Melbourne Institute of Applied Economic and Social Research - Research Publications
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ItemRural specialists: The nature of their work and professional satisfaction by geographical location of work(WILEY, 2017-12)OBJECTIVE: Systematically describe the characteristics of rural specialists, their work and job satisfaction by geographical location of work. DESIGN: Cross-sectional. SETTING AND PARTICIPANTS: Three thousand, four hundred and seventy-nine medical specialists participating in the 2014 Medicine in Australia: Balancing Employment and Life (MABEL) survey of doctors. MAIN OUTCOME MEASURE: Location of practice, whether metropolitan, large (>50 000 population) or small regional centres (<50 000 population). RESULT: Specialists working in large regional centres had similar characteristics to metropolitan specialists, however, those in small regional centres were more likely men, later career, overseas-trained and less likely to work privately. Rural specialists had more on-call requirements and poorer professional development opportunities. However, satisfaction with work hours, remuneration, variety of work, level of responsibility, opportunities to use abilities and overall satisfaction did not differ. Specialists in general medicine and general surgery were significantly more likely to work rurally compared with anaesthetists, particularly in small regional centres, whereas a range of other relevant specialists had lower than the average rural distribution and paediatricians and endocrinologists were significantly less likely to work in large regional centres. CONCLUSION: Rural specialists are just as satisfied as metropolitan counterparts reporting equivalent variety and responsibility at work. Better support for on-call demands and access to professional development could attract more specialists to rural practice. Increased rural training opportunities and regional workforce planning is needed to develop and recruit relevant specialties. Specifically, targeted support is warranted for training and development of specialists in general medicine and general surgery and overseas-trained specialists, who provide essential services in smaller regional centres.
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ItemAustralia's rural medical workforce: Supply from its medical schools against career stage, gender and rural-origin.(Wiley, 2017-10)OBJECTIVE: The aim of this study was to explore the association between career stage and rural medical workforce supply among Australian-trained medical graduates. DESIGN AND SETTING: Descriptive analysis using the national Medicine in Australia: Balancing Employment and Life (MABEL) longitudinal study. PARTICIPANTS: Australian-trained GPs and other specialists who participated in the MABEL study, 2008-2013. MAIN OUTCOME MEASURE(S): Proportions of GPs and specialists working in rural locations, according to career stage (establishing, early, mid and late), gender and childhood-origin type (rural versus metropolitan). RESULTS: Logistic regression models revealed that establishing- and early-career GPs had significantly higher likelihood (OR 1.67 and 1.38, respectively) of working rurally, but establishing and early-career doctors were significantly less likely (OR 0.34 and 0.43, respectively) to choose general practice, contributing proportionally fewer rural GPs overall (OR 0.77 and 0.75, respectively) compared to late-career doctors. For specialists, there were no significant associations between career cohorts and rural practice. Overall, there was a significantly lower likelihood (OR 0.83) of establishing-career doctors practising rurally. Women were similarly likely to be rural GPs but less likely to be rural specialists, while rural-origin was consistently associated with higher odds of rural practice. CONCLUSIONS: The supply of Australia's rural medical workforce from its medical schools continues to be challenging, with these data highlighting both their source and associations with doctors at different career stages. Despite large investments through rural medical training and rural workforce recruitment and retention policies, these data confirm continued reliance on internationally trained medical graduates for large proportions of rural supply is likely.
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ItemHow does the workload and work activities of procedural GPs compare to non-procedural GPs?(Wiley, 2017-08)OBJECTIVES: To investigate patterns of Australian GP procedural activity and associations with: geographical remoteness and population size hours worked in hospitals and in total; and availability for on-call DESIGN AND PARTICIPANTS: National annual panel survey (Medicine in Australia: Balancing Employment and Life) of Australian GPs, 2011-2013. MAIN OUTCOME MEASURES: Self-reported geographical work location, hours worked in different settings, and on-call availability per usual week, were analysed against GP procedural activity in anaesthetics, obstetrics, surgery or emergency medicine. RESULTS: Analysis of 9301 survey responses from 4638 individual GPs revealed significantly increased odds of GP procedural activity in anaesthetics, obstetrics or emergency medicine as geographical remoteness increased and community population size decreased, albeit with plateauing of the effect-size from medium-sized (population 5000-15 000) rural communities. After adjusting for confounders, procedural GPs work more hospital and more total hours each week than non-procedural GPs. In 2011 this equated to GPs practising anaesthetics, obstetrics, surgery, and emergency medicine providing 8% (95%CI 0, 16), 13% (95%CI 8, 19), 8% (95%CI 2, 15) and 18% (95%CI 13, 23) more total hours each week, respectively. The extra hours are attributable to longer hours worked in hospital settings, with no reduction in private consultation hours. Procedural GPs also carry a significantly higher burden of on-call. CONCLUSIONS: The longer working hours and higher on-call demands experienced by rural and remote procedural GPs demand improved solutions, such as changes to service delivery models, so that long-term procedural GP careers are increasingly attractive to current and aspiring rural GPs.
