Distribution problems can stem from difficulties in attracting the medical workforce to rural and remote areas and then in retaining those who have relocated, at least for a reasonable period. Research indicates that it is the total personal and professional experience including non-remunerative benefits and not salary alone that impacts on recruitment and retention.87
The Commonwealth provides a range of financial and non-financial incentives with the aim of attracting and retaining the rural and remote health workforce. These incentives may provide some support but are unlikely to be the sole or even main factor in choosing a career in rural health. Multiple lifestyle and financial factors are likely to influence a health practitioner’s decision to practise in rural or remote Australia.
In response to the 2008 Audit of the Health Workforce and the subsequent review of rural health programs, the $134.4 million Rural Health Workforce Strategy (RHWS) was announced as part of the 2009-10 Federal Budget. The RHWS included several existing workforce programs and introduced a number of new initiatives.
The RHWS is underpinned by two key reforms:
- Transition of program eligibility to a new geographic remoteness classification system; and
- Scaling or gearing of incentives and return of service obligations (RSO) to provide greatest benefits to the most remote communities.
Since the introduction of the new incentives in 2010, concerns have been raised by stakeholder groups that the Australian Standard Geographical Classification – Remoteness Area (ASGC-RA) system, which categorises communities into remoteness areas, is disadvantaging some rural communities across Australia. These concerns are addressed in detail towards the end of this chapter.
Medicare billing data indicates that as at 30 June 2012, the number of full-time workload equivalent (FWE) general practitioners in regional, rural and remote Australia had increased by 9.7% since the introduction of the RHWS on 1 July 2010. Because of the many factors influencing location of practice, it is not possible to determine how much of this increase is attributable to the RHWS alone. Programs under the strategy are listed below:
- The General Practice Rural Incentives Program (GPRIP), which provides incentives to encourage medical practitioners to move to and remain in a regional, rural or remote area.
- The Rural GP Locum Program, which helps to provide access to locum services for rural GPs.
- The HECS Reimbursement Scheme, which introduced scaling to fast track the repayment of medical school fees for doctors practising in outer regional, remote or very remote areas.
- The Scaling Incentive for overseas trained doctors (OTDs), which enables a reduction of the ten year Medicare moratorium for participants practising in a regional, rural or remote location.
- Scaling of Medical Rural Bonded Scholarship and Bonded Medical Places return of service obligations to encourage bonded scholars to complete their obligations in more remote areas.
- The Department also conducted a range of communication activities under the RHWS to address some of the preconceived notions regarding rural practice and promote the benefits of regional, rural and remote opportunities.
Financial incentives for rural doctors are a key element of the Government’s rural workforce strategy and were a major focus of consultations with stakeholders as part of this review process. A significant ongoing investment has been made in the distribution of retention and relocation payments to rural doctors through GPRIP, which has an allocation of $116.4 million in 2012-13.
GPRIP was implemented in 2010 as part of the RHWS. The purpose of the program was to address the maldistribution of the medical workforce by providing targeted financial incentives to encourage doctors to relocate to and remain in rural and remote areas. The introduction of GPRIP streamlined and consolidated two existing rural incentive programs for general practitioners and registrars that were run separately, the Rural Retention Program and the Registrars Rural Incentives Payments Scheme. This streamlining sought to address inequities in payment amounts between registrars and GPs.
Originally GPRIP was intended for general practitioners providing primary care services. However, because of the way in which the eligibility criteria are set with regard to the Medicare Benefits Schedule some specialist medical practitioners (i.e. anaesthetists, cardiologists, and obstetricians and gynaecologists) were subsequently given access to incentive payments.
As outlined above, there has been a significant increase in the number of doctors providing services in regional, rural and remote areas since the RHWS was introduced. Incentive payments for rural doctors may have played a part in contributing to this growth. It is therefore recommended that incentives should be a feature in ongoing efforts to support rural workforce sustainability.
However it is difficult to determine if the GPRIP on its own has generated rural workforce increases as the overall rural package contains a range of initiatives including rural education programs, support for rural and remote general practitioners and various locum support schemes. There has also been an increasing number of medical graduates entering the workforce as a result of the increases in medical student numbers over the past ten years.
Whilst the GPRIP has only been in operation for a little over two years, take-up and participation rates for the two retention components have been much higher than originally forecast (noting that forecasts were not prepared on the basis that non-GP specialists would be eligible for the payments). In 2010-11 and 2011-12 more than 11,000 participants were assessed as eligible to receive annual incentives. This includes specialists (billing the Medicare Benefits Scheme), GPs and GP registrars. Existing participants (as of 1 July 2010), including GP registrars, are grand-parented under their previous scheme for a three year period to ensure that they are not disadvantaged by the transition to GPRIP.
