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National Rural General Practice Study (NRGPS) - Exective Summary & Final ReportThe final report for the National Rural General Practice Study includes six complete individual reports covering the key topic areas included in the Study, and two introductory reports dealing with key literature and methodology. Each of the eight reports are presented according to the report style required by the General Practice Evaluation Program and the National Information Service. The introductory reports are:
The six topic-area reports are –
Results were disseminated through a series of Working Papers and are include on this site for your perusal (see Abstracts section). Background to the StudyThe National Rural General Practice Study was concerned with describing the rural medical workforce in Australia. The Study aimed to identify the goals, criteria, and evaluation factors involved in general practitioners’ decisions to practise in rural areas. The results of the Study will assist policies, programs and initiatives in providing information to practitioners and prospective practitioners which may influence decisions about where to practice. Four key studies of the rural medical practitioner workforce in various parts of Australia were conducted between 1987 and 1992. While these four do not constitute the total literature regarding the rural medical workforce, they are generally recognised as the key quantitative studies, and have had substantial influence on workforce policy, including training programs, in the various States in which they were undertaken, as well as nationally. The four key studies were –
The major focus of the previous studies into rural general practice in Australia was on the issues of recruitment, retention, and training. A deal of information has been gathered about training needs, barriers to remaining in rural practice, and barriers to undertaking rural practice. There has been less attention paid to the actual workforce experiences of practitioners beyond workload issues. For example, the previous studies did not consider the characteristics of the communities in which doctors practiced. It appears that there is diversity in experiences between rural and remote areas, for example, but studies have not yet looked for diversity between different rural communities, or between different types of practices in similar communities. The role of the community in shaping the nature of the local general practice services is not well understood. The issues of recruitment and retention in particular are very broad ones, and there is a wide range of information which could be used to help understand the issues and design programs and policies to address them. For example, doctors’ attitudes to their work environments have been used to promote measures for improving locum services in response to concerns about high workloads and poor opportunities for leave. Doctors’ concerns about opportunities for their families have lead to attempts to provide support programs for doctors’ spouses in particular. Perceptions that medical schools haven’t prepared practitioners for country life and country practice have lead to programs to increase the rural oriented focus of medical training, including early exposure to rural practice. The previous studies have placed value on developing profiles of rural general practice in order to identify issues which may be addressed in programs and policy, but also to serve as a baseline for monitoring changes in rural practice over time. While some data items have not been specifically used to influence programs and policies, their value has been to record the status of rural practice so that future studies may be sensitive to any changes that occur. There is a firm policy setting for the National Rural General Practice Study within the National Rural Health Strategy. The Study is both relevant in responding to existing policies, and in influencing the future directions of those policies. The broad purpose of the National Rural General Practice Study was to examine factors influencing the decisions of general practitioners in relation to undertaking rural general practice. In order to maintain the focus of the Study within this broad purpose, some specific aims were identified :
Methodology and Data QualitySome controversy exists about how to identify rural practitioners. The National Rural General Practice Study was able to explore both geographic and functional notions of the rural practice community by comparing geographic location with practice characteristics and practitioner perceptions of community. There was a high response rate to the National Rural General Practice Study national survey of rural doctors. Survey data, combined with analysis of existing data about rural practice, was able to extend knowledge about the nature of rural practice, and identify important changes in rural practice that may have occurred since studies were conducted in the late 1980s and early 1990s. Despite many difficulties in identifying both theoretical and practical population frames, there is strong evidence to suggest that the National Rural General Practice Study survey reached a high proportion of rural and remote general practitioners across Australia. The available databases of rural and remote general practitioners, both nationally and at State level, had a number of limitations in identifying rural and remote general practitioner populations, and this may be a barrier for future studies which may not be able to adopt the census approach which was adopted in the National Rural General Practice Study. Confidentiality concerns mean that the NRGPS results cannot be used to assist database development, but database managers may be able to pursue more rigorous updating of their databases if they wish to specifically identify rural and remote practitioners. The National Rural General Practice Study national survey achieved an estimated response rate of over 75% for rural and remote doctors. This response rate, while quite high, may have been further improved by more accurate databases (allowing more targeted reminders) and central management of survey administration. The administration of the survey by different agents in each State and the Northern Territory had many positives, including a strong involvement by those agencies in developing and promoting the Study. The trade off of potentially lower response rates (especially in Queensland) was considered well worthwhile. The mail out survey methodology was the only methodology seriously considered for contacting such a geographically diverse population. The survey appeared to produce good quality data as a result of adhering to specified principles –
