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Beyond money: what do rural doctors want?

Health economist Dr Abby Kamalakanthan writes:

In an interview on ABC Radio’s Afternoons with Georgia Stynes last week and in the UQ News article ‘Incentives won’t fix the rural doctor problem’, I argued that although the Australian Government in recent times has introduced various financial incentives aimed at enticing more urban GPs to the rural areas of the country, we are still witnessing a supply shortage of GPs in many rural and remote communities.

Clearly then, throwing more money at GPs is not going to solve the rural supply problem.

It is time that the Federal Government realises this and starts looking elsewhere for solutions.

Unlike the bureaucrats in Canberra, I decided to go straight to the source (the GPs themselves) when conducting my PhD research to find out what incentives would really keep GPs in the rural areas. My survey of 1,000 GPs in four states was a real eye-opener.

What’s Available Now

The main financial incentive available to rural GPs right now is the General Practice Rural Incentives Program (GPRIP) which came into effect on 1 July 2010 and was funded in the 2009-10 Budget as part of the Australian Government’s Rural Health Workforce Strategy (see the General Practice Australia website for more information on this scheme).

Basically the program combines the previously separate Rural Retention Program and the Registrars Rural Incentive Payments Scheme, and introduces a relocation incentive grant. Incentive payments are based on the length of time a GP Registrar is placed in an Australian Standard Geographical Classification – Remoteness Area category, on a sliding scale.

The other financial incentive is the HECS-HELP reimbursement program for Australian graduates who graduated in 2000 or later. Participants in the scheme will have one fifth of their HECS-HELP fees reimbursed for each year of medical training undertaken or service provided in the Rural, Remote and Metropolitan Areas zones 3-7 (these locations include large and small rural and remote centres).

Are These Incentives Working?

A day after the GPRIP was announced by Canberra, rural doctors attacked the scheme in The Australian, saying the rules were “ridiculous” and gave doctors the same amount for moving to Hobart as to the tiny NSW town of Tumut.

Rural Doctors Association of Australia President, Dr Paul Mara, a GP at Gundagai in southern NSW, said the program was a good idea but it “falls to pieces when put into practice”, and the zones were “completely ridiculous”.

So What Do Rural GPs Really Want?

When deciding their practice location, most GPs have a tendency to compare financial incentives against non-financial incentives.

My GP survey results show that there are a number of non-financial incentives which are of particular relevance to policy-makers as possible solutions to improve rural GP supply.

These include many important factors which GPs in urban areas take for granted, such as basic orientation, support for families and good schools for children, support for further study, local community support, infrastructure support, locum relief and adequate IT facilities such as having broadband Internet access.

Younger GPs, in particular, are inclined to make decisions based on such benefits as leave entitlements, flexible working hours, and gaining recognition for teaching; and such costs as the extent of social isolation.

In addition it is necessary to provide foreign-born overseas-trained doctors with a standard accredited orientation program, give them the opportunity to enrol in the GP fellowship preparatory program, help them to understand the Australian culture, and provide them with English language support. Another suggestion is that after working in rural locations for three years, overseas-trained doctors on temporary visas should be granted permanent resident status of citizenship.

Policy-makers need to also acknowledge that rural GPs might want to return to the cities at some stage in their career because working in the rural areas may hamper their access to specialty training.

One of the policies that could be considered by Canberra is if GPs work for at least five years in a rural area and they choose not to remain in general practice, then they should be rewarded with admission to a specialist training program.

The moral of this story is without some out-of-the-box thinking in Canberra, doctor supply in rural Australia is unlikely to improve either now or in the future.

• Dr Abby Kamalakanthan obtained her PhD in Health Economics from The University of Queensland. The title of her thesis was ‘An Economic Analysis of the Supply of General Practitioners in the Rural and Urban Areas of Australia’. Her study received financial support from The University of Queensland Special Graduate School Scholarship and UQ School of Economics PhD Research Grant.

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  • 1
    Gavin Mooney
    Posted May 25, 2011 at 2:14 pm | Permalink

    This sort of research is so welcome.

