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

Overview of Programs

Page last updated: 04 July 2012

The NRLP

The NRLP is an element of the Rural Health Workforce Strategy and was developed to assist rural doctors to obtain locum relief for leave and professional development. The program provides relief to medical practitioners working in ASGC-RA 2 to 5, which ranges from ‘inner regional’ to ‘very remote Australia’. It contributes to the Australian Government’s overarching objective to provide Australians living in rural and remote areas with access to quality health professionals.

Each of the three programs comprising the NRLP is funded and administered separately. RANZCOG administers SOLS; the ASA administered GPALS up to 1 November 2010 (now currently administered by the Department of Health and Ageing); and Rural Health Workforce Australia (RHWA) administers the RGPLP.

SOLS overview

SOLS is administered by RANZCOG. It commenced as a pilot in 2006 and was used as a model for the subsequent NRLP schemes.

In 2004, the Rural Specialist Group of the Rural Doctors Association of Australia (RDAA) identified the shortage of obstetricians and lack of locum support and services in rural and remote Australia as a priority issue. At the same time, RANZCOG also noted that there was a ‘critical shortage of obstetricians in rural and remote Australia. Only 16% of the 1160 practising obstetricians reside and practice in rural Australia’ (AMWAC, 2004).

In addition to the shortage of obstetricians, the current rural workforce is ageing, with a median age of 56 years (Robson, Bland and Bunting, 2005). This leaves open the possibility that there will be continued and greater shortages, as older clinicians retire. The impact of a diminishing workforce on those who remain is extremely serious and will exacerbate what has already been described as a critical situation.

The inability of rural specialist and GP obstetricians to take personal leave and professional development leave underlines the vulnerability of current service provision and the very real disadvantages and risks faced by rural women in need of obstetric services.

In 2005, in collaboration with the New South Wales Rural Doctors Network (NSW RDN) and RANZCOG, the RDAA approached the Department of Health and Ageing (DoHA) for funding for a scoping study to investigate the establishment of a subsidised national locum scheme for specialist obstetricians practising in rural and remote areas.

The scoping study found there was a definite need to assist rural specialist obstetricians in obtaining affordable locum cover, in order to enable them to take much-needed study and recreation leave. It recommended that funds be made available for a pilot to trial a scheme based on its findings.

SOLS Pilot I ran from July 2006 to September 2007. It was followed by Pilot II which ran from October 2007 to September 2008. SOLS as a program commenced in October 2008 and is funded until 30 June 2011. In January 2009, SOLS was expanded to include GP obstetricians.

The aim of the SOLS program addresses the findings and outcomes of the scoping study and pilots described above. It aims 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.

SOLS supports clinicians working in rural and remote areas, defined as ASGC – RA 2 to 5. It operates by providing host doctors with subsidised support to offset the cost of obtaining a locum. Hosts are eligible for a maximum of 14 days of subsidised support per financial year, which can be taken as a block or a number of shorter placements. After this, hosts can use the SOLS program to connect with locums who will provide locum services, but no further subsidies are offered in that year.

Program outline

SOLS provides subsidies for locum costs, travel time and travel costs. In the most recent funding period, the subsidies offered were as follows:

CostInformationSubsidy (ex GST)
Specialists
Locum subsidySubsidy per day for maximum of 14 days per obstetrician per financial year
$1000
Locum travel timeMaximum per placement
$1000
Locum travel costsMaximum per placement
$2000
GP Obstetricians
SubsidySubsidy per day for maximum of 14 days per obstetrician per financial year
$750
Locum travel timeMaximum per placement
$750
Locum travel CostsMaximum per placement
$2000

Figure 1: Schedule of Subsidy for SOLS

Locum subsidies have been determined based on approximately 50% of the current market rate although it is acknowledged that locum rates vary and can be much higher at times.

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SOLS placements

Target placements and target days have been agreed for the SOLS program as below. The SOLS secretariat manages the program towards achieving these targets, keeping in mind the needs of the host while ensuring they stay within budget and within the guidelines of 14 days of subsidy payment per host per year. This may be taken over a number of placements.


