This literature scan provides a brief overview of a number of key issues related to supporting rural medical practice. Specifically, it addresses:
- current strategies being employed internationally to support rural medical practice
- strategies employed to increase locum supply internationally and within Australia, including government subsidisation of rural locum services
- characteristics of rural medical locum services that are considered to be important.
The inequitable distribution of health workers in rural and remote areas is a global issue of relevance to both developed and developing countries. Approximately one half of the world’s population lives in rural areas, yet these people are served by only 24% of the world’s physicians (WHO, 2009).
This situation is more acute in some countries than others. In South Africa, for example, 46% of the population live in rural areas, while only 12% of doctors work there (Hamilton and Yau, 2004). In the United States, 20% of the population live in rural areas, while only 9% of registered physicians practice in these areas (WHO, 2010). In Canada, 2006 figures revealed that 24% of the population in lived in rural areas, with only 9.3% of the physician workforce represented (WHO, 2009).
In Australia, rural medical workforce issues are also a major health planning issue. In 1995, 27.7% of the Australian population lived in rural and remote areas, whereas 20% of primary care practitioners were located in these regions. The majority of these doctors were living and working in small coastal towns, making the scarcity of medical practice far more significant in the more remote regions of Queensland and Western Australia (AMWAC, 1996).
While the actual number of doctors practising in rural and remote areas of Australia has increased in the last decade, the number of doctors practising in metropolitan areas has also increased. Consequently the proportion of doctors in rural practice compared to urban practice remains essentially the same (National Health Performance Committee, 2004).
Various strategies have been employed both internationally and in Australia to develop a more equitable balance of medical service provision. Many of these strategies are only now being evaluated, and some have not been in place long enough to show a significant impact.
One strategy aimed at supporting practitioners in rural locations is the establishment of programs to provide locum tenens or locums. These programs have been highly praised by those they serve. However, they have their own inherent challenges and barriers that impede their effectiveness. The most significant of these appears to be sufficient supply of general practice locums.
Some of the strategies identified in Australia and internationally to address this and other challenges are discussed below.
As discussed above, the inequitable distribution of health workers in rural and remote areas is more acute in some countries than others.
Given its status as a global issue, attraction and retention of doctors to rural and remote regions has been a focus of study and intervention internationally as well as in Australia. The World Health Organisation noted that strategies employed to address this situation essentially focus on two interwoven aspects of the issue:
- the factors that influence individual choice to both move to rural areas and to leave them
- the extent to which health systems respond to those factors (WHO, 2009).
Interventions designed to encourage health professionals to choose to move to rural areas have been categorised by the World Health Organisation into three domains:
- financial incentives
- management support programs.
Education interventions include targeted admission of students from rural backgrounds, recruitment from and training in rural areas, specific training in rural medicine and compulsory service requirements. This latter strategy has been highly successful in Japan, for example, where Jichi Medical University runs a bonded rural service program whereby tuition fees are waived in return for up to six years of rural service. As a result of this program, the number of rural communities without access to at least one medical practitioner has been reduced by 73% (Matsumoto, et.al., 2002).
Financial incentives for rural service are also offered in many countries and include higher salaries for rural practice, access to loans for housing and vehicles, and access to special grants (WHO, 2009).
While financial incentives have been seen to be important, they are not necessarily found to be the most important factor in attracting and retaining doctors to rural practice. In addition to financial incentives, other management strategies are employed to provide support to doctors living and working in rural areas. These include improved living conditions, support for professional development opportunities and the provision of locum services to release individuals for holidays and further training. The Jichi Medical University for example, runs a locum service to supplement the bonded rural workforce described above (Inoue et.al., 2002).
Management support programs
The provision of locum services to support rural practice is one of the most successful strategies used globally. In addition to the Japanese example already discussed, the British Colombia Medical Association has a longstanding rural locum program and has increased the financial benefits for locums in the most remote regions to ensure continued supply (British Colombia Medical Association, 2009). The University of New Mexico Health Sciences Center and the East Carolina University School of Medicine also provide locum tenens services for practitioners in rural and underserviced regions (Association of American Medical Colleges,1999). Available evidence suggests that all of these Programs have been widely utilised and are considered highly effective by the practitioners using them.
While different operational structures appear to work in different environments, the common variable for an effective rural locum program appears to be adequate funding and institutional support.
Benefits of locum availability
Common beneficial outcomes of rural locum programs globally include:
- coverage for practitioners unable to pay for practice support in busy times
- coverage during vacations or while attending further education
- training in rural practice for the locums
- recruitment of physicians to rural practice sites (Inoue et.al., 2002; Association of American Medical Colleges, 1999).