Given the fundamental purpose of the scheme, it is important to note that the major growth in GPRIP retention payments has been in ASGC-RA 2 areas (inner regional) and not the more remote ASGC-RA 3–5. When the Government adopted the ASGC-RA system for incentive payments (in July 2010) a large new geographic area in RA2 and some areas of RA3 became eligible for support. In 2010-11 almost 8,000 doctors became newly eligible for retention payments.
Program data indicates that the majority of the medical practitioners currently accessing retention payments are those practitioners who have in fact been providing services in the area for a significant amount of time, and may indeed have chosen to remain in the location regardless of whether the new retention allowance had become available. While payments are clearly appreciated by doctors (based on feedback received during the consultation process) it is far from clear that retention payments in inner regional settings have been a major or deciding influence on career choices.
While the retention component of GPRIP has clearly been embraced by rural doctors, the results for the relocation element have been disappointing. Program data shows that only 33 doctors qualified for relocation payments in 2011-12, against a target of 70. Stakeholders such as Rural Health Workforce Australia (RHWA) have suggested that the strict eligibility requirements for this component of the scheme may be partially to blame for the limited uptake. This includes the need to apply for the relocation incentive prior to commencing work at a rural location rather than seeking these funds retrospectively. Stakeholders gave strong evidence to this review that the process was frustrating and overly bureaucratic.
In 2011-12, at least half the number of participants that received initial approval for relocation incentives had withdrawn from the program. This was primarily due to participants not meeting the minimum level of service requirements in order to receive their first and second grant payments and therefore being deemed ineligible for the program. This issue should be addressed to reduce the rate of withdrawal. Increasing the number of doctors who relocate to rural areas and remain rather than simply retaining the current workforce is a key policy imperative.
While program eligibility rules are likely to be a factor in the slow uptake of the relocation grants, it also appears that the level of the grants themselves may not be sufficient to motivate doctors to take up rural careers. Research undertaken by the Monash University School of Rural Health indicates that of the very small subset of practitioners prepared to consider relocation in any circumstances, practitioners would only consider relocating to a rural location of 5,000 people or less for an additional 64% of their current salary. For towns with a population size between 5,000 and 20,000, an additional 30% incentive would be required.88 This level of payment far exceeds the current GPRIP relocation incentive amounts.
It is important to note that of the survey participants in the Monash research, 86% of doctors would not move at all, regardless of the level of incentive.89 This evidence suggests that monetary incentives are not the critical factor in increasing the health workforce in rural and remote settings. It also provides further evidence to support the need for a vertically integrated model of rural training described above.
Proposed regional incentive model
One of the major themes arising from the stakeholder consultation process conducted as part of this review has been the need for programs to be more flexible and better targeted at the regional level. A range of stakeholder groups have suggested that one-size-fits-all models for delivering government programs are often administratively complex, don’t allow innovation to match regional needs and can result in perverse unintended consequences.
The current system of administering GPRIP appears to be an example of this sort of approach, where a significant investment in Government funding support is in fact generating considerable frustration for stakeholders. Groups such as the RDAA have suggested that the current GPRIP system is in fact providing an incentive for doctors to move from under-serviced smaller locations into the larger regional centres and is fundamentally unfair in the way it allocates financial support.
The primary issue with GPRIP in its current form is that it is almost entirely driven by the ASGC-RA rural classification system (to determine payment levels) as well as the use of Medicare billing data (in terms of eligibility). The program is administered by the Department of Human Services (DHS), with policy oversight from DoHA. Central administration costs are high, with DHS receiving an ongoing allocation of over $1.7 million to maintain its GPRIP payment system. Any system changes within DHS also attract additional costs. There are also costs within DoHA, with approximately three ongoing staff devoted to GPRIP management.
An alternative approach to managing GPRIP could provide a range of benefits. This would involve moving the program to a system of regional management under a set of broad outcomes-based funding parameters supported by simplified eligibility requirements determined by the Government. The allocation of funding to individual participants would occur at the regional level and would be based on an assessment of local workforce needs rather than the current entitlement approach.
A number of management models could be adopted to implement this approach. One model that has been suggested involves harnessing the regional knowledge, expertise and local networks of agencies such as the Rural Workforce Agencies (RWAs), of which there are seven, and/or rurally based Medicare Locals (of which there are approximately 41).