The most immediately valuable existing data source has been the Australian Institute of Health and Welfare Medical Labour Force Series, while the Australian Bureau of Statistics data, although expensive to access, would also provide valuable information. Adhering to the design principles resulted in a relatively short, well targeted survey with a mix of attitudinal and quantitative data. The survey results represented a valuable source of information about rural and remote general practitioners across Australia, which was able to be analysed in conjunction with existing information. 1. Demography and Family CharacteristicsThere was strong evidence of an ongoing increase in the percentage of female rural practitioners. While this has been previously anticipated and acknowledged, there was also evidence that rural practice is not seen as attractive for female practitioners. Female practitioners were not entering rural practice at the rate that they were entering metropolitan practice. Rural practice models may not encourage or even permit some of the practice characteristics that have been noted as different for female as opposed to male practitioners. Regardless of whether this is a ‘reality’ or a perception held by female doctors, the effect may be that female practitioners will continue to avoid rural practice. Communities, rural Divisions of General Practice, training programs, and individual practices need to make the decision to permit and encourage different ways of practising, and to promote this decision to female practitioners. Rural areas may not be perceived as being able to provide adequate support for the families of female practitioners, especially their partners. While this may also be a factor for male doctors, the evidence suggests that male doctors are more likely than female doctors to undertake practice in an area where there are not good opportunities for their partner. Female doctors will avoid these areas. Rural communities and practices which are attempting to attract doctors must acknowledge this and promote the opportunities (not all of which need to be related to employment) that they can offer to doctors’ partners and families. The difficulties experienced in attracting female doctors may also be related to difficulties in attracting young doctors, as the greater proportion of female practitioners are in younger age groups. There was no evidence that a focus of recruitment programs on young doctors and medical students has so far contributed to any increase in the uptake of rural practice among those doctors. This may be a pointer to some lack of success by such programs, or it may indicate that many of these programs have not been implemented for a long enough period of time to be showing results at this stage. The lack of uptake of rural practice by young doctors may also indicate that young doctors want to work in different ways from the traditional rural practice model (myth?). The perception may be that rural practice does not allow for flexibility in working arrangements to the same degree that metropolitan practice does. There is an apparent continued shrinking of the population of doctors who are willing to practice in the way that they perceive rural practice requires. In order to increase recruitment into rural practice, either the myths of practice requirements (long hours, lifetime commitment, procedural emphasis etc) will need to be dispelled, or models of practice implementation (if these characteristics are not myth) will have to be changed. Promoting rural practice as a distinct discipline which requires unique skills and a special character may be damaging the potential to recruit young doctors. Promoting the diversity of practice experiences available in rural areas may be a more positive recruitment strategy than the distinct discipline approach. There was no evidence of change in the marital rate of rural doctors, however there was some evidence within Australia that people are getting married later, having fewer children, and having them at older ages. These trends need to be investigated in relation to rural practitioners and their families, as previous studies and National Rural General Practice Study data both suggest that family issues are very important in doctors decisions about where to practice and for how long. The National Rural General Practice Study data related to family structures and locational decision making highlighted a need to recognise that doctors do not spend their entire career in a single practice. There are some characteristics of workforce mobility which may be taken advantage of by communities and practices. For example, communities who are able to emphasise what they can offer a family at a certain stage of its life cycle (for example, a good primary school education for doctors’ children) and at the same time accept that the doctor and their family may leave when that life cycle stage is complete, will have the advantage of a level of confidence that they will retain the doctor throughout that life cycle stage. The emphasis of recruitment and retention programs on the doctor’s family is a valid approach, but it needs to be accompanied by a more accurate picture of doctors’ family types. Previous research, for example, has de-emphasised the importance of female doctors’ partners by excluding them from family data. This has contributed to a less complete understanding of the dynamics of female doctors’ families than male doctors’ families, and may therefore contribute to difficulties in attracting female doctors to rural practice. 2. Quality of LifeThere were some differences in quality of life expectations and experiences between male and female, younger and older, and rural and remote doctors. The Study was able to provide a method of investigating differences between groups of doctors. The quality of life analysis presented in the Study report really only touched the surface in terms of the depth of knowledge that can be gained about different groups of practitioners and their expectations and experiences. Quality of life profiling in particular can be used to help design and evaluate recruitment, retention and support programs, and models of general practice service delivery. There were some further fundamental issues relating to quality of life and the value of profiling which were addressed in later working papers –
