Review of the National Rural Locum Program - Final Report - April 2011

Appropriateness of the NRLP

Page last updated: 04 July 2012

Continuance of Australian Government support for the program

Feedback from both hosts and locums within the NRLP is strongly supportive of its continuation as an appropriate way to provide locum support. Additionally, nearly 200 respondents to the electronic survey conducted as part of this review agreed that the Australian Government should continue to provide support to enable locum relief to rural GPs (see Attachments 5, 6 & 7). They particularly noted the role of the NRLP in supporting rural clinicians to take personal and professional leave, to address the costs of locum relief and, as a consequence, to aid in retention of the rural medical workforce.

Respondents to the survey identified a range of personal benefits of using a locum service. Of most significance was the opportunity to obtain a break from work — to prevent burnout, spend time with family, and have a holiday:

  • ‘Finally able to get a holiday with the family, would not have lasted much longer without.’
  • ‘Ability to get away with family and have a break.’
  • ‘Provided much needed relief.’

Other benefits identified by respondents included:

  • subsidised costs making a break more affordable
    • ‘A break without huge financial cost.’
    • ‘Access to the rebate to assist with expenses’
  • ability to reduce pressures of workload on themselves or colleagues
    • ‘Sharing of workload.’
    • ‘Helps colleagues cope in my absence.’
    • ‘Don’t have a mountain of work on my return.’:
  • peace of mind while away
    • ‘Ability to be able to leave town and not worry about practice and hospital.’
    • ‘Peace of mind while on maternity leave.’
  • the opportunity for education or professional development
    • ‘Chance to get refreshed in education …’
    • ‘Allowed me to travel to go to an overseas meeting.’
  • continuity of service to patients
    • ‘Ability to keep practice running while away.’
    • ‘I didn't have to shut up shop.’

SOLS

There has been strong stakeholder feedback on the continued need for SOLS. There are many case examples provided where, without the scheme, obstetricians would either not have taken leave or would have had to close services, resulting in women travelling considerable distances to access services. Given the reasonably good uptake of SOLS, the consequences of not continuing the scheme would be felt across up to one quarter of the rural medical obstetric workforce.

RANZCOG’s evaluation report of August 2009 notes that SOLS directly assisted in the prevention of transfer to a more distant medical centre for at least 224 rural women during the absence of their regular obstetrician, enabling rural women to remain close to family and community support.

Based on transfer costs of between $4,000 and $5,000, this represented a health service saving of approximately $1,000,000. This does not take into account other economic costs such as those incurred by the women or their significant others, or the potential quality and safety gains of not having to travel whilst in the later stages of pregnancy or, in fact, in labour.

GPALS

The final report on GPALS from ASA noted that during the period of operation, GPALS locums undertook a total of 381 anaesthesia cases. Of these, 305 were elective anaesthesia, and 76 were emergency and obstetric-related anaesthesia.

Due to the limited uptake of GPALS to date, there has not been strong stakeholder feedback on the continued need for GPALS as a program. When GPALS placements have taken place, there have certainly been benefits to the host in terms of enabling access to leave and subsidy relief and to the local rural community by providing continuity for local health services.

Overall, however, the consequences of not continuing the scheme would be small. These would largely relate to not meeting the expectations of those few who know about the scheme and intend to use it in the future. In addition there may be some reputational risk to the Department in appearing not to specifically support this sector of rural medicine.

RGPLP

The RGPLP has been successful in terms of uptake of the program, providing 141 placements in the July to December 2010 period and exceeding their whole year targets. While these placements constitute a very small percentage of the overall GP workforce in RA 2 to 5 locations (3.1%) to date, the program has the potential to increase its reach over time.

The benefits of providing affordable locum relief to GPs are not easily measured but it is known to be a factor in aiding rural workforce retention. Discontinuation of the program may impact on the retention of GPs in rural practice and possibly disrupt the provision of health services to rural communities.

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Demand for the NRLP

Demand for GPALS and SOLS

Data from the Rural Procedural Grants Program show that 253 GPAs, 313 GP obstetricians, and 292 GPAs/GP obstetricians accessed grant money to support training in these procedural areas in 2009–2010. This is many more than the numbers that accessed SOLS and GPALS to take leave for the purpose of undertaking continuing professional development .