Figure 2: SOLS targets versus actual placements and days for specialistsD

Figure 2: SOLS targets versus actual placements and days for specialists


Figure 3:  SOLS targets versus actual placements and days for GP ObstetriciansD

Figure 3: SOLS targets versus actual placements and days for GP Obstetricians

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Unsubsidised placements


Figure 4: No of unsubsidised days — SOLSD

Figure 4: No of unsubsidised days — SOLS

A number of placements included both subsidised and unsubsidised days, but there were few wholly unsubsidised placements. The unsubsidised days were spread across all RAs, and occurred in all states and the Northern Territory (NT). However, the highest demand for unsubsidised days has occurred in RA 2 and 3 and in terms of jurisdictions, from Victoria and Queensland.

The number of unsubsidised days may suggest that rural and remote clinicians desire more than the 14 subsidised days SOLS currently offers. However, even with the unsubsidised days included, the average placement length for specialist placements from July 2007 to December 2010 has remained relatively constant at 9.25 days.

SOLS placements by jurisdiction


Figure 5: % of overall SOLS placements by State/Territory Jul 06 to Dec 2010D

Figure 5: % of overall SOLS placements by State/Territory Jul 06 to Dec 2010

Figures 5 demonstrates the usage of SOLS by jurisdiction. Victoria has utilised the highest number of placements over the life of the program, accounting for 35% of all placements. This has become particularly pronounced for specialists since July 2009. The Queensland usage of both specialists and GP obstetricians has been consistent at 25%, while usage in NSW has fallen since July 2009.

The usage by South Australia, Western Australia, Tasmania and Northern Territory, although small, has remained relatively consistent over the life of the program.

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Placements by RA location

1 Jul 2009 – 30 June 2010
1 Jul – 31 Dec 2010
RASpecialist PlacementsGP PlacementsSpecialist PlacementsGP Placements
Total
% of Placements
2
56
10
41
8
125
71%
3
12
15
5
8
40
23%
4
4
1
0
1
6
3%
5
1
3
0
1
5
3%

Figure 6: Placements by RA location

The above table shows SOLS placements by RA category between 1 July 2009 and 31 December 2010. By far the largest percentage of specialist placements was in RA 2, however placements for GP obstetricians were spread between RA 2 and RA 3. Only a very small percentage of placements were in RA 4 and 5 locations.

Placement locations (towns)

The SOLS program is used across all jurisdictions and certain locations have used SOLS on multiple occasions. One of these locations has used SOLS on 20 occasions during the life of the program. There is no evidence to explain why some locations utilise SOLS often and other locations of similar size do not. Stakeholders suggest that influencing factors may be:

  • the higher number of specialists and GP obstetricians within the location
  • satisfaction with, and awareness of, the SOLS service
  • already established locum replacement arrangements including utilising others within their practice or location.
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Type of placement

Type of placement
2006/07 SOLS Stage 1
2007/08 SOLS Stage 2
2008/09 SOLS Program
2009/10 SOLS Program
1 Jul–31 Dec 2010
Spec
Spec
Spec GPO
Spec
GPO
Spec
GPO
Public
70%
77%
67%
94%
57%
52%
66%
22%
Private
16%
13%
31%
6%
35%
14%
21%
22%
Combined
14%
-
2%
-
8%
34%
13%
56%

Figure 7: Type of placement (public, private or combined)

This table confirms that there is a higher demand for SOLS for both specialists and GP obstetricians from public health services compared to that from private practices and that this has been a consistent trend over the life of the program

Length of placement

The average length of placements over the life of the program has remained relatively consistent. There are a higher number of short placements (1-3 days) especially for specialists. It is difficult to know if this is due to demand from hosts for shorter placements or if the availability of locums is influencing this pattern and hosts are accepting shorter placements because that is all that is available.