Recruitment, retention and support programs may find some value in using quality of life profiling as a tool in designing strategies to attract doctors to the country and provide an environment that those doctors find satisfying. Quality of life profiles could be used to identify target markets (ie. Groups from which future rural and remote doctors may be drawn) and strategies to make rural and remote practice attractive to those markets. 3. Practice Length of StayUnderstanding of the length of stay of rural and remote practitioners in given locations could assist in devising strategies for improving the retention of practitioners in rural practice. Information obtained through 1991 census data showed that rural and remote doctors move around more often than city doctors. This creates a problem in rural areas because shortages of doctors mean that vacancies are difficult to refill. The findings of the National Rural General Practice Study showed that the average length of time rural doctors had been in their current practice was approximately 10 years. Doctors intended to stay in this current practice for a further 8 years. All up doctors total anticipated length of stay in a single practice was close to 20 years. The current and intended length of stay of female doctors was less than for male doctors. Younger doctors also had shorter anticipated lengths of stay than older doctors. For those doctors intending to leave their current practice similar percentages planned to move to either a metropolitan, provincial or rural practice. 21% planned to retire, and small minorities wanted to go to remote areas or engage in specialist training. From these results a number of predictions can be made about what rural and remote doctors are likely to do in the future. It is predicted that two thirds of doctors starting in their current practice in 1997 will still be there in the year 2001. However, by the year 2010 less than 50% of these doctors will have remained in their current practice. About a third of remote doctors starting in their current practice in 1997 will be still be there in the year 2005. Length of stay analysis can be applied to a range of groups of doctors to estimate turnover or departure rates. These predictions provide important information that can be used to plan for recruiting and retaining doctors in the rural and remote workforce. 4. Training and SupportThe majority of doctors’ comments about currently offered training and support programs were negative. Additionally, many of the programs had notably low levels of awareness and involvement. This may be due to the programs having very specific target markets, however these were not easily identifiable. Additionally, low levels of involvement could be the result of the relatively short time that many of these programs have been in existence. Generally, the lack of clear markets and objectives of many of the programs made it difficult to offer any substantial performance evaluation. It appeared that the programs may offer more to doctors than just training and professional support. Consequential benefits may include giving practitioners a sense of belonging and validation. Further analysis of how these programs deliver these latent impacts would be very useful in gaining a greater understanding of doctors needs and of coming up with alternative and perhaps more relevant ways to meet them. Further evidence was gained from this study to support the notion that the programs need to pay greater attention to accurately identifying whether their services are congruent with doctors needs. Involvement in training programs did not significantly affect doctors perceptions of training adequacy, either for those whose training adequacy had improved since entering their current practice, or for those whose level of adequacy had been maintained or declined. It may have been that the programs did not affect doctors perceptions of training adequacy because doctors were reluctant to say that they were adequately trained due to a belief that medicine is an area that requires constant training and skills updates. The training programs themselves may influence this reluctance because of the many areas of continuing medical education that they present to doctors, raising awareness of the need for continued training. Doctors who felt adequately trained were more likely to have had more years of experience both medically and in the one location than doctors that did not feel confident with their level of training. Doctors who felt adequately trained were more likely to want to stay in the one location. For retaining doctors this is an important variable. Furthermore, female doctors were less likely than their male counterparts to feel that their training had become adequate. This has additional implications for the training programs to pay particular attention to the training needs of female doctors. The majority of doctors surveyed indicated some specific training needs. The most popular of these was for general continuing medical education, followed by emergency medicine, obstetrics and gynaecology. Remote doctors were more likely than rural practitioners to identify other specialist areas as being ones for which training was required. Interestingly, there were few doctors who indicated training needs in Aboriginal health despite there being many doctors who had contact with these patients, and 15% who expressed dissatisfaction with these consultations. On the other hand the study did show that there was a commitment by doctors to improve their contacts with drug and alcohol dependent patients. Drug and alcohol dependent patient consultations received a high degree of unsatisfactory ratings and to match this a substantial minority of doctors indicated training needs in this area. 5. Attitudes to ChangeThe results of the National Rural General Practice Study suggest that most doctors perceived that there had been influential change in a range