Country practice: recruiting doctors to work in the bush

If you live far from a city, you are likely to be in poorer health than your urban counterparts; you’re also less likely to use health-care services and if you do, you’ll have to wait longer for care. In rural areas, almost one-third (29%) of patients wait 24 hours or more to see a GP for an urgent appointment. Waiting times for emergency hospital care are also getting worse in rural areas but improving in major cities.

If you live in the country, your GP is more likely to have qualified in Europe, the Indian sub-continent, or Asia, than Australia. GPs from overseas are forced to work in rural areas for a fixed period after they arrive, with around 40% of doctors in rural areas qualified in other countries.

These GPs fill an important gap; in the absence of effective policies to encourage Australian-trained GPs to work in rural areas, we will continue to rely on overseas-trained doctors for some time. This is a very cost-effective policy for Australia, but the ethics of depleting the supply of doctors from developing countries are murky.

Many of these doctors want to eventually work in the city, and so they are difficult to retain once their obligatory time in the bush is completed.

The release on Friday of a Commonwealth-commissioned, independent review of Australia’s health workforce programs is one in a long line reports that have attempted to shift the balance between metropolitan and rural access to health care. Yet after each review, we find ourselves in the same position: spending hundreds of millions of dollars on new programs with no evidence of their effects.

Yes, there are many and well-intentioned policies that focus on recruiting people into medicine who grew up in rural areas, and increasing the amount of medical training based in rural areas through rural-based clinical schools. But these policies are expensive and we don’t know whether they work.

A lack of any proper and rigorous evaluation means that we cannot move on because we do not know if anything has changed. In the meantime, rural waiting lists are getting longer and health inequities widen between those living in rural and metropolitan areas, suggesting we need to do more.

Not just money

Persuading a doctor to move to the bush, or to persuade doctors already there to stay, depends on a complex mix of family, professional, and social factors.

Funding and financial incentives play an important role – and are the government’s main policy lever. Funding can be paid directly to GPs, or can be used to fund locum cover (replacement doctors) or other means of support. But a financial solution alone isn’t cheap; a recent study found that GPs would need to be paid A$270,000 in take-home pay to move to the “worst” rural area. But improved working conditions would reduce this amount.

Financial incentives are certainly not the only way to recruit and retain doctors in the bush. The MABEL survey of Australian GPs identified six key factors that influence doctors’ decisions: on-call requirements, hours of work, the ability to take time-off, spouse employment opportunities, schooling arrangements, and public hospital work.

These six indicators have been used to develop a new rural classification system based on population size, which will be developed further over the coming months.

This new system will be used to improve the allocation of funding for rural incentive schemes. Ideally, the distribution of these funds should be based on which areas and towns are in more “need” of doctors than others. The areas that have higher needs than others – poorer health and worse risk factors for disease, longer waiting times, and GPs who working long hours and provide 24-hour care – should therefore receive a greater level of funding to attract more doctors.

So will this new classification system lead to more doctors in the bush? Better targeting of incentives should mean that areas that really need a doctor are more likely to get one.

But to demonstrate this and ensure the goals are being met, we need good evaluation built into the program roll-out. Policymakers are often too keen to get the money out of the door than spend some time and money building in proper evaluation. This needs to change, otherwise we will be having the same discussion in five to ten years time.

Anthony Scott receives funding from the Australian Research Council and National Health and Medical Research Council (NHMRC). The NHMRC funds the Centre for Research Excellence in Medical Workforce Dynamics, which houses the Medicine in Australian: Balancing Employment and Life (MABEL) longitudinal survey of doctors. A key research theme of the Centre is rural workforce supply and distribution, and MABEL data were used in the latest government report mentioned in the article.