However, SOLS and GPALS were not established to meet all locum needs of rural GP obstetricians or anaesthetists — rather, to address the gap thought to exist in preventing some from taking much-needed leave. This gap has never been accurately quantified. Current target placements for both SOLS and GPALS (as a percentage of estimated eligible practitioners) are 24% for rural specialist obstetricians, 4.3% for GPs with obstetrics specialty and 10.3% for GPs with an anaesthetic speciality. 8 These crude percentages of coverage would suggest that for both SOLS and GPALS the targets set are only addressing a small fraction of overall potential need.

Specialist Obstetricians

The demand for locum support for specialist obstetricians is strong and consistent. The highest demand is from RA 2 services with 71% of specialist placements since July 2009 occurring in this category.

The demand is stronger from the public sector with an average of 62% of all specialist placements occurring in hospitals. The demand for specialist placements has been stronger from Victoria over the life of the program, accounting for 35% of all placements.

GP Obstetricians

The demand for GP obstetrician locums is also growing steadily since the inception of the GP obstetrician component of the program in July 2008. There is a trend for more frequent placements of shorter duration.

As with the specialists, the demand for locums is stronger from the public sector with an average of 54% occurring wholly within public placements and a further 32% occurring in a combined public/private placement. Only 14% occurred wholly within private practice.

The demand for GP obstetricians has been stronger in RA 3 with 48% of placements since July 2009 occurring in this category. Demand was also strong in RA 2 with a total of 38% of placements.

The jurisdiction with the highest number of placements is Queensland, which accounts for 44% of all GP obstetrician placements since July 2008, followed by Victoria with 25% and South Australia with 7%. NSW accounted for only 6% of all GP obstetrician placements and there were none in Tasmania.

GP Anaesthetists

The feasibility study undertaken by the ASA indicated a need for this program. Despite this identified need, GPALS has fallen significantly short of the target placement days as of 31 December 2010 providing only 133 placement days out of 500 available. A further 227 days requested were unable to be met which still indicates demand for the program is relatively low.

GPALS data shows that demand for rural anaesthesia locums is predominantly from public hospitals and that during the life of the program under ASA, NSW and SA were the highest users of the program. Of the 18 successful placements, 9 were in RA 2 and 7 in RA 3.

Demand for proceduralists with multiple specialities

The unmet need for GP proceduralists with multiple specialties is even less clear. From the Medical Practice in Rural and Remote Australia: National Minimum Data Set 30 November 2009, it is known that at least 337 GPs have two or more specialties. None of the three programs within the NRLP cater well to this target group. Anecdotal feedback from stakeholders indicate that periods of leave for multi-proceduralists are managed as follows:

  • by other GPs within the practice or community, as generally these proceduralists practise in larger towns
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Demand for the NRLP

  • by hospitals, as these procedures are primarily undertaken in hospitals therefore periods of leave are managed (particularly for surgical and anaesthetics specialties) through re-scheduling and the employment of specialty locums. It is rare that a GP with multiple procedural specialties would be replaced by a locum with the same skills. In most instances the obstetrics component of multi-disciplinary GP placement is prioritised for locum replacement.

The need to support GP proceduralists is important not only in order to provide appropriate health services close to home for the rural community. The diversity and challenge of procedural medicine is shown by research to be central to attraction and retention in rural practice, and evidence suggests a strong link between the cessation of procedural services and the decision to stay or leave rural practice altogether. 9

There are many factors which influence the number of GP proceduralists available to practise in rural and remote communities; however the provision of support for the maintenance of work/life balance and to attend education through locum availability and financial subsidy are considered key issues. 10

Demand for RGPLP

Similarly, the RGPLP provides support where other locum programs are unable to meet the need. Demand for the RGPLP is strong and will continue to grow as awareness of the program improves.

Clearly, an unmet need for the provision of GP locum services is emerging. Despite the various other subsidised locum schemes and the commercial agencies available, the demand for the RGPLP has been strong and 49 requests for placement remained unfilled largely due to the inability of the RWAs to supply a locum at the time or location requested. Other contributing factors leading to the unmet placements included hosts cancelling the placement or amending the placement dates.

