Practitioner perceptions of locum access and availability in rural and remote Queensland
Col White
Frances Parsons
and
Sandra Fergusson
Queensland Rural Medical Support Agency
Queensland Rural Medical Support Agency 2002
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no part may be reproduced without prior written permission from the Queensland Rural Medical Support Agency. Requests and enquiries concerning reproduction and rights should be directed to the Queensland Rural Medical Support Agency, PO Box 167, Kelvin Grove DC, Qld 4067.
Suggested citation
White, C., Parsons, F., & Fergusson, S. (2002). Practitioners perceptions of locum access and availability in rural and remote Queensland. Paper presented at the ARRWAG Third National Conference Rural and Remote Health, Adelaide.
ABSTRACT
Access to, and availability of locum relief has been long identified as a key factor that impacts on the recruitment and retention of a well-trained medical workforce in rural and remote communities. The purpose of the current study was to examine the perceptions of medical practitioners in rural and remote Queensland as to the adequacy and availability of locum relief, and their degree of satisfaction with current services available. 206 practitioners responded to the survey and although all questions were not applicable to all respondents, analysis of valid responses indicated that 56.9% were dissatisfied with their access to, and availability of locum relief. Data further indicated that over 88% of respondents believed that access to locum relief influenced their decision to remain in rural practice. Further analyses indicated that degree of remoteness impacted on practitioners appreciation of locum relief with results suggesting that perceived importance of access to locum relief increases significantly in line with changes in the degree of remoteness/isolation.
Data also indicated that 56.8% of respondents were unable to take the amount of recreation leave they desired in the preceding 12 months. The impact of locum costs on their ability to take adequate recreation leave and/or attend education and training activities was also seen as somewhat to very important by 82.2% of respondents in relation to recreational leave and 75.4% in relation to education and training. A number of significant differences between private practitioners and Queensland Health employees in regard to access to, and appreciation of locum relief services are also discussed.INTRODUCTION
Access to, and availability of locum relief has been long identified as a key factor which impacts on the recruitment and retention of a well-trained medical workforce in rural and remote Australia.1,2,3,14 The Kamien Report in 1987 found that difficulty in obtaining locum relief was rated as an important issue for 55% of his sample and in a subsequent review of stayers and leavers in rural practice, the ultimate pressures to leave for rural doctors in both Queensland and Western Australia were found to be the constancy of after hours work and difficulty in obtaining locum relief.3 Subsequent studies undertaken in Australia throughout the 1990’s have tended to suggest that practitioners in rural and remote location tend to work harder than their urban colleagues, require a broader range of clinical skills and have more difficulty in accessing continuing medical education (CME) and obtaining locum relief. 2,4,5,6,7
Research over the past 10 to 15 years has tended to suggest that the key issues facing rural general practice are largely related to the isolation resulting from geographical problems and the resultant "burn-out" and stress, the lack of availability of adequate and accessible quality continuing medical education, and the lack of availability of locum cover.8,14,15,16 The problems encountered by rural and remote medical practitioners in accessing adequate locum relief has not been unnoticed by government and other relevant health authorities. Indeed a number of initiatives including the Rural Locum Relief Program (RLRP) have been instigated by the Department of Health and Aged Care (DHAC) to alleviate actual and potential deficiencies in locum support for rural and remote medical practitioners.
However, in a current review of the RLRP, the Locum Relief Review Group have noted a number of impediments to the provision of adequate locum services to rural and remote practices.9 These include the recognition that the economics of general practice add to the complexity of provision of locums services and that practices can achieve economies of scale by employing four or more practitioners. For a large majority of rural and remote practices, this is not a viable choice and the review group acknowledges that regional, rural and remote areas have a much higher proportion of small and solo practices compared with metropolitan areas.10 The review group also acknowledges that factors that could compound the shortage of locums, particularly in regional, rural and remote areas include:
· Higher turnover of doctors in regional, rural and remote areas;
· Unfilled permanent positions, particularly in public hospitals;
· Provider number restrictions;
· GP’s in more remote areas may need greater support from locums as they are often on call 24 hours a day, seven days a week and are often the only GP in the area;
· Increased importance of Continuing Medical Education – this can often take GP’s away from their practice and they may need locum support to cover their absence;
· Increasing number of part-time GP’s, which may impact on the total availability of the workforce;
· Unattractive working conditions and associated burn-out;
· Paperwork and legislative restrictions, e.g., difficulty in obtaining visas for Temporary Resident Doctors (TRD’s).
The purpose of the current study was to examine the perceptions and needs of medical practitioners in rural and remote Queensland as to the adequacy and availability of locum relief and degree of satisfaction with current services available. As a major component of its recruitment and retention strategies, the Queensland Rural Medical Support Agency (QRMSA), currently provides 5 full time equivalent contracted overseas doctors who are used for locum tenens in rural and remote Queensland. Additionally, the QRMSA maintains a backup service of 32 urban GP’s who are available for short term locum tenens under our ‘City Docs Go Bush’ program. Despite the availability of this subsidised locum service, data compiled by the QRMSA suggest that approximately a quarter to a third of requests for locum relief remain unfulfilled over any six-month period of time. For example, in the financial year ending June 2001, the QRMSA locum services provided 243 locum placements for a total of 3,268 days. These placements satisfied 73.9% of total requests.
This shortage of locums tends to suggest that many general practitioners in rural and remote areas not are accessing sufficient leave and therefore may experience high levels of burnout that will impact on retention in these areas.
