The shortage of doctors and other health professionals in rural and regional Victoria is an ongoing barrier to providing health services to all Victorians. AMA Victoria has released a document, Medical Workforce Futures, which outlines some of the steps that need to be taken to improve the recruitment and retention of medical practitioners in provincial Victoria. 

 

The decision to set up and remain in rural practice for health professionals is complex, influenced by professional and non-professional factors, including:

 

 

Professional programs and service models alone will not solve the problem of rural workforce supply unless they are accompanied by a range of other incentives including good community infrastructure, locum relief measures, adequate remuneration, spouse support and educational support for children. To fill these gaps requires a whole of government response.

 

To recognise the importance of the medical workforce to rural and regional communities, the Victorian Government must match the incentives offered by other state governments for general practitioners and specialists. A comprehensive Provincial Victoria Medical Workforce Rescue Package should include:

 

The AMA Victoria Provincial Victoria Medical Workforce Rescue Package is designed as an integrated package of health care measures aimed at rural and regional Victoria. The package should be seen as the first part of a whole of government approach to the health of rural communities, which will aid the recruitment and retention of doctors in country Victoria.

 

More details of these measures are at attachment B.

 

Rural public hospitals, and to a significant extent regional public hospitals, rely for their medical workforce on local doctors in private practice. A medical workforce is available to country hospitals only to the extent that country towns can attract and retain medical practitioners.

 

Research by Humphreys, Jones, Jones & Mara (2002) identifies the importance of professional factors as determinants of retention and length of practice in rural areas. The key problem for rural doctors is inability to get time away for recreational leave and family considerations, and for emergency relief and relief to complete CME programs.

 

In the absence of good on-call arrangements and professional support, the unrelenting nature of the demand for after-hours care imposes an excessive workload, with negative effects on health and well-being.

 

A broad strategic solution incorporating several measures is required, including: 

• competitive rates of pay consistent with New South Wales and Queensland;
• improved staffing levels, including more VMOs, at rural hospitals. The high risks of fatigue due to poor roster design and staffing shortages are well known in rural hospitals, and junior doctors often highlight the significant burden of responsibility placed on them when working in rural hospitals;
• more doctors to help provide a reasonable on-call ratio and ensure comprehensive after-hours care; 
• enhanced support for nursing and allied health; and
• incentives contained in the AMA Victoria Provincial Victoria Medical Workforce Rescue Package.

The importance attributed to the variety experienced in rural practice as a factor influencing the length of time in rural practice is also important. Many doctors move to rural areas because of the opportunity to practise procedural and comprehensive care. The factors that determine opportunities to engage in a variety of rural medical practices are complex, including other support staff, availability of facilities, changing technologies, improving transportation and changed community expectations.

 

The challenge is to develop an integrated rural medical workforce retention strategy which takes account of the nature, complexity, and context of rural and remote general practice; leads behavioural change; provides professional support and remuneration appropriate to skills and responsibilities; and is based on a model of sustainable practice for doctors into the future.

 

 

 

 

 

 

 

 

	2008-09	2009-10	2010-11	2011-12
Centre for International Medical Graduate Support	3.0	3.0	3.0	3.0
IMG assessment funding	- 2.1	- 2.1	- 2.1

	2008-09	2009-10	2010-11	2011-12
GP after hours telephone consultations	0.693	0.693	0.693	0.693

 

 

 

 

With the current shortages in several medical specialties, hospitals are finding it harder and harder to attract and retain specialist medical staff. Rural hospitals often find themselves needing to stretch their budgets to attract or retain specialists, as the shortages mean that salaries in rural and regional areas are often higher than in urban areas.

 

To avoid such strains on hospital budgets and to maintain a balanced mix of services in country Victorian hospitals, a central pool for specialist rural location allowances would help country hospitals attract staff without compromising other services.

 

Rural location allowances would be payable from $10 000 per annum in major centres like Ballarat and Bendigo, to $30 000 per annum in Mildura and East Gippsland. Payments would be made on a pro rata basis for part time staff, including visiting medical officers. The payment would be available to all doctors working in Victorian public hospitals.

 

	2008-09	2009-10	2010-11	2011-12
Hospital medical practitioners’ rural location allowance	13.5	13.5	13.5	13.5

 

 

 

Every doctor deserves a break from practice, either for continuing medical education, family leave or recreational leave. Data demonstrate that locum support is a vital predicator of rural attraction and retention.

 

The proposed locum support service would provide a $2000 subsidy to every medical practitioner in rural and regional Victoria to subsidise a locum for two weeks. The subsidy would be available as a rebate to either individual medical practitioners or their employer who pays the cost of attracting a locum. The subsidy would be $200 per day for a maximum of ten days each year.

 

This initiative would complement the proposed Statewide Locum Service that the Department of Human Services is considering. The Statewide service would be run by the Rural Workforce Agency Victoria and Divisions of General Practice.

 

Medical practitioners would need to have spent a minimum of one year in rural and regional Victoria before becoming eligible for support under the scheme.

 

	2008-09	2009-10	2010-11	2011-12
Locum support services	4.0	4.0	4.0	4.0

 

 

 

General practitioner in some areas have had a relocation allowance payable to doctors moving to some country locations for many years, paid by the Commonwealth Government. AMA Victoria has been advised by the Rural Workforce Agency Victoria that such allowances are not available in Victoria. Specialist practitioners are not eligible for relocation incentives.

