Rural recruitment and training promotes rural practice by GPs, but is it enough to retain them?
Geetha
Ranmuthugala1,2
1 University
of New England, Armidale, NSW
2 Rural
Clinical School, University of Queensland, Toowoomba, QLD
Challenges to keeping general
practitioners in the bush remain
The findings reported by McGrail and
colleagues in this issue of the MJA support the effectiveness of
Australian government incentives for recruiting and training general
practitioners in rural areas as a strategy for reducing rural medical workforce
shortages.(1)
The study found that rural origin of trainees and rural vocational training of
GPs were each strongly associated with their practising in rural areas in the
early years after completing vocational training. However, their findings also
suggest that these effects had started to diminish by 4 years post-training.(1)
This finding is consistent with another recent Australian study, which found
that the effects of rural recruiting and training diminished over time.(2)
As evidence emerged in the early 1990s
that a rural background and a positive rural training experience promoted the
subsequent uptake of rural practice by trainees, the Australian government
introduced several initiatives for recruiting and training medical students in
rural areas. The Rural Undergraduate Support and Coordination Program (RUSC)
was in 1993 among the first of these initiatives, followed by the Rural
Clinical School (RCS) and the Rural Clinical Training and Support Program
(RCTS). These initiatives required that 25% of the intake of students by
federally funded medical schools be from a rural background; that all federally
supported medical students undertake a 4-week structured rural placement; and
that 25% of students undertake at least 12 months’ clinical training in a rural
location.(3)
Initiatives such as the Australian General Practice Training Program followed,
ensuring that at least 50% of general practice vocational training placements
are in rural or remote areas.(4)
These training initiatives have contributed to the success achieved in
increasing the number of GPs who adopt rural practice: it was recently reported
that the rural and remote GP workforce increased by 23% between 2010 and 2014,
compared with a 3.5% increase in the rural and remote community population, and
a 10% increase in the metropolitan GP workforce over the same period.(5)
It is now timely to consider whether an
increase in the number of rural and remote GPs necessarily translates into a
sustained and well supported workforce which can deliver quality health care
that meets the needs of rural communities. Factors that motivate practitioners
to remain in rural areas include access to training, professional development
and career development opportunities.(3)
While I focus in this article on the role of training and education in rural
retention, other factors known to be important include peer and professional
support, assistance with heavy workloads and on-call requirements, locum
relief,(3)
access to infrastructure (such as information and communication technology and
electronic health data systems), housing, and family support.(6)
In addition, being a principal of the
medical practice has been identified as significantly increasing the likelihood
of a doctor remaining in a rural location (by 72%), while being a salaried or
contracted employee significantly reduces the likelihood (by 20–30%).(7)
GPs in rural and remote locations work longer hours than their metropolitan
counterparts, increasing steadily from an average of 38 hours per week in
metropolitan locations to 45.8 hours in very remote locations.(5)
Such demands, and the need to travel, make it more difficult for rural or
remotely located practitioners to participate in professional development and
to take up training opportunities. Innovative business and work model solutions
are needed to support the rural GP workforce.
It should also be noted that the
proportion of GPs practising procedural skills increases with remoteness (from
8.0% in inner regional areas to 13.8% in outer regional and 20.9% in remote and
very remote locations).(5)
Recognising that rural and remote practitioners must have procedural skills in
general surgery, obstetrics, anaesthesia, radiology and endoscopy, the Royal
Australian College of General Practitioners has incorporated procedural skills
training into their curriculum.(8)
Additional training is provided through the General Practitioner Procedural
Training Support Program. Nevertheless, the period 2010–2013 saw a drop in the
proportion of GPs practising procedural skills; (5)
the decline was greatest in outer regional areas (4.1%), followed by remote
(3.9%), inner regional (1.9%) and very remote locations (0.6%). Reasons for
this decline are not clear and need further exploration, especially given a
recent finding that undertaking hospital work significantly increases the
likelihood that rural and remote GPs remain in rural locations (by up to 40%).(7)
As exercising one’s skills contributes to increased job satisfaction,
motivation, commitment and retention,(9)
there is a need to provide the infrastructure and opportunity for these
practitioners to enhance and practise the procedural skills that have been
identified as an important aspect of rural practice.
The early training initiatives are having
positive effects on recruitment, but they must be reviewed and updated as new
evidence emerges. Accordingly, in light of consistent support for the influence
of longer term rural clinical placements on the likelihood of choosing rural
practice, the initial requirement that all federally supported medical students
undertake a 4-week rural placement has been reduced to 50% of students, but
with no change to the proportion required to undertake a year-long rural
clinical placement.(10)
It will be another 5–10 years before the effect of these revised funding
parameters on the recruitment and retention of the rural medical workforce will
be apparent.
References
1.
McGrail MR, Russell DJ, Campbell DG. Vocational training of general
practitioners in rural locations is critical for Australian rural medical
workforce. Med J Aust 2016; 205: 217-221.
2. Hogenbirk
JC, McGrail MR, Strasser R, et al. Urban washout: how strong is the
rural-background effect? Aust J Rural Health 2015; 23: 161-168.
3. Mason
J. Review of Australian government health workforce programs. Canberra:
Department of Health and Ageing, 2013. http://www.health.gov.au/
4.
Australian Government, Department of Health. Australian general practice
training. 2017 handbook. Canberra: Department of Health, 2016. http://www.agpt.com.au/
5. Rural
Health Workforce Australia. Regional, rural and remote GP workforce trends:
developing evidence-based health workforce policy. Melbourne: RHWA, 2014. http://www.rhwa.org.au/client_
6. Rural
Health Standing Committee (Australian Health Ministers’ Advisory Council).
National strategic framework for rural and remote health. Adelaide: RHSC, 2016.
http://www.health.gov.au/
7.
Russell DJ, McGrail MR, Humphreys JS, Wakerman J. What factors contribute most
to the retention of general practitioners in rural and remote areas? Aust J
Prim Health 2012; 18: 289-294.
8. Royal
Australian College of General Practitioners. RH16 Rural health. Melbourne:
RACGP, 2016. http://www.racgp.org.au/
9. Skills
Australia. Better use of skills, better outcomes: a research report on skills
utilisation in Australia. Canberra: Commonwealth of Australia, 2012. https://docs.education.gov.au/
10.
Australian Government, Department of Health. Rural health multidisciplinary
training (RHMT) 2016–2018 programme framework [website]. Updated Mar 2016. http://www.health.gov.au/
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