RWAs are well established, mature organisations with a demonstrated track history in successfully delivering rural workforce support initiatives.90 Medicare Locals are at least potentially a vital mechanism for delivering support to health practitioners, including for after-hours services. Combined, the two organisations offer great strengths that could be utilised to deliver more effective incentives.
Under this system DoHA would provide funding under a formula for allocating incentives to each area. This could be based on determinants such as rural population, the level of remoteness of rural population centres, the number of smaller population centres servicing communities, the chronic disease profile and the rural Aboriginal and Torres Strait Islander population. Clearly, such an approach places an emphasis from the outset on outcomes for patients and population health, which is highly desirable, rather than an approach which focusses on the appropriate remuneration of practitioners, important though that may be. This funding formula would then provide an allocation of funds to be managed within that area by the relevant RWA or Medicare Local, through an agreement with DoHA.
RWAs would then be charged with managing a process to allocate funds to each of the Medicare Locals in their state or territory, either through a competitive tender process or through reaching a consensus through discussions. They would be responsible for broad oversight of this funding allocation but would leave the determination of local needs to each Medicare Local.
Regional organisations like Medicare Locals, RWAs, or a partnership between these (and potentially other) organisations, would then be responsible for disbursing funds to individual practitioners or categories of practitioner, based on an assessment of where the greatest workforce needs lie. In some cases continued retention payments to local doctors may be the priority. In others, regional needs analysis may determine that enhanced relocation incentives would provide a greater boost to the local workforce, which would provide benefits to all service providers by reducing their workload. There would also be the opportunity to design regionally based incentive arrangements to reward procedural doctors involved in teaching or providing critical after-hours services, or to provide incentive packages to other health practitioners needed in that local area.
Administrative costs of delivering this type of model would be offset by savings made in releasing DHS from its role in administering payments to thousands of individual practitioners. It would nevertheless be important to contain administrative costs, recognising the core funding that both RWAs and Medicare Locals already receive.
RHWA, the peak national body for the RWAs, could play a valuable role in supporting the RWAs. RHWA could promote a collaborative approach between the RWAs and would also assist in maintaining effective links between each RWA and DoHA. The Australian Medicare Local Alliance (AMLA) could play a similar role in assisting to maintain positive relationships within the Medicare Locals network. RHWA could potentially also play a fund-holding role involving management of one large agreement with DoHA and the disbursement of funds to each RWA.
This type of regionally based approach also provides an important opportunity to broaden the allocation of incentive payments beyond doctors. Subject to local requirements, there may be instances where incentives would best be directed towards supporting nurses, dentists and allied health providers working in the private sector. Retention and relocation incentives could make a substantial difference in making rural private practice in the allied health and nursing disciplines more attractive and sustainable.
This proposed broadening of incentive arrangements would encourage a more multidisciplinary approach to delivering health care where the emphasis would be on enabling investment to meet local needs rather than encouraging an entitlement approach. Incentives should be provided to generate good evidence-based outcomes, rather than being based on competition between professional groups.
While Figure 4.4 below presents one approach to reform, there are of course other options for the administration of regionally based incentives. DoHA funds Medicare Locals directly to undertake a range of functions, including after-hours services, and a similar approach could be adopted for incentive payments. However, the involvement of the workforce agencies would enhance their existing recruitment and support role and would be a simpler management model at the departmental level, involving seven agreements instead of 41 or more, with consequent saving of administrative costs.
An appropriate transition period would be important to test the practicalities of implementing such a model and ensure it could be implemented without undue disruption. It will also be important to align any changes with proposed reforms to the rural classification system, as discussed below.
On this basis existing GPRIP arrangements would need to stay in place during at least 2013-14; although this of course means that the scheme is likely to continue its current trajectory of over-expenditure with a trade-off in reduced funding for other DoHA programs given a budget neutral environment. During this transitional period the Government would need to carefully consider the future quantum of its investment in rural incentives to determine the level of capped funding to be allocated to the proposed new scheme.
Figure 4.4: Regionally based retention and relocation incentives for private health practitionersD
The alternative approach
A second option is to retain GPRIP in its current form with revised eligibility criteria linked to a better defined rural classification system. Improvements to the classification system will allow better differentiation between locations which are currently considered equivalent for incentive purposes but which have very different service level challenges. This approach would allow funding to be reprioritised towards smaller locations and more remote areas. This could assist to address some of the concerns raised by the RDAA and other rural groups during their participation in this review. Potential improvements to the current ASGC-RA system are described later in this chapter.
