Effectiveness in improving locum supply
In order to provide a successful service, all three programs were required to establish an adequate locum supply as part of the overall aim to increase access to locum relief for rural hosts.
SOLS has been effective in building locum supply with a total of 157 locums currently registered. Despite this, in the 2009-10 period, SOLS was unable to fill 32 requests for locum placements and the data is tracking for similar levels in the 2010-11 period. One of the issues which impacts upon locum supply relates to private medical indemnity insurance. Only about 30% of SOLS locums have private medical indemnity insurance, therefore restricting their access to public patients only. This subsequently reduces the number of locums available to fill placements in private practice. SOLS has recently negotiated a special rate with an insurance company for SOLS locums which may, depending on uptake from SOLS locums, improve locum supply to private practice.
Another area where SOLS has difficulty in providing a locum service is for GP proceduralists with more than one specialty. It is known that of the total of 583 GP obstetricians, 322 of these also undertake other procedures in either anaesthetics and/or surgery. It is unlikely that potential hosts seeking a locum for a GP with multiple specialties would initially look to SOLS to fill the vacancy.
Overall GPALS has not been effective in improving locum supply. Of the 24 medical practitioners registered with GPALS for locum work, only 7 participated actively as a locum during the program.
The fundamental difference between SOLS and GPALS is that the SOLS model of providing subsidies to specialist obstetricians was not extended to GPALS, that is specialist anaesthetists are out of scope as hosts for the program. This difference was not considered to be a barrier during the GPALS feasibility study but was found to be a very significant barrier during ASA’s administration of the program. From the feasibility study it was anticipated that approximately 100 specialist anaesthetists would register as locums for GPALS. However, the anticipated participation in the scheme has not been borne out in registrations with only 4 practitioners with specialist qualifications registering with GPALS.
The ASA argue that expanding the GPALS scheme to cover specialists may increase the overall involvement of specialist anaesthetists in the program and may increased the likelihood of increasing locum supply. Conversely, however, potential locums who responded to the ASA survey in the feasibility study did not exhibit a strong desire to become a locum without an explicit requirement or inducement to do so. Therefore opening up GPALS to specialists may not necessarily increase the supply of locums, only the demand.
Additionally, increasing the supply of specialist locums may not necessarily meet the demand for GPA locums. There are a number of barriers to employing specialists in the GPA role. These include the following.
- Unlike SOLS, GPALS only offers one level of subsidy, so the cost to the host of employing a specialist locum could be much higher than a GPA locum. Although the ASA study found that rural hospitals were agreeable to employing specialist anaesthetists in place of GPAs it is unlikely that GPAs would employ specialist anaesthetists as locums due to the associated higher costs.
- There are difficulties in finding specialist anaesthetists who can match the clinical skills of the GPA and are prepared to undertake the GP component of the role. Additionally, the GPA may also be a multi-proceduralist who provides obstetric, surgical and emergency services.
The reality is that there may only ever be a small pool of GPA locums to draw from. The majority of GPAs work in the rural sector and are more likely to need locum relief than to be able to supply it.
Any strategy to increase locum supply must look to other sectors of the medical workforce to supply these locums. Options to increase locum supply include employing salaried locums with the skill set required, and expanding on the Rural LEAP model to include proceduralists such as anaesthetists.Top of page
RGPLP has had mixed success to date in relation to increasing locum supply, with some states and territories reporting success in registering new locums and others reporting minimal increased registration. Despite this, 56 new locums have been introduced as a result of the RGPLP in the second half of 2010.
The demand for the RGPLP has been strong. The 49 unfilled requests were largely due to the inability of the RWAs to supply a suitable locum at the time or location requested by the host. In other instances, the skills/needs of the locum and the needs of the host (on call, after hours, emergency skills etc) could not be matched, or the host had cancelled the placement or amended the placement dates.
One of the key success factors in the RWAs delivery of the program is that the RGPLP runs concurrently with other locum programs that the RWAs administer. This increases administrative efficiency and enables the efficient use of locums (often salaried) to interchange between the various locum programs.