 

The Victorian Government is responsible for our public hospital system, so should provide additional incentives to entice hospital-based medical practitioners to country Victoria. A suitable package could include: 

• a relocation allowance of up to $20,000;
• accommodation or accommodation assistance;
• fee assistance for the education of children; and
• assistance with finding suitable employment for other family members. 

Such a package would encourage medical specialists to live and work in country Victoria, and aid recruitment.

 

 

 

 

 

The Forster Report (2005) of the Queensland health service recognised that more flexibility was needed to secure young specialists returning from work overseas and who were wanted to work in the public sector, as often they were unable to do so because of inadequate available resources. Inflexible budget arrangements lead to an inability to employ young specialist staff on meaningful contracts.

 

Entry to the public hospital specialist workforce in Victoria has customarily been through the allocation of a small number of sessions so as to help establish a viable practice. However with increased competition and focus from other states on this workforce cohort a more systematic strategy is required.

 

The Forster Report suggested a range of options including:

 The ability of rural and regional health services to attract hospital specialists without divesting the services of existing specialists is minimal. Budgets are not large enough or flexible enough to allow for transitional arrangements. Thus a common pattern is for a specialist to give notice of retirement, the hospital advertising for a replacement, but not being able to have a handover period or the training opportunities. This lack of flexibility also can result in long term vacancies, as the health service is not able to take advantage of new opportunities before the outgoing specialist has gone.

 

AMA Victoria recommends the Department of Human Services set up a flexible funding pool that may be accessed by health services from time to time to assist the establishment of new specialist and mentoring roles across regional Victoria to improve access for patients.

 

 

 

The experience of general practice amalgamations over the previous decade demonstrates that practice amalgamations improve recruitment and retention. Practice amalgamations mean that doctors have less on call requirements, more professional support and greater opportunity to employ practice staff.

 

Virtual amalgamations between rural and urban practices have also had some success, with urban doctors in larger practices able to fill in for rural colleagues in smaller practices.

 

While small, this initiative is designed to lead behaviour by providing a trigger and small incentives for medical practitioners to consider practice amalgamation.

 

The successes of practice amalgamations in general practice suggest that a trial for specialist practices, and practices where general practitioners do at least 0.2 FTE in a rural hospital, are worthy of support from the Victorian Government. Small grants for practice amalgamations where the practices can demonstrate improved access to services in country hospitals would demonstrate the Victorian Government’s commitment to supporting general practice’s role in hospitals. 

 

 

 

Grants of up to $40 000 per practice for a maximum of ten practices for a time limited, three year program. 

 

 

The Victorian Government’s investment in information technology, primarily through HealthSmart, promises to improve patient care across Victoria. For these promises to be fulfilled, IT systems in hospitals must be able to communicate with IT systems in general practice and private specialists practices.

 

Recognising that rural Victorians have greater health needs, and that rural medical practitioners are under pressure, the Victorian Government should support early integration of rural hospitals and rural private practices.

 

A grant of $5 000 per FTE rural medical practitioner should be made available to assist the practitioner integrate practice computer systems with hospitals. This grant would be payable to private practitioners who choose to integrate their computer systems and participate in electronic patient management systems. The incentive package is designed to promote private practitioners integrate with hospital IT systems.

 

 

 

There are 2500 practitioners in rural and regional Victoria, of whom it is assumed 70 per cent work predominantly in the private sector, at an FTE of 0.75. Thus there would be approximately 1300 eligible practitioners, of whom half would seek the grant, spread evenly over the four years. 

 

Specialist trainees now incur significant fees for College annual membership, training, compulsory course and exams. This cost is in addition to HECS debt. Most trainees would incur costs of at least $3000 per annum, with expenses often exceeding $6000 per annum up to a current maximum of about $14,000 for advanced surgical trainees undertaking exams. An explicit contribution to these postgraduate education costs recognises the direct benefits to the community of having a highly skilled medical workforce. Payments of these education expenses would also make Victoria a preferred employer for this important sector of the workforce who will soon be making major investment decisions about the establishment of a specialist practice.

 

Doctors in training who do rural rotations have particular training needs that require an additional CME allowance. For example, they are often required to undertake additional travel, and are often required to double up on Internet connections. An additional allowance of $1000 for doctors in training who do a minimum of 13 weeks in rural placements would defray some of the additional costs and provide added incentive to train in regional Victoria.

 

 

 

There are an estimated 4000 doctors in training, of whom around 800 are in placements in regional Victoria for a minimum of 13 weeks a year. 

 

Retention allowances for hospital medical staff are an important and cost effective recognition of service, demonstrating to the individual practitioner and to the profession that long term service in rural communities is valued by the Victorian Government.

 

Dissatisfaction with public hospitals is leading to many experienced clinicians taking the option of early retirement. Older clinicians have decades of knowledge of a community and clinical expertise, so health services may need to offer alternative attractive methods of employment (Royal Australasian College of Surgeons 2005). Retention allowances are a token of appreciation of long term service, and may delay retirement.

 

In addition to more flexible working arrangements, AMA Victoria recommends that the DHS hold a pool of funds to encourage the retention of senior doctors in rural and regional Victoria. Doctors who have worked for a minimum of seven years in rural and regional public hospitals would receive an additional annual payment of $5000, payable from a fund held by DHS so that hospitals’ budgets are not put under additional pressure.