According to the National Minimum Data Set 2009, the number of practitioners in RA 2 to 5 locations, excluding proceduralists, is 3697. This is potentially the number of GPs eligible for the RGPLP subsidy. Of the total number of practitioners, 556 or 12.1% are solo GP practices, which are arguably the population that will most benefit from this program. However it is important to note that over 462 of these solo GP practices are in RRMA 4 and 5 areas, so this does not necessarily mean that they are solo GP practice towns.

Currently, the RWAs prioritise the demand for the program to solo GP practices, solo practice towns and towns with 3 GPs or less. It is clear that a further prioritisation process will need to be considered in order to manage the demand for the program or consideration will need to be given to the expansion of the program.

Length of leave required

In relation to the amount of leave that rural and remote GPs wish to take, the data set report indicates that, on average, GPs take approximately 4.5 weeks of leave per year compared to the average of 6.1 weeks of leave per year that they wish to take. There is a wide variation in this data with some GPs reporting they have taken as little as 0.5 week leave per year and others 10 weeks per year.

There are other factors to be taken into consideration in looking at leave data. Many of these GPs have significant ‘on call’ requirements with an average of 8.1 hours per week worked ‘on call’ and an average of 54.6 hours per week available ‘on call’. Again there is wide variation in these figures, with some GPs working 40 hours per week ‘on call’ and available up to 168 hours per week ‘on call’. It is reasonable to conclude that GPs working and available for significant periods of ‘on call’ would require more leave in order to maintain some work–life balance.

Another factor to be taken into consideration when determining priorities and appropriate leave levels is the workload of practitioners. For those GPs working full time it may be appropriate to prioritise locum support and/or to offer more leave. The data shows that 2724 or 77.3% of the GPs who provided information to the National Minimum Data Set 2009, self-reported working more than 35 hours per week. 11 The average number of self reported GP hours worked (including travel, teaching, training and hospital hours) is 43.49 per week.

The NRLP provides for 14 days of subsidised leave relief per year. However, the average length of placement for the SOLS program (including subsidised and unsubsidised days) is approximately 9 days per placement. There is a tendency towards more frequent placements of shorter duration. Since July 2009, 69% of all placements for specialist obstetricians have been for 1–7 days due to the preference of hosts for shorter placements.

Similarly, the average placement duration for RGPLP is 8 days, despite the 14 days being available to hosts. However, it is known that some RWAs allow placements of shorter duration in order to spread the finite resources of the program more widely. Offering less than 14 days of subsidised leave may not be an appropriate strategy to try to manage demand, particularly in more remote locations. Hosts, particularly those from more remote communities, require an adequate block of leave in order to maximise the benefits of the leave period.

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Appropriateness of SOLS, GPALS and RGPLP as the subsidy provider

There are mixed views regarding the appropriateness of the NRLP subsidies being administered through the selected organisations.

Some stakeholders consulted during this review outside of RANZCOG, ASA and RHWA have noted that the structure of the schemes may restrict access to the subsidies. This is because of its availability only through SOLS, GPALS and RGPLP, despite the high number of locums being placed through other providers, including commercial locum schemes. This may become an issue if the NRLP schemes are unable to supply a locum and the host is forced to procure a locum through another source, and yet is unable to access the subsidy. It must be noted that all three programs will provide the subsidies if the host arranges the locum themselves and registers them with the NRLP schemes. So although this requirement does allow wider access to the subsidies, it does provide a barrier in that:

  • hosts may not be aware they are able to refer their potential locum to the individual program so that they are able to access the subsidy
  • it involves more paperwork for the potential locum in terms of registering with the NRLP scheme. The amount of paperwork required was a factor which was highlighted in the survey as a potential barrier for both hosts and locums

In 2009–10, SOLS was unable to fill 21 specialist and 11 GP obstetrician requests for placement. GPALS was unable to fill 11 requests during the life of the program and RGPLP could not fill 49 requests from eligible GPs during the period July to December 2010.

For SOLS and GPALS, this is largely due to the program’s inability to provide a suitable locum to fill a particular need at a particular time (such as a placement in a private practice requiring the locum to have private medical indemnity insurance). For RGPLP, access is more likely to be limited by its finite funding which, due to demand, resulted in the program being fully subscribed both in 2009-10 and 2010-11.