The HECS Reimbursement Scheme
TheHECS Reimbursement Scheme was established following the 2000-01 Budget and aims to promote careers in rural medicine and increase the number of doctors in rural and regional areas. Up until 2010, participants in the scheme had one fifth of their Higher Education Contribution Scheme (HECS) fees for the study of medicine reimbursed for each year of training undertaken or service provided in rural and remote areas of Australia.
With the introduction of the RHWS, the scheme was modified to allow doctors to reduce the period for reimbursement of the cost of their medical studies from five years to two years, depending on the classification of their training or practice location, with more remote locations attracting higher payments.
DoHA has policy responsibility for the scheme, including managing it as an uncapped demand-driven initiative. DHS administers payments to individual recipients.
Despite its title, the program does not operate within the straightforward administrative pathway of a revenue foregone scheme and payments are subject to taxation requirements. Recipients have no requirement to use the funds to pay off their HECS debt. Figure 4.5 below indicates the complicated and administratively expensive process applicants must undergo to participate in the scheme.
The analysis of the scheme during this review process has revealed that uptake of the HECS incentives has mostly been by trainee doctors undertaking their intern year, rather than fully registered doctors. Given that interns have limited options for where they undertake their training, this suggests that the incentive effect of the scheme is limited. As discussed elsewhere in this review report, rural internships are limited and in high demand so financial incentives at this stage of vocational training may be an unnecessary and inefficient use of resources.
The scheme has not been meaningfully evaluated since 2003 at which time there were only 40 participants. As such, there is no currently meaningful data as to its effectiveness (or, indeed evidence to the contrary). Anecdotally, the scheme is viewed by rural stakeholder groups as a simple and clear potential policy lever available to government. Representations are frequently made to expand eligibility to include other health disciplines.
Figure 4.5: Claims process under HECS Reimbursement SchemeD
The Senate Community Affairs Reference Committee also recommended that the expansion of the scheme should be explored and it is arguable that HECS reimbursement for other health professionals may be more effective than it has been for doctors. The relative gap in salaries and the potentially larger effect that receiving a financial incentive may have on other professionals could mean that providing funds to cover HECS debts could be more effective for these groups. Certainly, this argument was made powerfully by some Aboriginal and Torres Strait Islander stakeholder groups.
An alternative HECS forgiveness scheme, administered by DIICCSRTE and the Australian Taxation Office (ATO), exists for nursing and education graduates who take up employment in their professions. Unlike the DoHA HECS Reimbursement Scheme, which effectively provides incentive payments, the DIICCSRTE scheme provides a reduction in the participant’s HECS-HELP (Higher Education Loan Program) debt owed through the taxation system. It would seem that awareness of this other program is fairly limited.
The DIICCSRTE scheme also has rural and remote eligibility criteria for certain professions (early childhood education) and appears to offer a simpler administrative model than the HECS Reimbursement Scheme. From a workforce development point of view, it makes more sense to have a consolidated, simpler scheme which would enable the targeted use of HECs forgiveness in response to evidence of changing workforce need. Consideration should therefore be given to transferring the HECS Reimbursement Scheme to DIICCSRTE to operate on the same basis as the nursing and education scheme.
Drivers for rural retention and relocation
Many of the current rural incentives for medical practitioners are focused on financial provisions as the main ‘carrot’ to entice rural practice. However, increasing amounts of literature in this space have found that there is a wide range of motivators for medical practitioners to take up rural practice and remain in these areas for extended periods of time. There is certainly an argument that policies which focus on financial incentives, and ignore issues such as community engagement and professional satisfaction are fundamentally counterproductive. It can also be argued that a model which focusses on financial compensation for ‘hardship’ instead of the advantages and attractions of rural practice is ultimately stigmatising and destructive.
During its investigation into the factors affecting the supply of medical practitioners in rural areas, the Senate Community Affairs Committee found the following causal factors to be of importance:91
- The need to provide training and professional development opportunities;
- The need to provide options for career development;
- Strategies to assist with high workload and on call hours;
- The need to provide opportunities for spouse and children;
- The need to provide peer and professional support;
- A reliable locum service;
- Appropriate remuneration and recognition;
- Provision for adequate housing/childcare; and
- Potentially higher incomes available in private practice in metropolitan areas a disincentive to rural practice.
The provision of purely financial incentives would not be enough to address all of these issues, and approaches which deal specifically with the issues of infrastructure, training and professional development need to be considered more carefully. Many of these matters cross portfolios and different levels of government and will require a more challenging combined response to addressing community needs.
