community.

In a small number of cases, deployments have resulted in serious concerns and consequences. The RAHC’s progress reports give detailed information about the few placements which have resulted in an adverse outcome. These are placements that have been cut short or been concluded with either the practitioner or health centre lodging a formal complaint. Analysis up to December 2009 showed that 24 placements (5.4 per cent) ended in an adverse outcome. This appears to be a relatively small number given the issues noted above. However, without a suitable comparison it is not possible to comment on whether this number of adverse outcomes is what would be expected in a program like the RAHC.
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5.6.7 The RAHC’s impact on workforce capacity in the NT

The RAHC’s website urges practitioners to ‘be part of the effort to improve Indigenous health’ and states that it ‘has been established to attract urban-based health professionals to provide short-term staffing needs for remote Indigenous communities in the Northern Territory’. This closely matches the Australian Government’s funding agreement with Aspen Medical which appears to have been modelled on the successful recruitment of urban-based practitioners for the CHCI.

Up to the end of May 2010 the RAHC had placed 227 individual health practitioners in 439 deployments.40 In the 23 months to November 2010, 
based on 2,747 weeks of service delivered, the RAHC has added around 
30 FTE positions.

There is no doubt that the RAHC model has been successful in adding to the number of health practitioners working in the NT. Practitioner interviews and RAHC reports indicate that most of the 227 RAHC practitioners would not otherwise have worked in the NT and to that extent represent additional capacity. As noted previously, 48 per cent of RAHC practitioners have 
returned for at least one further deployment.

This data indicates that the RAHC is steadily building a corps of health practitioners who have experienced NT placements and many who have had multiple deployments. There is, therefore, potential for the RAHC to continue to add to the NT health workforce, at least on a temporary basis.

These deployments represent 13 per cent of the 1,632 people on the RAHC database. The comparatively low conversion rate from practitioners showing an interest through to practitioners being deployed raises a number of questions about the success of the RAHC model. In its March 2010 progress report the RAHC notes ‘some significant attrition in numbers between those that have registered an interest or requested an application pack to those that have submitted an application, to those that have a completed all the requirements for credentialing and thus are deemed ready for placement’ (RAHC 2010).

Advice from the RAHC’s general manager is that very few applicants fail at the credentialing stage. Some practitioners who indicated an interest will never follow through, for a variety of personal or professional reasons. On the demand side, the RAHC may have difficulty matching ‘ready-to-deploy’ practitioners to vacancies, or health service managers may not find suitable candidates on the RAHC lists. Despite this, 
RAHC’s general manager reported that ‘there aren’t many people that are put through credentialing that 
don’t end up deployed’.

The RAHC and other sources of short-term practitioner capacity

Although the RAHC has grown since its inception, interviews with managers responsible for recruitment in both DHF and ACCHO services indicate that it is still far from being the only, or even the main source, of practitioners for short-term deployments.

DHF nursing and medical workforce managers use a number of the commercial nursing and medical agencies even though this can result in exceeding budgets for staff costs. When the RAHC first began, DHF policy stated that the RAHC should be used wherever possible and recruiters say that if they have a choice of two equally suitable practitioners they would give the RAHC practitioner preference. Informants stated that the RAHC cannot generally put forward an equally suitable candidate.

Both DHF regions still operate a pool of casual nursing staff and they tend to approach these practitioners first about vacancies. Because there are financial incentives to the DHF to use RAHC staff, the DHF wrote to nurses in the casual pool asking them to consider applying to be on the RAHC database. Few nurses have done so, perhaps because there would be an extra administrative burden for the nurse with little clear individual gain. The impression from interviews was that DHF has not promoted RAHC application to its casual nursing pool despite the significant potential savings. As already reported, ACCHO managers were generally more positive about the RAHC. Several said that they use the RAHC as much as possible to supply their short-term staffing needs.

Table 59 shows the wide range of ways that different sized clinics use the RAHC for nurse deployments and the potential for expanded use-that is, the difference between the mean and the maximum. Interviews with managers show that there should be considerable scope for expanding the role of the RAHC if it can provide staff perceived as meeting the clinics’ requirements.
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Table 59: Average and maximum RAHC nurse deployments by clinic size(a) (December 2008–May 2010)
Number of clinics(b)
Average deployments 
per clinic
Maximum deployments per clinic
Large
7
8.0
22
Medium
15
5.4
32
Small
61
1.8
24

(a) The size of clinics was based on the number of nurse positions. Small clinics had three or fewer, medium clinics had four to seven, and large clinics had eight or more nurse positions.
(b) Services that do not use nurses or where nurses are used across a region are excluded.
Source: Data supplied by the RAHC.


