Report offers solutions for rural health workforce

FROM: Dr Tim Malloy, Chairman Rural General Practice Network

DATE: 13 March, 2001

SUBJECT: Report offers solutions for rural health workforce

Solutions to the problems of recruiting and retaining doctors for rural areas are outlined in a report released by the Rural General Practice Network today.

"The rural general practice workforce is struggling. We are confronting one crisis after another in rural communities around New Zealand," said Rural General Practice Network Chairman Dr Tim Malloy.

The Network developed the report to seek support and provide solutions for recruitment and retention issues. Nearly a quarter of New Zealanders live in small towns or rural areas and the Network is concerned that the healthcare infrastructure in many of these areas is insufficient to retain and recruit GPs and allied health professionals to provide the quality care that communities need. Some rural communities now have significant gaps in their access to GPs.

The doctors who work in these areas face long-working hours, a high level of on-call responsibilities, the need for extra competencies (such as advanced obstetrics and emergency skills), limited or absent back-up from specialists and other health professionals, limited opportunities for education or training, professional isolation, and high practice start-up costs.

"If we are to begin to address the problems of supporting our country doctors within their communities, then we must address all the issues, not have a piecemeal approach to crisis management," Dr Malloy said.

The report contains 29 recommendations in the areas of training, compensation and work/lifestyle support.

"Some of these recommendations have begun to be implemented, and we would seek to have them endorsed nationally as policy.

"Others have not been tackled at all and we believe that it is time the Government confronted the issue in its entirety, or we fear for some rural communities which are facing the prospect of a failing primary health care service," Dr Malloy concluded.

CONTACT DETAILS ARE:

Dr Tim Malloy (025) 767 152

ATTACHMENT FOLLOWS...

Rural General Practice Network (Inc.)

Recommendations for Recruiting and Retaining Doctors to Work in Rural New Zealand

PREAMBLE

The recommendations in this document by the Rural General Practice Network Inc. (RGPN) pertain to rural general practitioners (GPs), as this is our field of expertise. However, we are forever conscious that effective healthcare can best be achieved by a team approach, particularly in rural areas. The ensuing document will be relevant, not only to rural GPs, but also to other rural health professionals, although each will have unique issues of their own. Our intention is to work collaboratively with all rural health professionals and others to ensure an integrated approach to recruiting and retaining all rural health professionals.

INTRODUCTION

The RGPN believes that all New Zealanders should have reasonable access to uniform, high quality health care. The RGPN is concerned, however, that the health care infrastructure, including level of professional support, in rural areas now is insufficient to retain and recruit GPs and allied health professionals to provide the quality care communities need.

Some rural populations now have significant gaps in their access to GPs within a reasonable distance for provision of adequate medical care. The lack of a defined rural health strategy in New Zealand (NZ), in the face of this growing crisis, reflects poorly on a Government which expressed a commitment to improving rural health before the last election. NZ is being targeted as a recruitment ground for countries seeking to address their needs by offering incentive packages for qualified people, including GPs, to emigrate.

The RGPN is concerned and is making these specific recommendations to assist Government in its efforts to retain and recruit rural GPs, and thereby maintain health services in rural communities.

The following 3 key issue areas are addressed in this policy:

training, compensation, and work/lifestyle support.

Commitment, cooperation, and coordinated action by all stakeholders, including governments, medical schools, professional associations, communities, iwi and others, are urgently required.

NZ GPs and other health care professionals are greatly frustrated by the impact that health care budget cuts and constant reorganization have had, and continue to have, on the timely provision of quality care to patients and general working conditions. For many GPs who practise in rural communities, the impact is exacerbated by the breadth of their practice, as well as long working hours, geographic isolation, lack of professional backup, and access to specialist services.

This policy has been prepared to challenge and assist Government, policy-makers, District Health Boards, communities, iwi and others involved in the retention and recruitment of rural GPs to understand the various professional and personal factors that must be addressed to retain and recruit doctors to rural areas of NZ. In addition, it is recommended that any strategies developed should not be coercive, and must include community and GP input. They must also be comprehensive, flexible and varied to meet and respond to local needs and interests.

DEFINITIONS

Rural: The terms ‘rural’ medicine may be related to many things: the GPs themselves, the population they serve, the geography of the community, or access to medical services. For each of these factors, there are a number of ways to define and measure rurality.