    I am however slightly surprised that ‘lack of professional/emotional support’ was not an issue, especially for young doctors. I recall that a young doctor colleague, working in a rural location (but in a hospital certainly), when one of their patients died (I don’t know the details), was very upset. This was the first time this had happened. They could not get professional or emotional support locally and had to rely on a psychiatrist friend over the phone from many hundreds of kilometres away. That must have been very difficult. That sort of lack of support cannot help to attract doctors to rural and remote areas.

    Far more important is that this research was done – and is now acted on.

  • 2
    abby kamalakanthan
    Posted May 25, 2011 at 4:35 pm | Permalink

    Thank you Gavin. I’m a big fan of your work as well.

    I fully agree with your comment. One of the main findings of my research was that there is a lack of professional support for GPs in the bush from other GPs and specialists. I spoke about this in both the UQ News article and on ABC Radio (click on the ‘UQ News Article link’ above). While I didn’t look into the emotional support issue, my research certainly acknowledges that social isolation is a major problem in the rural areas.

    I suppose that emotional support is another issue that should be added to the list of ‘types of support’ that are needed in the rural areas.

  • 3
    Jonny Levy
    Posted May 26, 2011 at 11:16 am | Permalink

    Hi Abby – great research.

    The view I have come to hold regards your conclusions.

    Nearly all of the general discussion around rural medical workforce supply concerns ‘carrots’. Many and varied carrots have been on offer for years. Some are lovely, fresh, juicy orange ones but some taste and look a bit funny. The end result, however, is rural starvation as these carrots are largely ignored.

    I hesitate to use the term ‘stick’ – but many out there will perceive what I suggest as just that. The rationale behind my view is that Australia’s rural population and overseas-born doctors have been mercilessly beaten by several sticks for ages – now it is time to stop and redirect legislative efforts.

    I strongly feel that there should be a component of post-graduate rural/remote medical service for ALL doctors, as a condition to be fulfilled before becoming eligible for any fellowship pathway.

    There are many reasons for this, such as re-instituting a sense of vocation onto our profession and expanding our primary care workforce skills. But mainly it is because rural folk are dying due to lack of access to timely medical care. This is unacceptable.

    We are not accountants or lawyers (sorry dad & wife!) – we are different and should be better. We have a duty. Those entering the profession should do so embracing such a societal duty. If the police and teachers have acted upon this rural need, why in the world can’t we?

    I do not advocate the 24/7 immersion of yesteryear at all – this is destructive. But, equally, the 9-5 jobnik attitude of so many current graduates stinks. There should be a compromise – and all of us (doctors and society) would be the richer (literally, figuratively and educationally) for it.

    s19AB is probably going to go, thus releasing (hopefully slowly and carefully) many thousands of overseas-born doctors from rural service. Many regional GPs are in their 50s looking down the barrel of retirement. If you reckon the workforce hole is bad now……..

    I think it is time to act – or at least discuss wehat action should be taken.

    I hope that this puts the cat amongst the carrots!