Additional incentives to affect distribution come at the point of medical school entry with the MRBS Scheme, which as outlined in Chapter 3, provides a relatively generous scholarship in exchange for a return of service obligation in a rural or remote area and the BMP Scheme, which provides a medical place in return for a commitment to work in a district of workforce shortage (see the discussion in Chapter 6 on return of service obligations). Other scholarships which support health education for the future rural workforce include the Rural Australia Medical Undergraduate Scholarship (RAMUS) scheme and the Nursing and Allied Health Scholarship and Support Scheme (NAHSSS). These latter initiatives have already been discussed in in the relevant sections in Chapter 3.
Alternative service models
For some locations considered to be either too small and/or too remote to support a permanent live-in doctor, it may be necessary to introduce alternative models of primary care. Options could include the implementation of an ‘easy-entry, gracious exit’ model which would require an external administrator to manage the practice; expanded services through a ‘fly in, fly out’ and/or ‘hub and spoke’ model; and the provision of funds to enterprises for the purpose of establishing medical clinics in underserviced areas.
It is recognised that the Government’s Medical Specialist Outreach Assistance Program (MSOAP) is meeting some of the service delivery needs of rural and remote communities experiencing market failure in the delivery of health services. This has ongoing substantial support from the Royal Flying Doctors Service. While valuable, these types of models of rotating services don’t provide the same level of continuity of care or community engagement that are highly valued by rural communities.
It has been suggested during this review process that there could be merit in examining enhanced linkages between rural and urban health care settings, with practitioners serving in both settings on a rotational basis.
There have also been some suggestions during the review process about the way Government programs could support overworked remote GPs by enhancing access to other health professionals to assist in delivering team-based care. Greater use of nurse practitioners and practice nurses is beginning to occur but could be expanded further, as discussed in Chapter 7 of this report.
One suggestion that may have some merit is to extend the current Practice Nurse Incentive Program (PNIP) to cover physician assistants in certain remote areas. While this new workforce may not be an appropriate solution in all areas (and is opposed by some nursing professional groups) it appears that, particularly in regional areas of northern QLD, these new professionals are playing a valuable role that could be enhanced with some targeted financial support.
All options would require careful consideration of their benefits and potential cost to the Commonwealth. However, the adoption of these new primary care alternatives could be used as an alternative to the current direct financial incentives that are paid to practitioners.
Continuing rural professional development
There are no DoHA programs which directly provide rural continuing professional development education, but some exist which support it either through the Rural Health Continuing Education (RHCE) grants or through the educational broadcasts delivered by the Rural Health Education Foundation through its satellite broadcast network and regular webcasts.
Maintenance of support for the Foundation, building on its new digital television channel, will provide a useful platform for delivering professional development services in more remote areas. This is critical to support rural health professionals to meet mandatory continuing professional development (CPD) requirements for registration.
Targeted at qualified practitioners the RHCE program was announced in the 2009-10 Budget and consolidates funding from the Rural Advanced Specialists Training Scheme, the Support Scheme for Rural Specialists, the Rural Health Support Education and Training Program and the Rural Health Education Foundation.
The RHCE provides access to professional training and support in rural and remote areas for medical specialists (stream 1), and for allied health professionals, nurses, general practitioners and Aboriginal and Torres Strait Islander Health Workers (stream 2).
Stream 1 of the RHCE is administered by the Committee of Presidents of Medical Colleges and provides project grants of up to $40,000 and $60,000 grants for accredited/registered training providers to develop and/or deliver relevant training programs for rural and remote medical specialists. While this program has been consistently oversubscribed, there have been challenges including participants experiencing difficulties commuting to training and arranging for their position to be backfilled.
Stream 2 of the RHCE is administered by the National Rural Health Alliance (NRHA) and is targeted at allied health professionals, GPs, nurses and midwives and Aboriginal and Torres Strait Islander health workers. It provides project grants of up to $60,000 to accredited/registered training providers for the development and delivery of CPD, continuing professional education (CPE), inter-professional learning (IPL), or orientation programs and support of up to $6,000 (per grant) for individuals or organisations to access CPD, CPE, IPL or orientation activities.
The allocation of funding between streams 1 and 2, particularly given the relative size and make-up of the workforces they apply to, requires further examination especially as both streams are currently oversubscribed.
An evaluation of stream 1 was completed in 2012. Analysis indicated that the direct workforce benefits of the RHCE program are difficult to measure, with little evidence available to demonstrate enhanced quality of care or staff retention. The evaluation noted better indicators were required to measure the longer term outcomes.
Further analysis of demand for specialist CPD training under the RHCE program would be beneficial to ensure this program is appropriately targeted and effective in delivering professional development support where it is needed most. Successful applications should not only be based on the rural classification model but also take into account areas of need and the benefit the training will provide to the community.