An alternative method should be considered to ensure that the subsidies are readily accessible to those hosts who have the greatest need for subsidised locum relief, regardless of how they source their locum.

In relation to RGPLP, the Communio survey found that there is some level of confusion among GPs as to what programs and levels of subsidies are available to them, and how to go about accessing these subsidies. There are many other locum service providers in the marketplace in addition to the RWAs (who themselves each run several different locum programs depending on the source of the funding). Other providers include commercial locum agencies and locums provided through Divisions of General Practice. There are also locums who are sourced through private arrangements and networks.

Stakeholders suggested that a more streamlined approach is required to simplify access to the subsidies for GPs.

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Appropriateness of SOLS, GPALS and RGPLP as the locum provider

There are also mixed views in relation to the appropriateness of the NRLP schemes as locum providers. RANZCOG, for example, has had reasonable levels of uptake and engagement amongst its members for SOLS, particularly specialist obstetricians. SOLS users note the increased comfort they have observed in using a locum system backed by their professional college, however in reality RANZCOG provides no additional vetting of quality to that of other locum providers.

There is a raft of Australian Government funded programs and subsidies available for rural and remote medical practitioners aimed at supporting workforce strategies or quality of practice. Knowing which initiative applies to whom requires considerable research, albeit through central information access points such as www.doctorconnect.gov.au

The NRLP has potentially increased fragmentation and market confusion in the already crowded medical workforce support environment with the introduction of three new schemes and two new administering agencies.

A Google search of Australian Medical Locum results in 109,000 listings and restricting that further to Australian Rural Medical Locum results in 14,000 listings. Australian Rural Anaesthetic Locum results in 55,000 listings. However, it should be noted that GPALS is the first listed. Similarly, a Google search of Australian Rural Obstetric Locum results in 426,000 listings, with SOLS as the first listed.

For potential locums, there are a number of benefits to using a private organisation rather than SOLS, GPALS or RGPLP. Many private organisations provide real-time online job listings with 24 hour consultants to help in arranging accommodation, travel, insurance and registration, and assist with completion of paperwork. Although it should be noted that the NRLP also provides assistance in these areas.

There appear to be fewer benefits for hosts in choosing private organisations. The most obvious drawback is that these organisations do not offer subsidies, so the cost of a hiring a locum is substantially higher. In addition, many private organisations charge hosts a percentage on top of total locum earnings.

Unless those arranging locums are clear about the specific advantages provided by the NRLP, then there would be no reason for them to search out these providers over and above the locum providers they may have used in the past.

The advantage of the NRLP being administered by the selected organisations is that, for SOLS at least, they are consolidating and building a supply of locums in what is a very small minority group in the overall scheme of locum supply. A fragmented supply of locums, particularly for rural GP obstetricians and anaesthetists, would mean that hosts may find it difficult to source an appropriately skilled locum from the multitude of locum providers in the market.

SOLS has proven that it has established a suitable supply of locums from which to draw and that it can mostly meet the requests from hosts.

GPALS has not managed to establish either sufficient demand from hosts or supply of locums to make the scheme viable. Given the GPALS experience, it is unlikely that any specialised locum scheme in the future will be able to improve on this due to the very small pool of potential locums. A different model should be considered for GPALS.

RGPLP has an adequate supply of locums, although this is mostly attributable to already established locum programs and locum supply in the RWAs. Increasing the supply of locums should be a focus of the program going forward.

Over 80 respondents to the Communio survey expressed no preference or were unsure whether any locum service provider was better placed than any other to provide services.

Sixteen respondents (10%) nominated private agencies as their preferred choice for their flexibility and ability to negotiate remuneration rates on behalf of the locum.

Rural Workforce Agencies were also nominated by some as being best placed to ensure scarce allocation of resources goes where most needed.

The concept of a centralised agency had appeal for a further 5% of respondents:

  • ‘It would be a lot easier for practices if there was one contact that can help with our locum needs rather than having a lot of different options and spending a lot of time dealing with multiple agencies.’
  • ‘They should all be rolled into one service that can be contacted. Why have multiple services? Just duplication again. Very frustrating to get the run around all the time.’