The RAHC’s impact on overall workforce pressures

The main workforce issues identified in interviews with health centre staff included the:
  • continued high level of reliance on agency nurses
  • need to resolve issues with AHW recruitment, training and support
  • need to overcome literacy barriers for AHWs and ACWs
  • lack of male AHWs and nurses
  • lack of accommodation continuing to be a barrier to recruiting permanent staff
  • competition to employ suitable local staff (such as from shire councils and schools).
Both DHF and ACCHO managers reported that the RAHC had made very little 
impact on overall workforce pressures in the NT. This is not surprising since the RAHC was only ever intended to supply the need for short-term staff. Those who were positive about the RAHC thought that having to worry less about short-term practitioners was supportive to other staff in the centres and made 
it more likely that they would stay. On the other hand, those who were less positive about the RAHC noted that existing staff were sometimes more stressed by a RAHC practitioner because they tended to be less experienced and needed more support.

Information from practitioners, managers and the RAHC indicated that a few RAHC practitioners have moved to work permanently in the NT. The small number involved means that these permanent moves have not had any significant impact on the NT healthcare workforce.

Recruiting and retaining a permanent workforce is still the major concern for the NT, particularly for remote communities. As noted above, the RAHC is not designed in a way that will make a significant difference 
in this area.

5.6.8 Sustainability of the RAHC

In the context of the RAHC, questions of sustainability centre on whether the model can provide an effective, appropriate and affordable way of helping make health care available to remote communities in the NT.
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Financial sustainability

The financial sustainability of the current RAHC model depends to some extent on whether it represents reasonable value for money compared to alternative models; however it is difficult to make value for money comparisons between the RAHC and other services because its purpose and objectives are different.

As explained above, after negotiations between the Australian Government and Aspen Medical, the Australian Government stated that $5 million would be paid to Aspen Medical for 2009–10 for meeting the agreed objectives and outputs. The agreed outputs included setting up and marketing the program and deploying at least 90 practitioners for an average of three weeks.

The RAHC easily met these minimum outcomes and it also exceeded the number of deployments (175) on which Aspen Medical had originally based its proposal for the program. As a result, the Australian Government agreed to a funding extension to cover January to June 2010. The extension involved extra expenditure for new fixed costs and a sum for increased deployments, based on $6,380 per deployment and an expected 25 deployments each month.

The funding agreement makes it clear that the RAHC is to:
    ... employ or contract health professionals and charge at direct cost to local NT health service providers or any other party for the supply and deployment of health professionals. For the purposes of this clause, direct cost means base pay, superannuation, payroll tax, workers compensation, leave provision, loading; and for contractors, the fee plus, if applicable, superannuation guarantee.
Thus the funding per deployment is exclusive of these salary costs.

In return for its funding, the RAHC has to:
  • advertise for, recruit and check practitioners to build its database
  • manage communications with recruitment managers for the health services to match practitioners with vacancies
  • cover the costs of training and travel to the placements (including salary while training)
  • provide support for practitioners in post
  • develop various support materials in hard copy and online.
Other agencies recruiting health practitioners provide some of the same services as the RAHC as shown in Table 60.

Looking at the variable costs for the functions in Table 60 associated with each deployment, the RAHC has to pay the costs of travel and training which other agencies do not cover. These costs will vary depending on where the practitioner is based but they could range, for example, from $1,200–$2,500 for return travel to Alice Springs or Darwin from Sydney and perhaps a further $500–$1,000 for return transport to the placement centre. Training costs (salary and the costs for the training) might add another $500–$1,000 depending on whether one or two days is required. These costs therefore may range from $2,200–$4,500.

On the basis of the latest funding extension, the RAHC is receiving around $6,380 per deployment with an average length of 3.8 weeks. Using the above estimates, after paying for travel and training there would be between $1,880 and $4,180 remaining per deployment. Assuming a 40-hour week and an average deployment of 26 days (the average so far has been 3.8 weeks less one day on average for training) this gives an hourly agency fee of between $9.20 and $20.40 (in addition to salary)-an average of about $14.