  • 4
    jhal4058
    Posted May 27, 2011 at 9:43 am | Permalink

    It is clear this was research done with good intent, however I fear the conclusions drawn from this could be ultimately damaging for the health of rural communities in Australia. The data collected in this survey based research confirmed what most rural health workers would have expected. Rural doctors are relatively happy with their pay but would dearly love more time with their families and a more healthy work life balance. If they were significantly unhappy with their pay they wouldn’t continue to work in the bush. What they need to improve their quality of life and reduce their on-call burden is more doctors in the bush. These extra doctors cost money and incentives are required to attract and retain them. If we really want to answer the question, “Do financial incentives improve recruitment and retention in rural medicine?”, the questions should have been asked of prospective rural trainees, ex-rural doctors and urban doctors. The question that needs to be asked of these folk is “What would it take, in terms of pay and conditions, to get you to move to the bush to work?”. There is good anecdotal evidence that improving pay and incentives puts bums on seats in the bush. Let’s take state funded rural practice in QLD over the past few years as an example. With the advent of significant industrial improvements in 2006 there has been a major increase in the number of doctors working in rural QLD. In the Darling Downs district of southern QLD alone there has been over 60% increase in the number doctors working in previously understaffed rural hospitals . To conclude that money based incentives won’t work because existing rural doctors are happy with their pay is flawed logic. As you have pointed out the reason why many of the federal based incentives aren’t working is because they are poorly thought out and administered and don’t go far enough. Many of the financial incentives are tied up in red tape and do not make a significant difference to peoples take home pay. Currently one can earn equal to or more than a rural practitioner in a 9-5 urban practice depending on the business model. Significant changes would have to have an impact on baseline pay i.e. rural based item numbers, that could include doctors, nurses, midwives and allied health. If we expect rural doctors to work in procedural practice, with a heavy burden of unsociable hours and complex emergency care, it follows there should be higher levels of remuneration to recognise the risk, responsibility and social impact they endure. Whilst there are numerous advantages to living and working in the bush one can’t discount the significant personal, social and financial costs involved in rural and remote living. Headlines splashed around in the media asserting rural doctors don’t want or need better pay to work in the bush sends the wrong message to government. They are looking for any excuse to cut funding to the politically marginalised minority in rural Australia. We need to establish and maintain a real pay differential for the rural health sector. Recently the Australian institute of health and welfare(see attached) reported a whopping 2.1Billion underspend annually on primary care in rural areas based on a per capita comparison to the urban Medicare spend. This money should be reinvested in premium salaries and improved conditions for all members of the multidisciplinary health care team to attract, retain and reward them for their tireless work. They have less access to specialist care and often perform generalist work covering large areas of their respective professions. No longer can governments exploit the good will and dedication of those willing to persist in caring for our rural and remote communities. Remembering it is these hardworking and stoic communities from whom we derive much of our nation’s wealth, culture, and heritage.

    Dr John Hall Bsc(Hons) MBBS FACRRM DRANZCOG(adv) FRACGP Grad Dip Rural Dip ACSM
    Secretary RDAQ

  • 5
    steve sant
    Posted May 27, 2011 at 10:47 am | Permalink

    Abby, I think you are half right in that half baked incentives such as those offered now do not work and will not work in the future. However, if you look at other research such as that undertaken by Tony Scott on the MABEL study it does support the notion that financial incentives are an important part of the picture in getting doctors and other health professionals to rural and remote Australia. In addition to appropriate financial incentives you must have good training programs that prepare doctors for rural practice and you must have other supports in place for them and their families. We also need to recognise that different models of practice are going to be needed and financial incentives support this e.g. if doctors in solo towns could make a good income from working less hours then we could perhaps support two doctors in a town rather that the overworked solo doctor that covers 24/7.

  • 6
    abby kamalakanthan
    Posted May 29, 2011 at 2:17 pm | Permalink

    Thanks for your comments Steve. Yes, I am very familiar with Prof. Scott’s work on the MABEL study. I think it is important for me to point out that many of my findings with regards to financial incentives are supported by the findings of the MABEL study and this is cited in my thesis.

    My study does not dismiss the importance of financial incentives in rural areas. What is important to note is that my study finds that non-financial incentives are as important as financial incentives in the rural areas. My study also supports your comments about the importance of good training programs etc. So I fully agree with your points.

  • 7
    abby kamalakanthan
    Posted May 29, 2011 at 2:23 pm | Permalink

    Thanks for your comments John. I agree with all of your points. I do however want to point out that my study did survey both urban and rural doctors and that similar questions to “What would it take, in terms of pay and conditions, to get you to move to the bush to work?” were asked in the survey.

    It is also important for me to point out that I never said that money based incentives do not work (see my comment above).

  • 8
    Jonny Levy
    Posted May 29, 2011 at 8:52 pm | Permalink

    Hi Abby,
    What are your thoughts on a legislative alteration to staffing the rural/remote medical workforce with medical graduates?
    Short of full legislative change (which may well fall foul of ‘civil conscription’ legislation) might you envisage any other ‘institutional’ changes that could impact positively on this issue?
    Ta.
    Jonny.

  • 9
    abby kamalakanthan
    Posted May 31, 2011 at 3:57 pm | Permalink

    Jonny, I don’t think I am the right person to comment about any potential legislative changes to solve this problem. I will however say that I don’t believe forcing doctors to go to rural areas is the way to go. The bonded scholarship program has its pros and cons in this respect.