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ItemDeterminants of rural Australian primary health care worker retention: A synthesis of key evidence and implications for policymaking.(Wiley, 2017-02)OBJECTIVE: To synthesise key Australian empirical rural retention evidence and outline implications and potential applications for policymaking. DESIGN: A comprehensive search of Medline, PsychINFO, CINAHL plus, Scopus and EMBASE revealed eight peer-reviewed empirical studies published since 2000 quantifying factors associated with actual retention. SETTING AND PARTICIPANTS: Rural and remote Australian primary health care workers. MAIN OUTCOME MEASURES: Hazard ratios (hazard of leaving rural), mean length of stay in current rural position and odds ratios (odds of leaving rural). RESULTS: A broad range of geographical, professional, financial, educational, regulatory and personal factors are strongly and significantly associated with the rural retention of Australian primary health care workers. Important factors included geographical remoteness and population size, profession, providing hospital services, practising procedural skills, taking annual leave, employment grade, employment and payment structures, restricted access to provider numbers, country of training, vocational training, practitioner age group and cognitive behavioural coaching. These findings suggest that retention strategies should be multifaceted and 'bundled', addressing the combination of modifiable factors most important for specific groups of Australian rural and remote primary health care workers, and compensating health professionals for hardships they face that are linked to less modifiable factors. CONCLUSIONS: The short retention of many Australian rural and remote Allied Health Professionals and GPs, particularly in small, outer regional and remote communities, requires ongoing policy support. The important retention patterns highlighted in this review provide policymakers with direction about where to best target retention initiatives, as well as an indication of what they can do to improve retention.
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ItemDuration and setting of rural immersion during the medical degree relates to rural work outcomes(WILEY, 2018-08)CONTEXT: Providing year-long rural immersion as part of the medical degree is commonly used to increase the number of doctors with an interest in rural practice. However, the optimal duration and setting of immersion has not been fully established. This paper explores associations between various durations and settings of rural immersion during the medical degree and whether doctors work in rural areas after graduation. METHODS: Eligible participants were medical graduates of Monash University between 2008 and 2016 in postgraduate years 1-9, whose characteristics, rural immersion information and work location had been prospectively collected. Separate multiple logistic regression and multinomial logit regression models tested associations between the duration and setting of any rural immersion they did during the medical degree and (i) working in a rural area and (ii) working in large or smaller rural towns, in 2017. RESULTS: The adjusted odds of working in a rural area were significantly increased if students were immersed for one full year (odds ratio [OR], 1.79; 95% confidence interval [CI], 1.15-2.79), for between 1 and 2 years (OR, 2.26; 95% CI, 1.54-3.32) and for 2 or more years (OR, 4.43; 95% CI, 3.03-6.47) relative to no rural immersion. The strongest association was for immersion in a mix of both regional hospitals and rural general practice (OR, 3.26; 95% CI, 2.31-4.61), followed by immersion in regional hospitals only (OR, 1.94; 95% CI, 1.39-2.70) and rural general practice only (OR, 1.91; 95% CI, 1.06-3.45). More than 1 year's immersion in a mix of regional hospitals and rural general practices was associated with working in smaller regional or rural towns (<50 000 population) (relative risk ratios [RRR] 2.97; 95% CI, 1.82-4.83). CONCLUSION: These findings inform medical schools about effective rural immersion programmes. Longer rural immersion and immersion in both regional hospitals and rural general practices are likely to increase rural work and rural distribution of early career doctors.