Factors impacting on locum availability
While it is generally agreed that the provision of locum services to rural practice in some form is a highly effective strategy in retaining permanent practitioners in these areas, one of the major challenges — as identified above — is in providing consistent supply of locums.
International studies have explored the reasons why medical graduates choose to enter locum activity, and why they choose to leave. A study carried out by the University of Calgary and the University of Alberta between 2001 and 2005 found that the average period of locum practice was nine months. The main reason given by graduates for taking on the work was the pursuit of varied experiences, while the main reason for leaving this type of work was the desire to settle into a permanent practice. The positive outcome highlighted by this study is that 45% of the participants joined practices where they had done locum work, and so contributed to the permanent rural medical workforce (Myhre and Konkin et.al., 2010).Top of page
The Australian context
The rural medical workforce remains a major challenge for policy makers in Australia. In 1995, the Australian Medical Association (AMA) identified the challenge of attracting and retaining an adequate supply of medical practitioners to rural and remote Australia as the single most important medical workforce issue (AMA,1995). The challenge remains current in 2011.
The problem is particularly acute in very remote areas of Australia which have the highest proportion of health staff vacancies, including physicians, in the country (National Health Performance Committee, 2004). This is accentuated by the fact that the majority of the population in these very remote areas are Aboriginal Australians who also suffer the highest disease rates and have the greatest need of medical care.
Bukyx et al (2010) note a range of factors contributing to the rural medical workforce shortage in Australia, including:
- inadequate workforce policies guiding the number of doctors in training
- changing patterns of employment of doctors as new graduates seek better work-life balance
- more female doctors in medical training
- rationalisation of rural health services and changes in the nature of rural practice
- increased doctor mobility and decline in hours worked.
Other factors identified as disincentives to rural medical practice include lack of exposure to the rural lifestyle; limited exposure in medical schools to rural medicine; fear of professional isolation; lack of access to continuing education opportunities and a greater workload with less opportunities for time off (AMWAC, 1996).
Rural and remote GPs in Australia are usually required to manage a wide range of complex cases with limited access to specialist services for referral. As a result rural GPs often work longer hours and require a broader range of skills than urban doctors (Britt et.al., 1993). McGrail et al (2010) note that this aspect of rural practice is often the basis of negative ‘marketing’ with ‘many reports and research studies highlighting overworked, under-remunerated and undervalued rural doctors struggling to deal with sicker patients in communities characterised by chronic workforce shortages’.
Government strategies addressing attraction and retention
The costs of poor workforce retention and high turnover are significant, including restricted community access to appropriate care and loss of skills and experience, compromising continuity and quality of care and resulting in high recruitment costs (Humphreys et al, 2009).
Australian Commonwealth and state governments have introduced a range of recruitment strategies and retention incentives over the past two decades to encourage more permanent doctors in rural general practice. These initiatives reflect global programs and include the provision of equipment, opportunities for continuing education, training and remote area grants, relocation assistance and locum support (Holub and Williams, 1996).
Specific examples include programs such as:
- the General Practice Rural Incentives Program
- Scaling of rural workforce programs, such as the Medical Rural Bonded Scholarship Scheme, the Bonded Medical Places Scheme and the HECS Reimbursement Scheme
- Rural Procedural Grants Program.
In their recent review of the effectiveness of retention incentives for health workers in rural and remote areas, Bukyx et al (2010) note that there is little evidence so far to show the effectiveness of any single retention strategy in making a significant difference to the medical workforce supply in underserved areas. They point out that, although provision of a financial incentive is the most commonly implemented retention strategy, evidence suggests that non financial incentives related to working and housing conditions have greater potential to influence decision-making about length of stay than financial considerations. This is consistent with the view of Humphreys et al (2002) who noted, some years previously, that factors affecting retention and turnover fall into three broad categories: professional issues, social factors relating to personal characteristics and the family, and external factors relating to the community and its geographical location.
For this reason, Bukyx et al (2010) propose a framework that ‘bundles’ retention incentives, identifying six key components that should be included in any comprehensive retention strategy. These are:
- maintaining adequate and stable staffing
- providing appropriate and adequate infrastructure
- maintaining realistic and competitive remuneration
- fostering an effective and sustainable workplace organisation
- shaping a professional environment that recognises and rewards individuals making a significant contribution to patient care
- ensuring social, family and community support.