of areas. While there were consistently positive views of the influence of change in the practitioner’s own employment and continuing medical education, there were consistently negative views of the influence of change in State and national health policy. A deal of variety in perceptions of the influence of change existed for most other factors, although only four factors had a higher percentage of respondents perceiving positive than negative change (own employment, C.M.E., staffing of the practice, and patients treated). There were few differences in perceptions of change based on age, sex or locality (rural and remote). Rural doctors were more likely than remote doctors to think that changes in social and economic conditions had been negative. Female doctors were more likely than male doctors to think changes in local health and hospital services had been negative. There were some indications that doctors with greater practice mobility had more positive experiences of recent changes. This may be related to a perception by these doctors that they had some control over the level of change that they experienced. There were no significant relationships between attitudes to change and involvement in any of the training and support programs except the Rural Training Stream of the RACGP. It is possible that the change items identified for this survey did not adequately identify aspects of the professional environment which may have been influenced by program content. More thought could be given to identifying such aspects in any future survey. Even with that possibility, however, there was little evidence to suggest relationships between perceptions of change (as positive or negative) and involvement in programs which may have been expected to have an impact on those aspects of change. Change management may be an important skill for rural and remote medical practitioners. This is evidenced by a strong perception that recent change in many areas of the professional environment had been influential. The national survey received a high percentage of qualitative responses from doctors about the types of changes they had experienced and the effects that these changes had on their professional and personal environments. The current study lacked the resources to explore these qualitative responses in any depth. Analysis of these responses may provide further valuable information about the ways in which rural and remote doctors perceive change as happening and the influences change has had. This could be used to help design training and support programs which are more sensitive to doctors needs to manage the change process. 6. State ComparisonsThis paper identified a series of key tables from previous working papers, and provided information based on these tables for each of the States and the Northern Territory. No attempt was made to quantify the significance of differences between the States. The paper demonstrated that the data from the National Rural General Practice Study could be analysed at State level, and that further analysis of similarities and differences between the States would be possible. The tables presented in this paper will be useful supplements for the tables presented in previous working papers for those readers particularly interested in the characteristics of specific States or the Northern Territory. ConclusionsThe key conclusions of the National Rural General Practice Study were that there is a clear need for policy and programs to more adequately consider the future nature of the rural and remote medical workforce. By concentrating on maintaining existing models of practice, and by designing programs which appeal mainly to the types of practitioners who are currently in rural and remote practice, there is a real risk that the total possible pool of rural and remote practitioners will continue to shrink. Past experience has demonstrated beyond doubt that there are not enough practitioners prepared to work under the type of conditions typically associated with rural and remote practice. Efforts to produce more such practitioners have been largely unsuccessful. Consequently, there needs to be substantial attention paid to making rural and remote practice a viable option for a greater variety of practitioner types. In particular, models of rural and remote practice should focus on the needs and wants of female practitioners and young male practitioners. Some practical changes to workforce policy which may have direct impacts on the range of practitioner types who may be attracted to rural and remote practice include –
It has become obvious that attempting to maintain the existing rural and remote practice models has contributed to a narrowing of the potential workforce base. There is an urgent need to address this issue, or under-servicing of rural and remote populations will not only continue, but will become a more acute problem in health service provision in Australia. The Future of the StudyThe National Rural General Practice Study offered a valuable source of information about the attitudes and experiences of rural and remote doctors across Australia. The information supplements existing data about rural and remote general practice, and would also serve as a baseline for monitoring changes in the nature of practice and the characteristics of practitioners. The total value of this Study will be realised if attempts are made to update the data set at regular intervals. The National Rural General Practice Study has indicated some areas where further research is required. General Practitioner mobility has been identified as a key issue, and the use of Census data to further explore this issue is recommended. It is also recommended that the career choices of female medical students be explored in greater detail. A further area of research would be in tracking the practice locations of General Practitioners throughout their practice lifetimes to investigate the patterns of movement around rural and remote practice Further InformationFurther information about the National Rural General Practice Study and its implications for rural general practice policy in Australia can be found in the study working papers and final report. You can obtain copies of the working papers and final report from the School of Rural Health. |
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