For example, the Rural Ranking Scale, developed by the RGPN, is now used by the HFA to define a ‘rural GP’ for purposes of claiming rural bonus payments. The key characteristics that define a rural GP on this scale are frequency and level of on-call responsibilities, distance to nearest major hospital, size of rural area, and distance to nearest GP colleague.

Table 1 shows NZ’s rural population according to the 1996 NZ census1. At least 24% of NZ people live in small towns or rural areas.

Table 1. NZ’s Rural Population

Rural areas (<1,000): 554,000 (15%)

Small towns (1-10,000): 325,000 (9%)

Big towns (10-30,000): 268,000 (7%)

Total: 1,147,000 (31%)

Medical education: For the purposes of this policy, ‘medical education’ is understood to encompass the entire continuum from undergraduate to postgraduate; including medical school, hospital rotations (house surgeons), registrars, advanced vocational education, and ongoing professional development including maintenance of professional standards (MOPS).

1) Training

International studies have shown that medical trainees who were raised in rural communities have a greater tendency to return to these or similar communities to practise medicine2,3. This is even more likely if the medical school educational experience is sited close to home4. Some studies also show that medical students who have an extensive undergraduate experience of rural practice as part of the curriculum5,6 and/or as an elective in rural or remote communities7 were better prepared to consider rural practice as a career choice. Exposure to a rural practice environment during residency or registrar training predicts not only greater preparedness to consider rural practice8 but also greater preparedness for small town living which results in longer retention in rural or remote communities9. Pathman et al9 found that “being prepared for living in a rural community is more important to retention than is being prepared for the practice of rural medicine.” Also “residency rotations in rural areas are the best educational experiences to prepare physicians for rural roles and promote their retention.”

The RGPN applauds those medical schools that promote careers in rural medicine and provide medical students with exposure to rural practice during their training. Regular collaboration and communication among directors of rural programmes, as well as rural medical educators and leaders from other health disciplines, are strongly encouraged so that rural training issues and possible linkages may be discussed. The benefits of rural training extend not only to those GPs who ultimately end up in rural practice; those who remain in urban areas also benefit by having an enhanced understanding of the challenges of rural practice. The RGPN believes that relationships among medical schools, the Royal NZ College of GPs (RNZCGP), the practising profession, and communities need to be formalized, particularly since medical schools and the RNZCGP have crucial roles in helping to recruit and retain GPs for rural communities.

The medical school’s role in such a partnership takes the form of a social contract. This contract begins with the admission of students who demonstrate a prior interest in working in rural communities and may even come from these communities. It also includes the exposure of students to rural practice during their undergraduate and post-graduate training. It is followed by the provision of specialized training for the conditions in which they will work and ongoing educational support during their rural practice. For these reasons, the RGPN strongly encourages academic centres, Government, professional associations (including the RNZCGP and NZMA), rural communities and iwi to work together to formally define the geographic regions for which each academic centre is responsible. The academic centres are also encouraged to include within their mission a social contract to contribute to meeting the health needs of their rural populations.

Rural GPs require a commitment to lifelong learning to ensure quality care for their patients. They must stay knowledgeable about clinical and technological advances in health and must maintain, as well as learn new, advanced clinical skills to better serve the patients in their communities, especially when specialist and/or hospital services are not readily available. There are many practical and financial barriers that GPs in rural communities face in obtaining and maintaining additional skills training, including housing, practice and other costs (e.g. locum expenses) while they are away from work. The RGPN strongly encourages Government to develop and maintain mechanisms to reduce the barriers associated with obtaining advanced or additional skills training.

In light of these issues, the RGPN recommends that

1.Universities, Government and others encourage and fund research into criteria that predispose students to select and succeed in rural practice.

2. All medical students, as early as possible at the under-graduate level, be exposed to appropriately funded and accredited rural practice environments.

3. Medical schools and the RNZCGP develop training programmes that encourage and promote the selection of rural practice as a career.

4. Universities work with professional associations, Government and rural communities to determine the barriers that prevent rural students from entering the profession, and take appropriate action to eliminate or reduce these barriers.

5. A website based compendium of rural experiences and electives for medical students be developed, maintained and adequately funded.

6. Advanced skills acquisition and maintenance opportunities be provided to GPs practising in or going to rural areas.

7. GPs who work in rural areas receive full remuneration while obtaining advanced skills, including support for the locum who will replace them.

8. Providers, funders and accreditors of continuing professional development for rural GPs ensure that the education is developed in close collaboration with rural GPs and is accessible, needs-based and reflective of rural GPs’ scope of practice.