Data as provided by respondents is reported ‘as received’. However, it should be noted that issues pertaining to locum provision and relief are often more pertinent to isolated rural and remote practitioners and responses may be slightly biased. In effect, provincial and large rural practices often have the advantage of economies of scale, and issues in regard to locum availability and relief may be less important or cognisant.
METHOD
A seven page questionnaire was distributed by mail to 759 non-specialist, rural and remote medical practitioners in RRMA’s 4 to 7 identified in the QRMSA database in late November, 2000. The questionnaire was multi-faceted in that it sought to explore practitioner’s needs, usage and perceptions of QRMSA’s CME program, Information Technology, and current locum programs. It is practitioner’s perceptions of locum usage and access that comprised the last page of the questionnaire which forms the basis of this paper.
The overall response rate was reasonable in that 206 of the 759 contacted (27.14%) completed and returned the survey. No financial or other inducements were offered for the return of the survey, and respondents returned the survey at their own expense. Completion and return of the survey was voluntary and no follow up contact was undertaken to increase response rates. While aware of potential biases such as self selection in the methodology utilised, we would contend that a response rate in excess of 27% of a finite population (total number of non-specialist medical partitioners in rural and remote Queensland) provides a reasonable baseline for deriving inferences.
RRMA is a Commonwealth Index developed in 1994 by the then Department of Primary Industry and Energy and Department of Human Services and Health.11 It is based primarily on Statistical Local Areas (SLA’s) and attempts to measure and designate locations by degrees of remoteness and accessibility to services. This index has seven levels with the designation, other remote centre (RRMA 7) being the most isolated and/or lacking access to services and facilities.
Table 1 details the RRMA category and gender composition of the respondents expressed in frequencies and percentages. The last two columns of this table provide total Queensland numbers of rural/ remote medical practitioners for RRMA categories and gender. Examination of this table suggests that while the gender composition of respondents is very similar to the statewide distribution, the number of respondents in RRMA category 4 are somewhat under represented and categories 5 to 7 are somewhat over represented compared to the statewide distribution of rural and remote medical practitioners. It is felt that the under representation of practitioners in RRMA 4 may be due to a relatively large number of general practitioners and resident medical officers in RRMA 4 locations such as Hervey Bay, Maryborough, Caloundra, Noosa Heads etc., many of whom do not readily self identify as being a rural medical practitioner.
Table 1: RRMA and gender distribution of respondents
RRMA Category
/ Frequency /Percent
/ Total Qld Frequency / Total Qld PercentRRMA 4
/ 53 / 25.7 / 268 / 35.31RRMA 5 / 102 / 49.5 / 325 / 42.83
RRMA 6-7 / 51 / 24.8 / 166 / 21.87
Total / 206 / 100.0 / 759 / 100.00
Gender
Male / 148 / 71.8 / 539 / 71.01Female / 58 / 28.2 / 220 / 28.99
Total / 206 / 100.0 / 759 / 100.00
A common feature of mail survey/questionnaires is that respondents often do not answer all questions and/or provide answers that are unanticipated, confusing or complex for the researcher. Additionally, not all questions are applicable to all respondents. The problem of how to deal with missing responses is always a contentious issue with no one correct answer. However, for the purpose of this study, it was decided to concentrate chiefly on valid responses and comment only where missing responses appear to be excessive
RESULTS
An initial question sought to determine respondents usual source of locums. Results are displayed in Table 2. These indicate that for respondents in this survey, QRMSA, Queensland Health and own practice are the most common sources of locums.
Table 2: Usual source of locums as reported by respondents
Source / PercentageQRMSA / 39.7%
Commercial agencies / 17.3%
Division / 12.1%
Other practices / 3.5%
Queensland Health / 26.4%
Own Practice / 23.7%
Other / 11.6%
Note: Totals in excess of 100% due to some respondents nominating more than one locum source.
Satisfaction with, access to, and availability of Locums provided by QRMSA and other agencies were also measured on a five-point scale ranging from very satisfied to very dissatisfied. One of these points was labelled, Irrelevant to cater for respondents who did not utilise locums. Results for other agencies were collapsed and the degree of satisfaction expressed with QRMSA and other agencies are displayed in Table 3.
Table 3: Number and percentage of respondents satisfied with access to, and availability of locums sourced by:
Agency / Number / PercentQRMSA / 63 / 92.6%
Other Agencies / 47 / 73.1%
While these results may be seen by some as somewhat biased, it is more probable that the vetting and quality control procedures implemented by QRMSA has resulted in the employment and placement of high quality, experienced locums compared with other placement agencies. For example, all locums employed by QRMSA undertake a one week, supervised orientation program in a rural practice prior to their initial placement.
The survey further sought respondent’s perceptions as to whether access to locum relief positively impacts on their decision to remain in rural practice. Data presented in Table 4 suggests that over 88% of respondents believe that access to locum relief influences their decision to remain in rural practice. The question was not applicable for 54 respondents and 13 responses were missing.
Table 4: Access to locums positively impacts on my decision to remain in rural practice
Frequency / Percent / Valid Percent / Cumulative PercentValid / Strongly Agree / 65 / 31.6 / 46.8 / 46.8
Agree / 58 / 28.2 / 41.7 / 88.5
Disagree / 11 / 5.3 / 7.9 / 96.4
Strongly Disagree / 5 / 2.4 / 3.6 / 100.0
Total / 139 / 67.5 / 100.0
Further analyses demonstrated that the impact that locums have on a doctors decision to remain in rural practice is greater the further remote his/her location as displayed in Table 5.
Table 5: RRMA by Access to adequate locum relief positively impacts on my decision to remain in rural practice