To increase the number of participants in RA 4–5 locations, an emphasis on training health professionals in these areas should be promoted by the administrator. Increasing the training opportunities for health professionals in the areas in which they live and work would obviously decrease travel costs and backfilling issues identified by stakeholders. However, the number of specialists by profession practising and living in each RA classification needs to be quantified. Also, in the case of specialists and nurses it should be considered whether they are currently provided with individual CPD funding from their employer (state Government).
As with the funding for specialists under stream 1 of RHCE, stream 2 is heavily oversubscribed. There is clearly strong demand for professional development support amongst rural allied health professionals with the 244 eligible grant applications received under the scheme far exceeding the 75 projects that have been supported within the available funds.92
In a similar way to the suggestions made in this review about other rural training programs, consideration should be given to how providers of professional development training funded through RHCE can be linked with similar organisations, like the UDRHs, to benefit from shared approaches and economies of scale.
Funding for locum back-filling is one of the other areas in which the Commonwealth provides valuable, less direct support for rural and remote practitioners. Funding for locums enables GPs and other professionals to take time for personal leave as well as to undertake professional development activities. Locum schemes are an important retention measure and generally provide good value for money provided they are not used as a replacement for permanent staff in rural areas. A number of Australian Government programs are in place.
The Nursing and Allied Health Rural Locum Scheme (NAHRLS)is a component of the Australian Government's health reform agenda. Two national Health Reform initiatives funded in the 2010-11 Budget: the Rural Locum Scheme for Allied Health Professionals and the Rural Locum Scheme for Nurses were combined to create the NAHRLS, which is externally administered by Aspen Medical Pty Ltd.
NAHRLS provides locum placements for up to 14 days to enable nurses, midwives and allied health professionals to take leave for personal and professional reasons. It also enables interested nurses, midwives and eligible allied health professionals to experience rural practice through a locum placement.
The program has not been operating long enough to assess its effectiveness. However, there has been a low uptake of placements. The administrators attribute this to low use by state public health systems who potentially have existing locum service arrangements and lack of funding for the locum’s wage. This is one example of differing levels of support between NAHRLS and other locum schemes which do provide subsidies for locum salaries. Pharmacy stakeholders have requested inclusion on the scheme. However, it should be noted that a separate pharmacist locum scheme is funded under the 5th Community Pharmacy Agreement.
The National Rural Locum Program (NRLP)was a consolidation of three previous initiatives: the Specialist Obstetrician Locum Scheme (SOLS) which commenced as a pilot program (funded by DoHA) in 2006; the General Practitioner Anaesthetists Locum Scheme (GPALS) which was an expansion of SOLS introduced in the 2008-09 Budget, and the Rural General Practitioner Locum Program (RGPLP), which was a component of the RHWS.
The NRLP aims to maintain and improve access to quality care for rural communities by increasing the locum support available to the rural medical workforce. Support to allow existing rural doctors to have time to rest and undertake ongoing education and training is a crucial retention mechanism. Eligibility is limited to doctors in ASGC-RA 2–5 areas.
From 31 January 2013, the funding for RGPLP has been devolved to Medicare Locals. A funding agreement was executed with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) on 4 October 2012 to administer the remaining elements (SOLS and GPALS), with the combined schemes now being called Rural Obstetrician and Anaesthetist Locum Scheme (ROALS). The funding agreement with RANZCOG operates until 30 June 2014.
The ROALS operates by providing eligible host doctors (specialist and GP obstetricians, and GP anaesthetists) with subsidised support to offset the cost of obtaining a locum. Subsidies are available for locum costs, travel time and travel costs. Hosts can claim up to 14 days of locum support per financial year.
The NRLP has been reviewed (completed in April 2011). The following key areas were identified for improvement:
- Streamlining of the current administrative structure of the program
- Development of a national approach to improving locum supply
- Review of the model to provide enhanced access to the subsidies
- Improved and refined definition of the target GP population group for the program
- Improved focus on meeting the needs of proceduralists with multiple specialties
- Reduced administrative requirements for locums.
The review also found that:
- SOLS and RGPLP have met targets and program objectives. GPALS has had limited reach with only small numbers of GP anaesthetists participating in the program.
- SOLS has been accessed by approximately 25% of the rural and remote specialist obstetric workforce.
- RGPLP exceeded its targets, but due to the capped funding of the program, the reach was less than 4% of eligible GPs.