9. In order to promote mutual understanding, universities encourage teaching faculty to work in rural practices (either based there or as locums) and that rural GPs be invited to teach in academic centres.

10. Medical schools and the RNZCGP develop training programmes for students, house surgeons and registrars that encourage and promote the provision of skills appropriate to rural practice needs.

11. Medical schools support rural GPs doing research and provide full faculty status to these individuals.

12. Universities must ensure that financially-supported research and both rural and core curriculum teaching occurs in rural practices.

2) Compensation

The RGPN believes that compensation for GPs who practise in rural areas must be flexible and reflect the full spectrum of professional and personal factors that are often inherent to practising and living in such a setting. These professional factors may include long working hours and the need for additional competencies to meet community needs, such as advanced obstetrics, emergency and general surgery skills, as well as, psychotherapy, chemotherapy, and working in a rural hospital. They may also include a high level of on-call responsibilities as well as limited or absent backup from specialists, nurses or other allied health services that are usually available in an urban environment. Other challenges are professional isolation, limited opportunities for education or training, and high practice start-up costs. Also, if for a number of reasons a physician wishes to relocate to an urban setting, he or she may face Section 51 restrictions as well as challenges in finding a replacement physician for the rural community. Compensation for these factors is necessary to help retain GPs and recruit new ones. In addition, compensation should guarantee protected time off, paid continuing medical education or additional skills training, and locum coverage. Any pool of locums for rural practice should be adequately funded and licensing problems should be minimized.

The personal factors also require recognition and the negative ones addressed. Living in a rural or remote community can be very satisfying for many GPs and their families; however, they must usually forgo - often for an extended period of time - a number of urban advantages and amenities. These include educational, cultural, recreational and social opportunities for their partner, their children and themselves. They may also face altered family dynamics due to a significant decrease or loss of family income if there are limited or no suitable employment opportunities for their partner. The RGPN believes that all GPs should have a choice of payment options and service delivery models to reflect their needs as well as those of their communities. GPs must receive fair and equitable remuneration and have a practice environment that allows for a reasonable quality of life. Although the RGPN does not advocate one payment system for urban GPs and another for rural GPs, it believes that enhanced total compensation should be provided to GPs who work and live in rural communities.

In recognition of these issues, the RGPN recommends that:

13. Additional compensation to GPs working in rural areas reflect the following areas: degree of isolation, community’s socio-economic deprivation, level of responsibility, frequency of on-call, breadth of practice and additional skills.

14. In recognition of the differences amoung communities, payment modalities retain flexibility and reflect community needs and GP choice.

15. Financial incentives focus on retaining GPs currently practising in rural or remote areas, and include a retention bonus based on duration of service.

16. Factors affecting the social and professional isolation of GPs and their families be considered in the development of compensation packages and working conditions.

17. Eligibility criteria for health professionals to work as locums in rural areas be developed in consultation with the providers who will be using the service.

18. The NZ Medical Council work to streamline licensing for overseas locums and ensure that any fees or processes associated with licensing do not serve as barriers to obtaining locums.

19. A rural locum programme be funded by Government and include adequate compensation for accommodation, transportation and remuneration.

20. Regional infrastructures be established to represent and support rural health professionals by organising and administering rural professional development activities and locum relief.

As previously noted, some studies show that exposure to rural areas during training influences students’ decision to practise in those communities upon graduation. The RGPN is concerned, however, that travel and accommodation costs relating to these experiences place an undue financial burden on students. In addition, most GPs in rural areas are already burdened with significant patient loads and find that they have limited time and resources to act as supervisors and teachers. The RGPN believes that, to ensure the ongoing viability of student rural experiences, GP supervisor/teachers should be compensated for their participation and should not incur any additional expenses, such as student or registrar accommodation costs.

The RGPN recommends that

21. Costs for accommodation and travel for student, house surgeon, and registrar rural training experiences in New Zealand not be borne by the trainees or the supervisors/teachers.

22. Training programmes assume responsibility for adequately remunerating supervisors/teachers in rural or remote areas, which includes their initial and ongoing training as teachers.