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ItemWhat principles should guide visiting primary health care services in rural and remote communities? Lessons from a systematic review.(Wiley, 2018-06)Visiting health services are a feature of health care delivery in rural and remote contexts. These services are often described as 'fly-in fly-out' or 'drive-in drive-out'. Posing the question 'What are the different types of visiting models of primary health care being used in rural and remote communities?', the objective of this article was to describe a typology of models of health services that visit remote communities. A systematic review of peer-reviewed literature from established databases was undertaken. Data were extracted from 20 papers (16 peer-reviewed papers and four from other sources), which met the inclusion criteria. From the available evidence, it was difficult to develop a typology of services. The central feature of service providers visiting rural and remote districts on a regular basis was consistent, although the service provider's geographical base varied and the extent to which the same service provider should be providing the service was not consistently endorsed. While a clear typology did not emerge from the systematic review, it became apparent that a set of guiding principles might be more helpful to service providers and planners. Focusing policy and decision-making on important principles of visiting services, rather than their typological features, is likely to be of ultimately more benefit to the health outcomes of people who live in rural and remote communities.
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ItemLong-term trends in supply and sustainability of the health workforce in remote Aboriginal communities in the Northern Territory of Australia.(Springer Science and Business Media LLC, 2017-12-19)BACKGROUND: International evidence suggests that a key to improving health and attaining more equitable health outcomes for disadvantaged populations is a health system with a strong primary care sector. Longstanding problems with health workforce supply and turnover in remote Aboriginal communities in the Northern Territory (NT), Australia, jeopardise primary care delivery and the effort to overcome the substantial gaps in health outcomes for this population. This research describes temporal changes in workforce supply in government-operated clinics in remote NT communities through a period in which there has been a substantial increase in health funding. METHODS: Descriptive and Markov-switching dynamic regression analysis of NT Government Department of Health payroll and financial data for the resident health workforce in 54 remote clinics, 2004-2015. The workforce included registered Remote Area Nurses and Midwives (nurses), Aboriginal Health Practitioners (AHPs) and staff in administrative and logistic roles. MAIN OUTCOME MEASURES: total number of unique employees per year; average annual headcounts; average full-time equivalent (FTE) positions; agency employed nurse FTE estimates; high and low supply state estimates. RESULTS: Overall increases in workforce supply occurred between 2004 and 2015, especially for administrative and logistic positions. Supply of nurses and AHPs increased from an average 2.6 to 3.2 FTE per clinic, although supply of AHPs has declined since 2010. Each year almost twice as many individual NT government-employed nurses or AHPs are required for each FTE position. Following funding increases, some clinics doubled their nursing and AHP workforce and achieved relative stability in supply. However, most clinics increased staffing to a much smaller extent or not at all, typically experiencing a "fading" of supply following an initial increase associated with greater funding, and frequently cycling periods of higher and lower staffing levels. CONCLUSIONS: Overall increases in workforce supply in remote NT communities between 2004 and 2015 have been affected by continuing very high turnover of nurses and AHPs, and compounded by recent declines in AHP supply. Despite substantial increases in resourcing, an imperative remains to implement more robust health service models which better support the supply and retention of resident health staff.
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ItemA review of characteristics and outcomes of Australia's undergraduate medical education rural immersion programs.(Springer Science and Business Media LLC, 2018-01-31)BACKGROUND: A key strategy for increasing the supply of rural doctors is rurally located medical education. In 2000, Australia introduced a national policy to increase rural immersion for undergraduate medical students. This study aims to describe the characteristics and outcomes of the rural immersion programs that were implemented in Australian medical schools. METHODS: Information about 19 immersion programs was sourced in 2016 via the grey and published literature. A scoping review of the published peer-reviewed studies via Ovid MEDLINE and Informit (2000-2016) and direct journal searching included studies that focused on outcomes of undergraduate rural immersion in Australian medical schools from 2000 to 2016. RESULTS: Programs varied widely by selection criteria and program design, offering between 1- and 6-year immersion. Based on 26 studies from 10 medical schools, rural immersion was positively associated with rural practice in the first postgraduate year (internship) and early career (first 10 years post-qualifying). Having a rural background increased the effects of rural immersion. Evidence suggested that longer duration of immersion also increases the uptake of rural work, including by metropolitan-background students, though overall there was limited evidence about the influence of different program designs. Most evidence was based on relatively weak, predominantly cross-sectional research designs and single-institution studies. Many had flaws including small sample sizes, studying internship outcomes only, inadequately controlling for confounding variables, not using metropolitan-trained controls and providing limited justification as to the postgraduate stage at which rural practice outcomes were measured. CONCLUSIONS: Australia's immersion programs are moderately associated with an increased rural supply of early career doctors although metropolitan-trained students contribute equal numbers to overall rural workforce capacity. More research is needed about the influence of student interest in rural practice and the duration and setting of immersion on rural work uptake and working more remotely. Research needs to be more nationally balanced and scaled-up to inform national policy development. Critically, the quality of research could be strengthened through longer-term follow-up studies, adjusting for known confounders, accounting for postgraduate stages and using appropriate controls to test the relative effects of student characteristics and program designs.