    It is important to find a solution that will attract doctors to rural areas, i.e. they want to go there of their own accord.

  • 10
    Jonny Levy
    Posted May 31, 2011 at 4:34 pm | Permalink

    Hi Abby.
    Thank you for your response. I think that – as somebody who has compiled, examined and considered the evidence – you are a great person to comment on the changes needed to solve the problem!
    I agree that, in a perfect world, each doctor would not require “forcing”. Indeed, I hope that such “forcing” self-ceases over the medium-term, as rural service becomes a vocational standard and an absolute expectation of all those entering medical school.
    In the meantime, however, rural folk are dying due to lack of medical access and the workforce hole looms ever larger as older GPs retire and, if anticipated correctly, s19AB is removed from the statute books.
    In this circumstance, providing ‘carrots’ to attract doctors and relying solely on those who go bush of their own accord just will not provide anything like the numbers of doctors needed.
    Is there another effective way to doctor the bush other than those thusfar considered?
    Cheers,
    Jonny.

  • 11
    abby kamalakanthan
    Posted June 1, 2011 at 4:39 pm | Permalink

    Johnny,
    I don’t think going the way of legislation is a solution to this problem. As far effective ways to doctor the bush goes, all the solutions currently in place in Australia such as bonding, rural medical schools, overseas-trained doctors are all solutions that have been tried and tested in many countries. All have their costs and benefits.

    One thing we do know is that the best way to ensure that rural areas have doctors is to encourage high school students from rural areas to enrol in rural medical schools. This was one of the key reasons for establishing the JCU medical school for instance. However, entry to JCU has been and continues to be exploited in the sense that many ‘city’ students attend JCU and nver work in a rural areas.

    Nevertheless, it has long been believed (and there is considerable evidence to back this up) that students who come from rural areas are more likely to remain in these areas because they have a family, social network already established. Given that social isolation is one of the main reason raised by doctors fleeing rural areas, this is an important factor.

    Of course, the other solution is to find more innovative approaches. This is where physician assistants (PA), pharmacy assistants and tele-medicine come in to the equation. It is unfortunate that the UQ PA program is being abolished. These sorts of initiatives would definitely have been a step in the right direction.

  • 12
    Jonny Levy
    Posted June 1, 2011 at 5:34 pm | Permalink

    Hi Abby.

    I really appreciate the time you are taking to reply to my comments.

    I agree with the substance of what you say, but differ in terms of belief in its application in reality.

    Very often, research seems to confirm what intuitively makes sense (in fact, if it doesn’t, one should question the findings carefully). And so it is with the finding the rural folk are more likely to practise in rural locales.

    If there were enough of them, this would be fine. And if they were all ready to go into practise now, that would be the perfect solution.

    However:
    1) Each year an estimated 4600 rural people die, who would not have done were they living in a city. Some of these are due to lack of timely medical access because fo workforce issues.
    2) Given this yearly mortality, solutions really need to be found now.
    3) Building up student groups from regional geographic locations will not yield results ‘on the ground’ for years.
    4) I believe that the only way to bring equality to healthcare provision in a timely fashion is via legislative approaches, that spreads the ‘burden’ amongst all – equally.
    5) The positive knock on effects of this will be:
    a) Some doctors stay out bush, who would otherwise not have if they had not been exposed to rural practise.
    b) Those (majority) doctors returning to metropolitan practise will have extra skills at their disposal that will have the secondary effect of better enabling metropolitan primary care doctors to handle the things often currently sent into hospital – with the resulting easing of pressure on tertiary centres.
    c) The overall culture of medicine in Australia will change with all those entering medical school having the foreknowledge that – upon graduating – they will have a societal obligation that they are expected to meet. Perhaps we – as a profession – will regain some sense of ‘vocation’ that seems to have gone by the wayside.

    Enlisting the aid of other professional groups and harnessing technology are certainly helpful – but not a replacement for actually providing communities with doctors. They, too, may take years to yield results.

    I just feel that the current situation is grossly unfair and contributes to unnecessary mortality and morbidity. It needs swift resolution.

    Jonny.

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