GPALS overview

GPALS was administered by the Australian Society of Anaesthetists (ASA) up until 1 November 2010, at which time it was transferred to the Department for interim management.

There is an identified skills shortage in rural anaesthetics.6 An integral part of maintaining rural and remote access to anaesthetics is to sustain existing services through appropriate locum support.

The number of GPAs remained steady during the first half of the preceding decade. The 2009 National Minimum Data Set Report indicates the total number of non-specialist practitioners undertaking anaesthetics has fallen from 488 in 2008, to 438 in 2009. However, this number has remained relatively steady since 2002 when it was 456.

Of the total 438 known GP anaesthetic practitioners, 248 of these also undertake other procedures in either obstetrics and/or surgery.7

During the early stages of scoping the feasibility of GPALS, the size of the pool of accredited GPAs was estimated to be 624, based on the number of GPA recipients who received a grant under the DoHA Training for Rural and Remote Procedural GPs Program (since then renamed to the Rural Procedural Grants Program (RPGP) during 2008–2009. This assumption has turned out to be incorrect as the RPGP does not require GPA participants to be accredited by the Joint Consultative Committee on Anaesthesia (JCCA) in order to participate in the program. Further enquiries have revealed that there is no data available to determine how many JCCA-accredited GPAs are currently practising in Australia.

According to the Australian Institute of Health and Welfare (AIHW) Labour Force Survey 2008, 3195 clinicians were working as specialist anaesthetists in Australia. However, the ASA note that there is a shortage of specialist anaesthetists in rural areas in relation to unfilled positions.

At the invitation of DoHA, the ASA undertook a study to determine the feasibility of establishing the GPALS program, based on the SOLS model. The review commenced on 8 August 2008 and was completed on 11 February 2009. The study found an overwhelming need for GPALS and recommended that DoHA fund the program at a rate of 100 locum days in year one and 200 in year two.

GPALS officially began on 8 September 2009 as an expansion of the SOLS model and its aims and objectives are in line with those of SOLS for specialist and GP obstetricians. That is, GPALS maintains and enhances 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.

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GPALS overview

As with SOLS, the program operates by providing host doctors with subsidised support to offset the cost of obtaining a locum. Unlike SOLS, however, GPALS provides support to GPAs through locums who can be either a GPA or a specialist anaesthetist.

Hosts are eligible for a maximum of 14 days of subsidised support per financial year, which can be taken as a block or a number of shorter placements. After this, hosts can use the GPALS program to connect with locums, but no further subsidies are offered. Priority is given to applications eligible for subsidised placements.

GPALS Program outline

GPALS provides subsidies for locum costs, travel time and travel costs. For the most recent funding period the subsidies offered are:

CostInformationSubsidy (ex. GST)
Locum SubsidySubsidy per day for a maximum of 14 days per GPA per financial year
$750
Locum Travel TimeMaximum per placement
$750
Locum Travel CostsMaximum per placement
$2000

Figure 8: Schedule of Subsidy for GPALS

Locum subsidies are approximately 50% of the current market rate for locums although locum charges can vary considerably. ASA did not charge an administration/application fee.

GPALS Placements

The ASA experienced difficulties in achieving uptake of GPALS. Initially the low numbers were thought to be a timing issue due to the program being launched in September when many of the rural anaesthetic workforce may have already arranged their locum relief. Despite this, the program continued to be challenged by the low uptake. The graph below demonstrates that actual placements and days have both fallen well below the program targets.


Figure 9: GPALS Target and Actual Placements and DaysD

Figure 9: GPALS Target and Actual Placements and Days

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Unsubsidised Placements

There were no wholly unsubsidised placements during the life of the program to date. However, there were 13 unsubsidised days where hosts requested locum relief beyond the 14 day limit on the subsidy.