DHF managers indicate that the hourly rate for agency nurses is around $90 compared to around $76 for DHF-employed casual staff. The difference of $14 per hour covers the agencies’ costs (and any higher salary that the nurse may earn).
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Table 60: Comparison between the RAHC and other recruitment agencies
FunctionThe RAHCOther recruitment agencies
Marketing and recruiting database of practitionersRequired to proactively seek practitioners from outside the NT who were not considering an NT deployment.
Focus on urban practitioners otherwise employed who have only short-term availability.
May recruit from anywhere.
Likely to already have some practitioners with NT experience.
Can build up workforce of practitioners who are only participating in short-term work.
Check credentialsNeeded on all new practitioners.Needed on all new practitioners (but many may be already checked).
Communicate with providersRequired under contract to work closely with NT providers and with an advisory group. Only NT clients.May wait for providers to make the contact. May have provider clients throughout Australia.
Train practitionersRequired to do this under contract—sometimes two days for new practitioners but returning practitioners need less.
Pay salary and costs of training.
Support wider professional development, for example, through arranging remote emergency care training and providing online training modules in remote health practice.
Not required to pay for training.
TravelRequired to pay for costs of deployment to placement centre (does not usually include salary costs since travel is at weekend). Is likely to include air travel to Alice Springs or Darwin and then land, air or combination to clinic.Travel not included (expense for provider or practitioner).
Support while in placementAs needed—usually making contact every few weeks for longer deployments.As needed—and usually making contact every few weeks for longer deployments.
Payment of salarySalary set by provider but practitioner paid by the RAHC.Salary set and paid by agency.
If these assumptions are accepted, the cost that the Australian Government is paying for the RAHC appears to be comparable to what providers would pay another agency for similar services. Most DHF managers would probably argue, however, that the practitioners available through the RAHC are less likely to be of an equivalent standard of skill and experience to those sourced through another agency.

It is possible that future RAHC costs per deployment may reduce to some extent since the proportion of repeat deployments is rising and training costs could therefore be expected to fall. Other changes as discussed below might also lead to lower costs. For example, if the RAHC builds a smaller corps of more experienced practitioners, marketing could be more targeted and less expensive.

Other aspects of sustainability

The RAHC’s experience so far has been that there are a significant number of health practitioners who are interested in short-term deployment to the NT. For a variety of reasons the majority of these practitioners never actually undertake a deployment.
To better meet the needs of communities, the RAHC has to build a corps of practitioners with experience of working in remote Aboriginal communities. The RAHC appears to be slowly increasing the number of such practitioners that it has available as shown by the number of repeat deployments, the stated willingness of practitioners to seek further deployments and the slowly increasing willingness of DHF clinics to use RAHC nurses. Section 5.6.9 discusses some other changes that might help build this corps of experienced practitioners further.

Perhaps the biggest challenge to RAHC sustainability is whether the model is accepted as a useful part of workforce arrangements by DHF. At present, ACCHOs are much stronger supporters of the RAHC than DHF whose managers are, on the whole, not convinced about the suitability of the model. The RAHC appears to have recognised this challenge and has been meeting with DHF senior management to address the issues. Changes are needed in the RAHC’s approach and contract to enable it to better meet DHF needs. These are discussed in the next section.


5.6.9 Possible changes to the RAHC to better achieve its purpose

While the RAHC has performed well in some aspects of its work, there are areas that need attention if the service is to improve its effectiveness and be sustainable.
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Scope expansion
The funding agreement notes that the RAHC is to be established to ‘supplement the recruitment efforts of Aboriginal Medical Services and DHF’. So far the RAHC has been used quite heavily by a small number of larger clinics, by many ACCHOs and for the Child Oral Health Program. There are still a quarter of communities that have never used RAHC practitioners and the RAHC does not seem to be meeting the needs of DHF clinics in particular.

If the RAHC had more practitioners with the skills and experience needed it could be more widely used and would benefit a larger number of Aboriginal communities. In particular, the RAHC needs to build a corps of nurses with the requisite skills and experience in working in remote clinics as described in the next section. There will, however, always be demand-side factors that need to be considered in any expansion of the RAHC. Many providers have existing arrangements for filling short-term vacancies and these arrangements may be cost-effective and the providers may have no real need for the RAHC.

Another potential area for expansion is shifting focus from recruiting short-term to long-term staff. Recruiting a permanent workforce remains a major issue for the NT and there are no sector-wide agencies focusing on the recruitment of health professionals other than doctors.

Practitioner suitability
The Remote Area Health Corps name suggests that the RAHC would be building a corps of practitioners suitable for working in remote NT areas. Most of the practitioners on the existing RAHC database lack the appropriate experience and skills needed for work in small, remote centres even for short-term placements. Given the short-term nature of the placements, it is never going to be possible for RAHC training to bring inexperienced practitioners up to the level needed for deployment to small, remote centres before their first deployment. This would require an extended professional training program, potentially involving a partnership between DHF, AMSANT, DoHA and ACCHOs, academic and professional organisations.

There is a degree of tension between the RAHC remit to draw practitioners from urban practice and the local centres’ needs for experience in remote settings. It may be that the RAHC should signal more clearly in its promotions that it is seeking practitioners with skills and experience that are more relevant to remote practice.