The most important goal is that rural and remote GPs can access locum support, when they need it, at a reasonable cost. In the end, if this aim is achieved, how the locum is supplied is largely of little importance relative to the overall outcome achieved.
A key factor to be considered in the expansion of the RGPLP will be the continued availability of locums and strategies to address the locum supply. The overall supply of locum doctors needs to keep growing over time to match the strong demand from host GPs.
An overarching focus on locum supply is required without necessarily involving attachment of the locums to any one program. The Rural Locum Education Assistance Program (Rural LEAP) is an example of this strategy. Rural LEAP provides urban GPs with up to $6000 funding to access three days training in emergency medicine in exchange for four weeks of rural locum placement (ASGC-RA 2 to 5) within a two year period. A similar focus could be applied to the Rural Procedural Grants Program if the criteria were extended to allow practitioners from RA 1 locations to apply in return for a commitment to provide a rural locum placement.
Another strategy to increase the overall supply of locums in rural Australia could be to work with the specialty medical colleges to encourage/mandate Registrar placements in rural locations of highest need (particularly targeting GP Registrars in the third year of Fellowship of RACGP). It is known that nationally, Registrars comprise approximately 10.8% of the rural and remote medical workforce. 15
This would require some negotiation in order to ensure the supervision requirements were met and review of the eligibility criteria for locums with RGPLP.
Stakeholders have suggested that providing incentives for potential locums to participate in the NRLP could also improve locum supply. Suggested strategies include:
- Subsidised travel for spouses/partners
- Subsidised professional development – this could be scaled so that it provides more incentive for:
- remote locum placements or
- longer locums placements or
- more frequent locum placement per year.
Effectiveness in subsidising locum costs
The second aspect of the overall aim of providing locum relief to hosts when they need it and at a reasonable cost must be addressed.
It is critical that access to the subsidies is targeted and provided to those GPs most in need of subsidy and/or locum support.
SOLS is required to prioritise solo or small practices, however, given that the current demand is not exceeding the program targets it is unlikely that this prioritisation is required.
GPALS is required to provide placements on a ‘priority of needs basis’. Given the low demand for GPALS to date, a prioritisation process has not been required.
RGPLP is prioritising placements to solo GP practices, solo practice towns and towns with three or less GPs. Given the demand for RGPLP to date and the high likelihood that this demand will increase, further refinement of the eligibility criteria for RGPLP may be required in the future or an increase in funding levels for the program. Consultation has revealed that the availability of subsidies is of greater importance to private practitioners than to hospitals.
For these reasons, it can be argued that locum subsidies could be more effective and targeted if eligibility was limited to private practitioners. If this were the case, access to the subsidies should not be through specific locum providers but through the NRLP regardless of where the locum was sourced.
Effectiveness in achieving market penetration
Each of the three programs has undertaken an extensive marketing program. The survey undertaken as part of this review assessed the level of awareness of the NRLP.
The survey found that overall, a majority of respondents were aware of the existence of the three locum programs:
- SOLS (75.0% or 165/220 respondents)
- RGPLP (72.2% or 161/223 respondents)
- GPALS (62.0% or 132/213 respondents)
Similar proportions understood that the Australian Government funds SOLS, GPALS and RGPLP (76.5%) and that financial subsidies are available to offset the cost of locums through these programs (73.5%).
The three administering agencies are working together to learn from one another and share resources as appropriate. The creation of the NRLP web page (www.rurallocums.org.au) has created a single front end access point to web-based information for the programs. A review of relevant web sites identified that there is inconsistent reference or links to the NRLP programs in other stakeholder websites, as tabled in Attachment 2.
Effectiveness in meeting program objectives
By funding three administering agencies and providing subsidies for locum placements including travel assistance, the NRLP has assisted rural doctors to obtain time for rest and professional development.
However, the level of allocated budget, the limited reach achieved by these programs, and the multi-factorial nature of leave would suggest that this model of implementing the NRLP has only partially met the program’s overall objective of ensuring rural doctors are able to obtain adequate time for rest and professional development.