The Rural Procedural Grants Program (RPGP), incorporating the Rural Locum Education Assistance Program (Rural LEAP) commenced in July 2004. In February 2012, Rural LEAP was included within the RPGP to allow urban GPs to undertake emergency medicine training. Rural LEAP originally commenced in early 2010. RPGP enables procedural GPs in rural and remote areas to access a grant to attend relevant training, upskilling and skills maintenance activities. The Program has two components offering a grant to cover up to:
- ten days training, to a maximum of $20,000 per GP per financial year for procedural GPs practising in surgery, anaesthetics and/or obstetrics in rural and remote areas (ASGC-RA 2–5); and
- three days training, to a maximum of $6,000 per GP per financial year for GPs practising emergency medicine in rural and remote areas (ASGC-RA 2–5) to attend approved skills maintenance and upskilling activities.
Rural LEAP provides financial assistance to urban GPs who undertake emergency medicine training and commit to a four week (20 working days) general practice locum placement in a rural locality within a two year period. This is a one off incentive with participants able to obtain financial assistance of up to $6,000 for three days of emergency medicine training.
The program currently substantially meets its targets. An external review was conducted in April 2008. The 2008 review found that the program was effective in helping GPs to access training to improve/maintain their procedural and emergency medicine skills. Anecdotal evidence suggests that Rural LEAP participants are committing to additional rural locum work over and above the required four weeks.
Locum programs are an important component of the Government’s rural workforce strategy and it is important that funds can be directed efficiently towards the areas of greatest need. While recognising this, the review has identified some inconsistencies between the different locum programs in terms of the support they provide to different professional groups and the administrative costs of delivering this funding.
There may be potential for administrative efficiencies by consolidating or streamlining these activities within the one administrative framework, while still enabling funds to be directed towards the different professional groups. A competitive tender process could be conducted to appoint one administrator. There would be benefits to this approach by co-locating all locum support activities with the one agency, making locum services easier to access to rural professionals.
If this option is not pursued, SOLS and GPALS could be integrated with delivery of the Specialist Training Program, with funding managed by RANZCOG under two targeted activity streams.
Rural workforce agencies
RHWA and the RWAs play a pivotal role in supporting and delivering rural health programs for and with the Commonwealth.
RWAs, located in each state and the Northern Territory, are funded by the Commonwealth to improve the recruitment and retention of GPs to regional, rural and remote areas (ASGC-RA 2–5) which includes helping communities to recruit GPs, finding appropriate placements for doctors who want to relocate to rural Australia, assisting with the costs of relocation, supporting families with fitting into a new community and helping doctors access the necessary infrastructure, support and training.
RWAs also promote rural and remote general practice to Australian and international markets and provide support to international and Australian medical graduates moving to rural areas, with a focus on job orientation, training and education support.
Funding is provided to RWAs through RHWA, the national peak body. RHWA also provides national advocacy and representation, coordination and administration, and management of national data relating to rural workforce activities.
In order to target some of the preconceived notions regarding rural practice, DoHA has conducted a range of communication activities under the RHWS. These activities are aimed at demystifying rural practice and promoting the benefits of regional, rural and remote opportunities. This includes the Rural Health Champions Project, a select group of medical professionals who speak, write and blog about their experiences in rural practice. The penetration of this initiative, in terms of its impact on influencing metropolitan health professionals, is difficult to assess. In addition to this, in 2011 DoHA commenced the ‘Go Rural’ project, where the RWAs in each state and the Northern Territory conduct a variety of events to promote rural practice.
The Rural and Remote General Practice Program (RRGPP)was established by the Australian Government in 1998-99 as a result of the “Report of the General Practice Strategy Review Group” (1998). Under this program RWAs are required to collect and report on a set of KPIs in relation to the recruitment and retention of GPs in regional, rural and remote Australia. Each state or territory has different benchmarks under the various KPIs. Some vary by up to 40% such as retention for a six month period after recruitment. The inconsistent basis of funding for RWAs, along with different performance benchmarks, suggests there may be scope for efficiencies in administration arrangements. Nevertheless, the program appears to have been successful in recruiting and retaining doctors in rural areas.
The implementation of more rigorous data reporting arrangements in response to the findings of the 2005 review of RRGPP has provided a basis for future workforce planning and the capacity to identify and respond to long-term workforce policy issues. The administrative arrangements for the program should be considered in light of the ongoing role of Medicare Locals, and the potential for efficiencies to be gained through contracting RWAs through RHWA.
RHWA’s submission to the review recommended that investment into specific workforce programs under the existing funding agreement be continued at current levels to support the RHW agency network's core business; key performance indicators associated with funded workforce programs administered by the network be reviewed and revised to better reflect the full scope of activities and services provided; improved structured collaborative arrangements are introduced to maximise the outcomes to rural and remote communities and provide a better return on Commonwealth investment by eliminating service gaps, unnecessary duplication and lack of system-wide clarity.