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ItemFamily effects on the rurality of GP's work location: a longitudinal panel study.(Springer Science and Business Media LLC, 2017-10-19)BACKGROUND: Reduced opportunities for children's schooling and spouse's/partner's employment are identified internationally as key barriers to general practitioners (GPs) working rurally. This paper aims to measure longitudinal associations between the rurality of GP work location and having (i) school-aged children and (ii) a spouse/partner in the workforce. METHODS: Participants included 4377 GPs responding to at least two consecutive annual surveys of the Medicine in Australia: Balancing Employment and Life (MABEL) national longitudinal study between 2008 and 2014. The main outcome, GP work location, was categorised by remoteness and population size. Five sequential binary school-age groupings were defined according to whether a GP had no children, only preschool children (aged 0-4 years), at least one primary-school child (aged 5-11 years), at least one child in secondary school (aged 12-18 years), and all children older than secondary school (aged ≥ 19). Partner in the workforce was defined by whether a GP had a partner who was either currently working or looking for work, or not. Separate generalised estimating equation models, which aggregated consecutive annual observations per GP, tested associations between work location and (i) educational stages and (ii) partner employment, after adjusting for key covariates. RESULTS: Male GPs with children in secondary school were significantly less likely to work rurally (inclusive of > 50 000 regional centres through to the smallest rural towns of < 5000) compared to male GPs with children in primary school. In contrast, female GPs' locations were not significantly associated with the educational stage of their children. Having a partner in the workforce was not associated with work location for male GPs, whereas female GPs with a partner in the workforce were significantly less likely to work in smaller rural/remote communities (< 15 000 population). CONCLUSIONS: This is the first systematic, national-level longitudinal study showing that GP work location is related to key family needs which differ according to GP gender and educational stages of children. Such non-professional factors are likely to be dynamic across the GP's lifespan and should be regularly reviewed as part of GP retention planning. This research supports investment in regional development for strong local secondary school and partner employment opportunities.
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ItemPatterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013-2015.(Springer Science and Business Media LLC, 2017-08-15)BACKGROUND: The geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics. METHODS: This study used the NT Department of Health 2013-2015 payroll and financial datasets for resident health workforce in 53 remote primary care clinics. Main outcome measures include annual turnover rates, annual stability rates, 12-month survival probabilities and median survival. RESULTS: At any time point, the clinics had a median of 2.0 nurses, 0.6 Aboriginal health practitioners (AHPs), 2.2 other employees and 0.4 additional agency-employed nurses. Mean annual turnover rates for nurses and AHPs combined were extremely high, irrespective of whether turnover was defined as no longer working in any remote clinic (66%) or no longer working at a specific remote clinic (128%). Stability rates were low, and only 20% of nurses and AHPs remain working at a specific remote clinic 12 months after commencing. Half left within 4 months. Nurse and AHP turnover correlated with other workforce measures. However, there was little correlation between most workforce metrics and health service characteristics. CONCLUSIONS: NT Government-funded remote clinics are small, experience very high staff turnover and make considerable use of agency nurses. These staffing patterns, also found in remote settings elsewhere in Australia and globally, not only incur higher direct costs for service provision-and therefore may compromise long-term sustainability-but also are almost certainly contributing to sub-optimal continuity of care, compromised health outcomes and poorer levels of staff safety. To address these deficiencies, it is imperative that investments in implementing, adequately resourcing and evaluating staffing models which stabilise the remote primary care workforce occur as a matter of priority.