The RAHC might also be encouraged to work with DHF and the ACCHOs to recruit practitioners who are known to these organisations. This could include managing DHF’s ‘casual pools’ in the way that the RAHC took over the lists of dental practitioners for the Child Oral Health Program. This could require a variation in the RAHC’s remit. The result could be that the RAHC would build and manage a recruitment database across ACCHO and DHF services. Any such move should be linked to establishing regional Aboriginal community-controlled health services and may require a strengthening of governance and oversight arrangements.

Another possible variation suggested by one of the managers interviewed is that providers should consider identifying a few suitable posts in some of the larger NT centres, perhaps in hospitals as well as large health centres. These posts could be earmarked to be filled by less experienced practitioners who have signed on to the RAHC but who are not yet ready for deployment to small, remote centres. They could gain experience working in such posts and their presence in those larger centres could free up a locally employed member of staff to rotate for a short period to a remote centre. After one or two such deployments the RAHC practitioner could be gradually moved out to less supervised posts.
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5.6.10 Conclusions

The RAHC has been operating for less than two years and in that time has successfully marketed short-term work in the NT and attracted over 1,500 health practitioners of various types. It has easily exceeded its contracted volumes and 227 practitioners have been placed in 439 deployments filling short-term vacancies in more than three quarters of all NT remote health services. The program has added to the workforce capacity in the NT (around 30 FTE positions a year). Costs of the program to the Australian Government are likely to be comparable to those that would have been incurred by providers if they were paying for practitioners through a commercial agency and covering the costs of travel and training.

The future of the RAHC model needs to be considered within the context of wider workforce issues in the NT. Strategically, an effective single agency for short-term recruitment across the NT funded by the Australian Government (rather than DHF) could be seen as a useful adjunct to help in the shift towards regionalisation and more Aboriginal community control. In time, it might also broaden its efforts to wider workforce and human resource issues, such as recruitment of the permanent workforce. But there would need to be careful consideration as to whether the RAHC model is the right one for providing this broader workforce role. Future considerations of any such privately run agency would also need to cover questions of competition and whether the costs over time might be expected to reduce as fewer practitioners need training and more live locally.

More immediately the RAHC has the capacity to deploy more practitioners to a larger number of communities. For this to occur:
  • The RAHC needs to be able to focus on building a corps of practitioners who have the relevant experience and training to work in small, remote Aboriginal communities. Explicitly allowing the RAHC to broaden its recruitment efforts outside main metropolitan areas, including in the NT, would strengthen the RAHC’s performance in this area.
  • DHF would need to be further encouraged to use the RAHC to manage its casual staffing needs, including passing management of its casual nursing pools to the RAHC as has been done for the Child Oral Health Program. Enabling the RAHC to specifically recruit experienced staff outside the main metropolitan areas would help change perceptions that RAHC practitioners are not particularly suited to NT deployment.
  • ACCHOs would similarly need to be further encouraged to consider the RAHC managing all their casual staffing needs.
This approach would be welcomed by some ACCHOs, who would appear to be more sensitive to the cost of using recruitment agencies, but it could be seen as threatening by existing agencies. It would only be possible following close negotiations with DHF and would require considerable time and trust-building to be successful. In considering such an approach, we would recommend that DoHA involve the DHF and AMSANT in planning for any reform or expansion of the RAHC.

30 - Funding agreement between Aspen Medical and the Australian Government.
31 Since the evaluation RAHC funding has been extended to 30 June 2011.
32 - Update: From 4 December 2008 to November 2010 there were 679 deployments, totalling 2,747 weeks.
33 - Update: From 4 December 2008 to November 2010 the average placement length was 3.7 weeks.
34 - The one-day deployment was the result of an adverse outcome. This means the placement was cut short or concluded with either the practitioner or health centre lodging a formal complaint.
35 - Update: From 4 December 2008 to November 2010 of the 679 deployments, 54 per cent were nurses, 12 per cent were doctors, nine per cent allied health and 24 per cent dental practitioners.
36 - In 2006 there were an estimated 866 medical practitioners employed in the NT (AIHW 208) and an estimated 2,976 registered and enrolled nurses in the NT in 2007 (AIHW 2009b).
37 - Update: From January 2009–November 2010, 54 per cent of placements were repeat deployments. From July 2010–November 2010, 73 per cent of placements were repeat deployments.
38 - Funding agreement between Aspen Medical and the Australian Government.
39 - Forty-six detailed community profiles had been developed by 21 June 2010 and many have been posted on the RAHC website.
40 - Update: From 4 December 2008 to November 2010 RAHC had placed 315 health practitioners in 679 deployments..


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