Some respondents, however, noted the value of local knowledge:

  • ‘Agencies that have good regional knowledge could provide a better service than one nationally based agency.’
  • ‘There is a place for some centralisation, but local knowledge application of locums is essential to ensure a good alignment of locums and locations

In summary, stakeholder feedback has indicated that the administering agency of a locum program should have a close relationship with the rural medical workforce and understand their needs. Bodies nominated as possessing these qualities include the RWAs, Divisions of General Practice, ACRRM and some commercial locum agencies.

Stakeholders also expressed the need for the administering agency to be able to tap into a supply of locums, but not necessarily own the locum supply. To effect this, a national approach is needed, with effective database management plus good relationships and networks between state and territory RWAs, Divisions of General Practice and medical colleges and associations.

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Appropriateness of the subsidy level

Data provided from hosts, the administering bodies and private locum providers would suggest that the cost burden of sourcing a locum is indeed high. In addition to the direct costs of securing a locum (travel, accommodation, daily rates) the host also bears the costs of the locum’s usually reduced capacity to bill during their locum placement. This is a result of a combination of potentially reduced scope of practice and being an ‘unknown quantity’ in the local setting.

Additionally, if the locum is sourced through a commercial agency, the practitioner will also have to pay an agency fee, the current market rate of which is, on average, 15% of the locum fee.12

The subsidy for the NRLP is set at approximately half the market rate for the relevant locum type for up to 14 days per year. The subsidies were intended to provide a cost offset for hosts and were never intended to try to cover the full cost of employing a locum. Anecdotal evidence would also suggest that the market costs for locums are rising, particularly being driven by the impact of the so called ‘mining states’ which are paying a premium to ensure they have adequate medical cover in their mining towns.13

Three quarters (75%) of survey respondents identified the subsidy payment as being important or very important in using SOLS, GPALS or RGPLP and over 90% rated the travel allowance as important.

Stakeholder feedback, including the survey found that there was recognition that the NRLP subsidies did not cover the entire costs to hosts of employing locum relief, but that the subsidies were nevertheless a welcome offset.

For all three programs, the amount of travel allowance for the locum was considered inadequate by stakeholders and an increase was recommended to cover the full amount of time taken to travel to and from the host location. This was particularly in relation to the more remote locations which require significant travel time.

Consultation has also revealed that the level of subsidy is of considerable less importance to hospitals than for private practitioners. The ability to access a locum is the primary incentive for hospitals to access the schemes whereas, for private practitioners, the availability of subsidies is of high importance.

In recognition of this, and in order to ensure the subsidies are delivered to the hosts who are most in need of the financial support, some stakeholders have suggested that consideration could be given to limiting access to subsidies to private practitioners only. Under this proposal, hospitals would be able to access locums through the scheme, but not the subsidies. This would enable the funds of the NRLP to be spread more widely across the GP sector.

The potential disadvantage to this model is mostly to SOLS, where 62% of all specialist placements and 54% of all GP obstetrician placements are within the public sector due to the high cost of private medical indemnity insurance required for private practice placements. Any disengagement of the hospital sector may affect the overall demand for the program and the supply of locums.

The appropriateness of capping the subsidies at 14 days was examined during this review. In the SOLS 2008-2009 Evaluation Report, it was noted that locations with more than one obstetrician generally underuse their eligible subsidised days as they can often access locum support from within their location. However, locations with only one obstetrician tended to use more than the 14 days support. This was particularly true for locations with only one GP obstetrician. This highlights the possibility that sole practitioners may require more subsidised days than those from larger practices or larger hospitals with multiple obstetricians.

The data for SOLS in 2009-10 showed 34 unsubsidised days in RA 4 and 5 locations which accounted for 18% of all unsubsidised days. These were mostly for GP obstetrician locums. 2010-11 data shows only 2 unsubsidised days for GP obstetricians in RA 4 and 5 locations year to date. There is no discrete data available to identify locations with only one obstetrician.

Given there is no obvious trend towards a need for RA 4 and 5 locations to have more subsidy days available, it would be reasonable to leave SOLS Management Group to provide discretionary extended support on a case by case basis.

There were no calls to increase the number of subsidised days available per year for GPALS.

Some of the state-based subsidised GP locum programs provide up to 8 weeks of subsidised locum relief per year. The higher number of weeks is generally in recognition of the extensive ‘on call’ requirements of solo practice towns and GPs who provide VMO services to local hospitals.