3) Work and lifestyle support issues

To retain and recruit GPs in rural communities, there are issues beyond fair and adequate compensation that must be considered. It is crucial that the aforementioned working conditions, professional issues and array of personal and family related issues be addressed. The ultimate goal should be to promote rural GP retention and implement measures that reduce the possibility of GP burnout. Like most people, rural GPs want to balance their professional and personal responsibilities to allow for a reasonable quality of life. GPs in rural areas practise in high stress environments that can negatively affect their health and well-being; and as a consequence, their standard of care to patients can suffer. This stress is intensified by excessive work hours, limited professional backup or support (including locums), limited access to specialists, inadequate diagnostic and treatment resources, and limited or no opportunity for vacation or personal leave. At particular risk for burnout is the rural GP who practises in isolation. For these reasons many GPs, when considering practice opportunities, tend to seek working conditions that will not generate an excessive toll on their non-working lives. This reinforces the need for rural practice environments that facilitate a balance between GPs’ professional and personal lives.

In light of these issues, the RGPN recommends that

23. There should be at least 3 health professionals sharing the oncall workload of any locality. However, for those few localities of remote (no other rural GP(s) within 1 hour) small (<1400) populations where it is difficult to justify more than 1 or 2 resident health practitioners, the 1 in 1, or 1 in 2 oncall requirements are compensated by statutory entitlement to extended compensated annual leave for recreation and professional development.

24. The on-call requirement for weekends should never exceed 1 in 4 in any rural locality. [NOTE: Recommendations #23 and #24 may have implications for the ability of some rural GPs to be able to continue to provide comprehensive 24 hour oncall cover.]

25. Government works with rural GPs to identify appropriate rural practitioner/patient ratios that will ensure quality of care and reduce the risk of provider burnout.

26. Government makes professional support (e.g. CME and locums) readily available to GPs who practise in rural areas.

27. Government recognizes the service of rural GPs by ensuring that mechanisms exist to allow future access to practise in an urban area of their choice.

The RGPN believes that rural physician retention and recruitment initiatives must address matters relating to professional isolation as well as social isolation for GPs and their families. This sense of isolation can increase when there are cultural, religious or other differences. For unattached GPs, zero tolerance and unreasonable restrictions with regard to relationships with potential patients can be strong disincentives to practise in rural communities.

The medical service infrastructure in rural areas is usually very different from that in urban settings. In addition to a lack of specialist services, GPs in these areas often have to cope with a number of other factors such as Maori health needs, limited access to diagnostic tests, limited if any rural hospital beds, and poverty. GPs and their patients expect and deserve quality care. The diversity and needs of the populations, as well as the needs of the GPs who practise in rural areas, must also be recognized and reflected in the infrastructure (e.g., demographic and geographical considerations).

The RGPN recommends that

28. Basic medical services infrastructure for rural areas be defined, such as hospital beds, paramedical staff, diagnostic equipment, transportation, ready access to secondary and tertiary services, as well as information technology tools and support.

29. Government recognizes that GPs who work in rural areas need an environment that appropriately supports them in providing service to the local population.

The Rural GP Network is prepared to further discuss the provision of adequate rural health services with any organisation seeking to enhance them. The RGPN believes the adoption of the above policy principles would lead to more sustainable, equitable, and responsible medical care of rural New Zealanders.

References

1. Statistics New Zealand, 1996, Census of Population and Dwellings.

2. Carter RG. The relation between personal characteristics of physicians and practice location in Manitoba. Can Med Ass J 1987; 136: 366-8.

3. Kassebaum DG, Szenas PL. Rural sources of medical students and graduates’choice of rural practice. Academic medicine 1993; 68: 232-6.

4. Magnus JH, Tollan A. Rural doctor recruitment: does medical education in rural districts recruit doctors to rural areas? Medical Education 1993; 27: 250-3.

5. Chaulk CP, Bass RL, Paulman PM. Physicians’ assessments of a rural preceptorship and its influence on career choice and practice site. Journal of Medical Education 1987; 62: 349-51.

6. Rolfe IE, Pearson SA, O’Connell DL, Dickinson JA. Finding solutions to the rural doctor shortage: the roles of selection versus undergraduate medical education at Newcastle. Aust NZ J Med 1995; 25: 512-7.

7. Peach HG, Bath NE. Comparison of rural and non-rural students

undertaking a voluntary rural placement in the early years of a medical

course. Medical education 2000; 34: 231-3.

8. Norris TE, Norris SB. The effect of a rural preceptorship during residency on practice site selection and interest in rural practice. J Family Pract 1988; 27: 541-4.

9. Pathman DE, Steiner BD et al. Preparing and retaining Rural Physicians through Medical Education. Academic Medicine July 1999; 74: 810-20.

Appendix 1. RGPN recommendations for recruiting and retaining doctors to work in rural New Zealand.