Humphreys et al (2009) provide a number of examples of ‘bundled’ retention strategies, including:
- A hospital in rural Victoria trying to attract and retain psychiatrists reorganised workloads, altered rostering to better meet the needs of staff, and introduced an orientation program incorporating cultural training for international medical graduates.
- The establishment of a network of university-linked family practices in South Australia. Retention strategies aimed at professional development included support for higher degrees, conference attendance and teaching commitments, and sessional and academic appointments. The network also attempted to overcome organisational barriers to retention by providing infrastructure support for general and ICT facilities; while leave and locum support were also incorporated into the program.
At the same time, however, Bukyx et al (2010) note that there is evidence to show that financial incentives might assist with short-term recruitment and retention. This finding may have implications for locum relief strategies.Top of page
Government strategies addressing rural locum availability
As discussed above in the international context, the availability of locum relief supports the retention of the rural workforce in a range of ways.
The Rural Health Workforce Strategy, as a result of the Rural Health Reform – Supporting Communities with Workforce Shortages budget measure, has seen a number of strategies introduced to strengthen rural workforce support through locum relief. These have included increasing the level of funding and reach for the National Rural Locum Program (NRLP). The NRLP comprises:
- Specialist Obstetrics Locum Scheme (SOLS)
The aim of the SOLS program is to maintain and improve the access of rural women to quality local obstetric care by providing the rural and remote obstetric workforce (both specialist and GP obstetrician) with efficient and cost-effective locum support. The program aims to sustain safety and quality in rural practice by facilitating access to personal leave, professional development or breaks from on-call commitments.
- General Practice Anaesthetist Locum Program (GPALS)
The aim of GPALS is to maintain and enhance the access of rural Australians to quality local GP anaesthetist care by providing the rural and remote GP anaesthetist workforce with efficient and cost-effective locum support. The program aims to sustain safety and quality in rural GP anaesthetist practice by facilitating access to personal leave for professional development or breaks from on-call commitments for rural and remote GP anaesthetists.
- Rural General Practitioner Locum Program (RGPLP)
The RGPLP is designed to provide support to rural GPs and improve rural workforce retention through the provision of locum services and subsidies to rural GPs to assist in meeting locum costs.
Characteristics of rural medical locum services that are considered to be important
The literature is clear that a locum-based strategy alone is not a sustainable long-term solution to address the challenges of rural health workforce attraction and retention (Humphreys et al 2009).
However, locum relief is recognised nationally and internally as an important component of a broader approach and set of strategies. Some of the factors identified as important in the provision of effective rural locum relief include:
- program guidelines that enable doctors to spend a ‘reasonable’ amount of time away from the practice (Humphreys et al 2002) for personal and professional rejuvenation
- program guidelines that support attractive financial incentives for short term recruitment and retention (Bukyx et al 2010)
- the possible development of regional medical practice models in appropriate rural settings so that the facility to cover after-hours and relieve pressure is built into the local practice staffing and organisation arrangements (Humphreys et al 2002)
- increasing the exposure of, particularly, new graduates to the rural lifestyle. Mills (1997) notes in his description of one community’s experience of recruiting a general practitioner: ‘Maybe new graduates could work with the resident GP in rural areas and be available to locum for him or her for short periods of time’
- promoting the ability to enjoy new and varied professional and personal experience (Myhre and Konkin et.al., 2010).
Factors impacting on locum availability
Factors impacting on locum availability in Australia reflect similar issues internationally.
Disincentives to rural medical practice include lack of exposure to the rural lifestyle; limited exposure in medical schools to rural medicine; fear of professional isolation; lack of access to continuing education opportunities and a greater workload with less opportunities for time off (AMWAC, 1996). Rural and remote GPs in Australia are usually required to manage a wide range of complex cases with limited access to specialist services for referral. As a result rural GPs often work long hours and require a broader range of skills than urban doctors (Britt et.al., 1993).
Attractions in rural practice have been reported to include variety of practice, lifestyle and the ability to provide continuity of care (Gill et.al.,1992; Strausser, 1992).
Many of these initiatives have not been evaluated and for some initiatives, such as recruitment of rural students into medical schools and increasing the curriculum time allocated to rural medicine, it will be another decade before the real implications can be properly assessed.Top of page
Current evidence appears to indicate that the provision of locums to rural practice is a well utilised and well received initiative. However, the direct impact this initiative has on retention of rural doctors remains unmeasured.
It seems apparent that the full range of strategies demonstrated in various countries globally is necessary to establish rural practice as a viable option for new medical graduates and to retain these rural doctors long term.
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