Given the limited resources of the RGPLP to meet the demand, stakeholders consider that capping the subsidies on a sliding scale depending on the circumstances of the GP will provide more adequate support to those GPs most in need of subsidy assistance.

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Appropriateness of the target placement and days

Targets have been set for the NRLP programs based on a range of factors including perceived need and available budget. Targets were set and agreed for both number of days and number of placements and have been renegotiated for SOLS and GPALS based on emerging trends.

During 2009-10, GPALS did not achieve the targets for placements and subsidised days, while SOLS exceeded placement targets, but did not meet the targets for subsidised days. SOLS is tracking well to meet its targets for 2010-11. RGPLP exceeded its target placements for 2010-11 in the first six months of the year and will certainly achieve its target number of days.

Whilst not formally set as an indicator, levels of satisfaction in the conduct of the programs have been high for all schemes (albeit on limited numbers for ASA).

Data suggests that SOLS is achieving approximately 25% reach of its specialist target group but less than 10% of GP obstetricians and 4.3% of all GPs with an obstetrics specialty (ie multi proceduralists). Therefore based on these crude figures, there is the potential for approximately 360 specialist placement requests per year and 260 GP obstetrician placement requests per year. However, given that SOLS is currently mostly meeting the demand and is steadily building a locum supply to meet that demand, there is no case to support any changes to target placements and days, however GP obstetricians in RA 4 and 5 locations (RRMA 6 and 7) should be particularly targeted as practitioners most in need of support.

It is difficult to quantify true demand for locum services for both GPA and specialist anaesthetists in rural and regional Australia. As many GPAs also carry a generalist GP load, it is unclear how many of these would require their anaesthetic component relieved as opposed to their generalist component, or both.

GPALS targets were set at 16 placements for 2009-10 and 45 placements for 2010-11. There is a total of 438 GPAs practising in RA 2 to 5. Of these, approximately 88 could be prioritised as solo GPA practices or in solo GPA towns, which should be the target group for subsidy and locum relief.

Therefore, the target of 45 placements for the period July 2010 to June 2011 appears reasonable yet the program fell well short of this. The challenge for GPALS in the future is to facilitate access to the program for those prioritised GPAs.

There are two aspects to be considered in relation to the appropriateness of the target placements and days for the RGPLP. Firstly, it assesses the appropriateness of overall targets set between DoHA and RHWA for the RGPLP and secondly it assesses the appropriateness of the targets for each state/territory as agreed between RHWA and the RWAs.

The initial targets set for placements and subsidised days for RGPLP appear reasonable for the early stages of a new program. RHWA has met these targets and it is clear that demand is increasing steadily as the program becomes more widely known. The RGPLP is at a critical point where a decision must be made either to expand the program with commensurate funding or maintain the current targets through more focused eligibility criteria.

The target placements and subsidised days subsequently set by RHWA for the RWAs have also been examined. It is appreciated that there was an initial need to allocate a base level of targets for each state and the Northern Territory in order to engage these areas in the program. However, for the next funding period it would be suggested that a more targeted approach be taken in order to ensure that the GPs most in need receive locum and subsidy relief. This will not necessarily be distributed equitably throughout the states and Territory as each of them have varying levels of:

  • state government support and
  • numbers of GPs who are solo or solo practice town, and
  • rurality and remoteness.

All of these factors should be taken into consideration when determining targets for the RWAs in the future.

As stated previously, there are potentially 3697 GPs currently eligible for the RGPLP subsidy. In the six month period to 31 December 2010, RGPLP facilitated 141 placements. This equates to less than 4% of eligible GPs. Clearly, as awareness of the program grows there will need to be further prioritisation around access to the subsidies to ensure the GPs most in need of subsidy and locum support can access the scheme, or an increase in funding levels. The current method of prioritising solo GP practices, solo GP practice towns and those towns with three or less GPs for RGPLP is reasonable. Depending on funding available for the scheme, there may be a further need to exclude those in RA 2 locations unless they meet the above criteria and to exclude those who already access other locum subsidy relief. There are currently 2662 practitioners (including proceduralists) in RA 2.

Finally, it must also be noted that the NRLP is just one of a number of subsidised locum schemes available and there is no expectation that it must meet all the demand. Rather it should be available to assist hosts who are unable to access subsidised locum relief through other programs.