Placement locations

State
RA
Total no of days
Vic
3
6
NSW
2
5
NSW
2
5
NSW
2
5
NSW
2
8
NSW
2
5
NSW
2
4
NSW
2
14
NSW
2
17
NSW
2
5
NSW
3
5
SA
3
14
SA
3
7
SA
3
5
SA
3
4
SA
3
5
NT
5
14
WA
4
21

Figure 10: GPALS Placement Locations

Of the 18 successful GPALS placements, there were only 10 separate locations. NSW and SA were the major users of the service.

Type of placement

During the GPALS operation, a total of 366 locum days were requested and 268 of those days were from public hospitals; however of these 268 days requested, only 57 days were able to be supplied.

Arrangement of locum

No of successful placementsLocum arranged by hostLocum arranged by GPALS
Hospital
8
6 (75%)
2 (25%)
GP Practice
9
3 (33%)
6 (66%)

Figure 11: Arrangement of locum

The above table demonstrates that of the small number of successful placements achieved by GPALS up to November 2010, only 8 of those locums were sourced and arranged by GPALS. The remaining number were found by the host and channelled through the program in order to access the subsidies.

Duration of placements


Figure 12: GPALS placements by duration (September 2009 to November 2010)D

Figure 12: GPALS placements by duration (September 2009 to November 2010)

RGPLP overview

The RGPLP is a component of the Rural Health Workforce Strategy and also forms part of the NRLP. The program 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. RHWA was commissioned in late 2009 to administer the program nationally and has subcontracted its partner Rural Workforce Agencies (RWAs) in each state and the Northern Territory to deliver the scheme. The RWAs are:

  • NSW Rural Doctors Network
  • Health Workforce Queensland
  • Health Recruitment Plus Tasmania
  • Rural Doctors Workforce Agency South Australia
  • Rural Health West Western Australia
  • General Practice Network Northern Territory
  • Rural Workforce Agency Victoria

This subcontracting arrangement between RHWA and the RWAs makes the administration of the RGPLP different to that of SOLS and GPALS which are directly administered by a national body.

RGPLP supports GPs working in rural and remote areas, defined as ASGC – RA 2 to 5. The program provides hosts with subsidised support to offset the cost of obtaining a locum. As with SOLS and GPALS, hosts are eligible for a maximum of 14 days of subsidised support per financial year, which can be taken as a block or a number of shorter placements. In addition, a further 14 unsubsidised days may be made available, subject to the availability of locums. Priority is given to subsidised locum placements.

RGPLP Overview

RHWA determines the allocation of targets for each of the RWAs from the total placements and subsidised days available. This determination involves more than an allocation per population base. It was recognised that it was important to allocate sufficient placements for the smaller states and the Northern Territory in order to provide an incentive to be involved in a national program. This determination based on allocation equity was also made more complex by the varying levels of assistance that is already provided by each state and territory government in accessing rural GP locums.

The states and Northern Territory are funded for the respective target placements plus 15% administration fee.

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RGPLP Program outline

RGPLP provides subsidies for locum costs, travel time and travel costs. The subsidies offered are:

CostInformationSubsidy (ex. GST)
Locum SubsidySubsidy per day per financial year, for a maximum of 14 days
$500
Locum Travel TimeMaximum per placement
$500
Locum Travel CostsMaximum per placement
$2000

Figure 13: Summary of RGPLP subsidies

RGPLP Placements


Figure 14: RGPLP target vs actual placements and subsidised daysD

Figure 14: RGPLP target vs actual placements and subsidised days

As can be seen from the above data, the number of RGPLP locum placements is high with the 2010/11 target placements being exceeded by 68% in the first six months of the year. The average length of placement is 7.6 days which has allowed many more GPs to access locum relief under the program.

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RGPLP Placements


Figure 15: Placements and subsidised days per state/territory Nov 2009 – Jun 2010 (Yr1) and Jul 2010 – Dec 2010 (Yr 2)D

Figure 15: Placements and subsidised days per state/territory Nov 2009 – Jun 2010 (Yr1) and Jul 2010 – Dec 2010 (Yr 2)

The data shows relatively steady uptake of the program across all states with the exception of Queensland and Western Australia, which both dramatically increased in Year 2 of the program. This may be due to some RWAs offering shorter placements to hosts in an effort to spread the RGPLP further. The data also shows relatively low uptake in South Australia which is due to the substantial locum program already provided by the SA State Government. Tasmania also demonstrates uptake levels comparable to NSW and Victoria.