Specific recommendations from RHWA regarding the RRGPP include ensuring that from July 2013 funding should be sufficient to reflect the breadth of core services provided, the expected increase in Australian trained graduates and the demonstrated need to continue international health professional recruitment and increase in workforce targets and geographical coverage resulting from the change from the Rural, Remote and Metropolitan Areas (RRMA) classification system to ASGC-RA in 2010.
RHWA also recommended that the National Rural Health Students Network (NRHSN) program continue to be funded and that the NRHSN extends the continuity of their involvement with the future health workforce through a graduate (Alumni) program. This could be a valuable contribution to supporting students as they commence their rural and remote health careers and may provide an avenue for postgraduate data collection and feedback gathering.
Administratively it may be possible to consider converting to a header agreement with RHWA, provided this is consistent with other activities to be delivered by RWAs. The efficiencies generated by this approach would need to exceed the overall risks. The difference in benchmarks for KPIs across jurisdictions should be considered as part of any future negotiations and a more consistent national funding methodology for the RWAs should be developed in consultation with stakeholders.
|Recommendation number||Recommendation||Affected programs||Timeframe|
|Recommendation 4.13||Continued support for rural doctors, including targeted financial incentives, should remain a key component of the Government’s health workforce strategy to address the serious ongoing maldistribution of health professionals. |
However, there is currently insufficient emphasis on support for other health professionals. A broader approach to rural health workforce development, focussing on social and professional issues as well as financing, needs to be taken consistently to complement the Government’s current investments.
|GPRIP, HECS Reimbursement||Ongoing, with longer term development of new approaches, as outlined below.|
|Recommendation 4.14||Expenditure on the General Practice Rural Incentives Program (GPRIP) needs to be better targeted for equitable workforce outcomes by:
Determining need at the local and regional level is likely to be more effective than the current centralised entitlement system. This approach also provides flexibility to direct resources to the recruitment and retention of other professional groups, subject to local workforce requirements and identified health needs.
|GPRIP||Medium term – new models of financial support will require extensive consultations with stakeholders and the development of revised administrative systems.|
|Recommendation 4.15||Any change to a new incentive system should feature an appropriate transition period, of at least one financial year, and further consultation with stakeholders about the detailed requirements and funding allocation systems. Arrangements for supporting rurally based GP registrars should be considered as part of this process.||GPRIP||Medium term|
|Recommendation 4.16||The HECS Reimbursement Scheme should be integrated with the similar HECS-HELP forgiveness initiative already managed by Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education (DIICCSRTE) and the Australian Taxation Office (ATO). |
While the latter scheme already covers nurses, the benefits and costs of participation by rural allied health professionals should also be examined.
Integration should achieve administrative savings and an ability to target HECS forgiveness in a responsive manner to projected workforce shortages.
|HECS Reimbursement||Medium term|
|Recommendation 4.17||The Rural Health Continuing Education (RHCE) program (Stream 2) provides a good basis for supporting postgraduate training in allied health and nursing, but is significantly oversubscribed. The Commonwealth should consider expanding this program and linking it to other training initiatives, subject to the availability of further funding.||RHCE||Longer term – expansion will be subject to funding availability.|
|Recommendation 4.18||The Commonwealth should progress the consolidation of the administration of the various discipline-based locum programs into an integrated rural multidisciplinary locum provision service.||SOLS, GPALS, Rural LEAP, NAHRLS||Medium term – consolidation should be pursued as existing funding agreements expire.|
|Recommendation 4.19||Government involvement in alternative rural health service models should continue to be explored. Investments in developing new practice models in areas of market failure may assist to ensure more remote communities can access reasonable levels of service.||Primary and Ambulatory Care Division programs, new workforce initiatives.||Longer term – new models require significant development for national implementation, subject to available funding.|
87 J Humphreys et al. “Improving Workforce Retention: Developing an integrated logic model to maximise sustainability of small rural and remote health care services”, Australian Primary Health Care Research Institute ANU College of Medicine, Biology & Environment, 2009.
88 Professor John Humphreys, Presentation to the Review of Australian Government Health Workforce programs, 2012
90 RWAs are discussed further on p. 144.
91 Senate Community Affairs Reference Committee, The factors affecting the supply of health services and medical professionals in rural areas, August 2012, pp. 19–23
92 Rural Health Continuing Education program summary data, Department of Health and Ageing, 2012