Appropriateness of GPALS guidelines and criteria

This review found that there were some particular issues in relation to program guidelines and criteria which impacted on GPALS.

Host eligibility criteria

In November 2010, ASA undertook a limited survey of rural and remote public hospitals across Australia to determine workforce trends in respect of demand for permanent staff and locums for both GPAs and specialist anaesthetists14. The report found that one third of rural/remote hospitals report a high frequency of difficulty in meeting required staffing levels, for both GPAs and specialist anaesthetists. Overall, the geographical region that consistently experiences a high frequency of difficulty in locating anaesthesia staff is RA 3. As such, the demand for locums strongly relates to maintaining staffing levels as much as it might relate to relieving practitioners for purposes of professional and personal leave. The report concluded that in respect to temporary staffing, interchangeability exists for some positions between specialist anaesthetist and GPAs, which reinforces that there is a market for specialist anaesthetist locums in rural and remote hospitals.

Under the GPALS model, specialist anaesthetists are ineligible as hosts. However, a specialist anaesthetist can be used as a locum to provide anaesthetic services to a rural hospital if the doctor being replaced is a GPA.

The ASA have stated that increasing host eligibility to include specialist anaesthetists would increase equity of access to health care for rural communities by maintaining their access to local anaesthesia, obstetric and emergency services and that this would reduce costs associated with transfer of patients to regional hospitals.

Locum Eligibility Criteria

The current policy that a GPALS locum must be Joint Consultative Committee on Anaesthesia (JCCA) accredited, reduces the number of GPAs who can participate as locums. Although there is no data available to determine how many JCCA-accredited GPAs are currently practising in Australia, it is known that it is a very small number which also means that there is a very small pool of potential locums. In addition these potential locums are most likely located in rural areas, as the use of the GPAs in metropolitan areas is declining. These potential locums then are more likely to require locum relief than be able to supply it.

The ASA state that consideration should be given to expanding the locum eligibility criteria by basing it not on JCCA accreditation, but on the amount and type of clinical experience, which is measurable as all GPAs keep record books of all their anaesthesia related procedures.

The Nomenclature “GPALS”

The ASA maintain that the name GPALS is likely to reduce the participation of specialist anaesthetists in the scheme because they may not associate their professional identity with the name GP Anaesthetist’s Locum Service. Additionally, the name ‘GPALS’ may also preclude hospitals from applying to the program as it may be seen as only providing a locum service for GPs and not hospitals.

For this reason the ASA recommends changing the name to Rural Anaesthesia Locum Service or similar so that it relates to rural anaesthesia more holistically and may increase the likelihood of gaining the attention of, and take up by, specialist anaesthetists and hospitals.

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Appropriateness of NRLP Performance Indicators

The administering bodies contribute towards the assessment and measurement of a range of objectives. Many of these are process-related. Other than the targets no numerical performance indicator is set. Given the qualitative nature of the issues this is appropriate.

It will be difficult to determine the overall impact of the NRLP in the absence of quality national workforce data. The current data sets do not allow for any tracking of leave taken or unmet demand with respect to leave. Data on total uptake for locum services is also unknown given that much activity occurs through the private sector. Retention data is also not available on an individual practitioner level so it is difficult to determine the impact on retention for any of the users of the NRLP programs.

8. HWQ and NSW RDN, 2009, Medical practice in rural and remote Australia: Combined rural workforce agencies national minimum data set report as at 30th November 2009 and AMWAC, 2004, Specialist obstetrics and gynaecology workforce in Australia – an update 2003 - 2013, AMWAC Report.
9. Rural Workforce Agency Victoria, Future of the GP Proceduralist Workforce, Submission to Health Workforce Australia 2010.
10. ACRRM Research Projects, Barriers to the Maintenance of Procedural Skills in Rural and Remote Medicine, 2002.
11. The Australian Bureau of Statistics defines full time work as 35 hours per week or more.
12. Discussion Paper: Review of Stage 1 Final Report National Rural Locum Program, November 2010, Australian Society of Anaesthetists
13. Pers com, Dr Hamish Meldrum, Ochre Health July 2010.
14. Rural Hospital and Anaesthesia Workforce Survey Report, November 2010, Australian Society of Anaesthetists