Figure 16: Placements by RA category by state/territory Yr 1D

Figure 16: Placements by RA category by state/territory Yr 1

RGPLP Placements


Figure 17: Placements by RA category by state/territory Yr 2D

Figure 17: Placements by RA category by state/territory Yr 2

The above two graphs demonstrate placements by RA category by state/territory over the time periods of Yr 1 and 2. Overall, most placements occurred in RA 3 (42.9%), followed by RA 2 (30.6%).

The share of RA 5 placements has decreased from 17 (21.8%) in Yr 1 of the program to 11 (7.8%) in Yr 2.

Unsubsidised Placements

There have been no wholly unsubsidised placements during the program.

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Placement duration

In Year 1, across the total placements:

  • the average number of subsidised days per placement was 8.5
  • the average range was 7.9 days in RA 2 to 9.7 days in RA 5

In Year 2, across the total placements:

  • the average number of subsidised days per placement was 7.6
  • the average range was 7.1 days in RA 3 to 9.6 days in RA 5
  • It is clear that the length of placement required by hosts is longer for RA 4 and 5.

    Type of placement

    RA
    2
    3
    4
    5
    Total
    % Share
    Solo Practice
    15
    32
    9
    7
    63
    25.51
    Group practice
    28
    36
    10
    4
    78
    31.58
    Hospital
    14
    28
    4
    4
    50
    20.24
    After Hours
    12
    28
    8
    8
    56
    22.67
    Total
    68
    124
    31
    23
    247
    100

    Figure 18: Type of Placement – Practice/Site* (July to Dec 2010)

    *Some placements may include both a private and/or hospital and/or after hours placement

    Of the total placements in the period July to December 2010, 63 or 45%, were for solo practices, enabling vital leave for the incumbent doctor. Due to the demand for the program being in excess of the funding available, the RWAs have been prioritising locum placements to solo GP practices, solo GP practice towns and towns with 3 GPs or less.

    Links with other programs

    The RWAs provide support to the rural workforce in each state and territory (except ACT) and run a number of programs, including other locum programs with various funding sources. The RGPLP is just one of those programs. However, good linkages exist and there is flexibility for RWAs to utilise locums registered with other programs for the RGPLP.

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    Overall results

    The success of SOLS, GPALS and RGPLP to date has been mixed.

    SOLS has been relatively successful in terms of meeting performance targets and enjoys good support from stakeholders. In 2009–10 it achieved 75 specialist placements which exceeded their target of 60 and 29 GP obstetrician placements which exceeded their target of 20. In the same period it provided 434 specialist subsidised days from a target of 478 and 200 GP obstetricians subsidised days from a target of 280. It has been successful in building a good supply of locums (104 specialists and 53 GP obstetricians).

    GPALS has not been successful in meeting performance targets. During its operation, GPALS provided just 18 placements from a target of 61, and 133 subsidised days from a target of 500. It was unable to attract a supply of locums with 24 registered with the program and only 7 providing actual locum relief. Demand for the program was also low with only 11 additional requests for placement received which were unable to be met.

    RGPLP has been very successful in terms of meeting performance targets. In the six month period July to December 2010 it has provided 141 placements, exceeding its total year target of 84 placements. Across the same period, it has provided 1075 subsidised days, well on track to meeting the total year target of 1176 days. In the six month period, the 141 placements were completed by 95 locums. Of these, 56 locums were introduced to the respective RWA for the first time via the RGPLP placement.

    6. ANZCA and ASA, March 2009, Australia’s looming Anaesthetist Shortage – New Study

    7. Medical Practice in Rural and Remote Australia: National Minimum Data Set 30 November 2009.