15 September 2010.

When people look for a place to live, they consider the attractions and services a region can provide. Rural and regional Victoria has many attractions — more jobs, better infrastructure, beauty and relatively accessible. Depending on stage of life, different services are important — shops, Internet, schools, clubs, banks and sport.

Whatever the stage of life — young families, tree-changers or young people looking for work — health services are vital. Simply put, without health services, a community cannot grow.

The State Government’s recent investment in rural health infrastructure is significant and welcome. However, almost nothing has been done to ensure there are doctors to work in these country hospitals. Without a strong medical workforce, country Victoria cannot thrive and prosper.

As part of a broader commitment to develop regional Victoria a package of incentives to support and retain country doctors should be implemented.

To recognise the importance of the medical workforce to rural and regional communities, the Victorian Government must match the incentives offered by other state governments for general practitioners and specialists. A comprehensive Rural Rescue Package should include:

• Payments for general practitioners for out of hours telephone consultations with hospitals to improve access to information and care.
• Rural relocation allowances for general practitioners and specialists, including recognising long service leave entitlements from other states, to aid recruitment.
• Retention allowances for hospital doctors who have spent at least seven years in regional Victoria to recognise service and improve access to care.
• Increased staffing levels, including more VMOs, at rural hospitals. The high risks of fatigue due to poor roster design and staffing shortages are well known in rural hospitals.
• More doctors to help provide a reasonable on-call ratio and ensure comprehensive after-hours care.
• More support for health ICT in regional and rural areas to improve the interface between general practice and hospitals.
• Increased CME allowances to account for the additional costs on CME, such as travel, and to improve the quality of services

The Rural Rescue package AMA Victoria is proposing should be seen as a building block for a broad approach to improve the health of rural communities, which will aid the recruitment and retention of doctors in country Victoria.

The decision to set up and remain in rural practice for health professionals is complex and is influenced by professional and non-professional factors, including the professional’s perception of rural locations, their knowledge and understanding of how well their profes sional aspirations will be met, and the best use of their skills, lifestyle expectations and cultural considerations.

We need an integrated rural medical workforce retention strategy which takes account of the nature, complexity, and context of rural and remote general practice, leads behavioural change, provides professional support and remuneration appropriate to skills and responsibilities and is based on a model of sustainable practice for doctors into the future. To fill these gaps requires a whole of government response.

Payments for after hours telephone consultations

Doctors on call have their family life and free time disturbed responding to requests for advice over the telephone, even without being required to return to the hospital. Such telephone advice is a valuable resource to a hospital in minimising risk and ensuring quality care.

The entitlement to a minimum payment of one hour overtime is available to most health professionals working in public hospitals, including allied health professionals, nurses, hospital pharmacists and medical scientists who provide telephone advice. To date this industry standard has been denied to medical practitioners.

Where recall to duty can be managed without the medical practitioner having to physically attend at a hospital, for example by telephone, that the medical practitioner should be paid for this recall work the equivalent of the fee for AMA item AA210, currently $77.

Rural relocation allowances

General practitioner in some areas have had a relocation allowance payable to doctors moving to some country locations for many years, paid by the Commonwealth Government. AMA Victoria has been advised by the Rural Workforce Agency Victoria that such allowances are not available in Victoria. Specialist practitioners are not eligible for relocation incentives.

The Victorian Government is responsible for our public hospital system, so should provide additional incentives to entice hospital-based medical practitioners to country Victoria. A suitable package could include a relocation allowance of up to $20,000, accommodation or accommodation assistance, fee assistanc e for the education of children and assistance with finding suitable employment for other family members.

Such a package would encourage medical specialists to live and work in country Victoria, and aid recruitment.

Retention allowances

Retention allowances for hospital medical staff are an important and cost effective recognition of service, demonstrating to the individual practitioner and to the profession that long term service in rural communities is valued by the Victorian Government.

Dissatisfaction with public hospitals is leading to many experienced clinicians taking the option of early retirement. Older clinicians have decades of knowledge of a community and clinical expertise, so health services may need to offer alternative attractive methods of employment (Royal Australasian College of Surgeons 2005). Retention allowances are a token of appreciation of long term service, and may delay retirement.

In addition to more flexible working arrangements, AMA Victoria recommends that a pool of funds be made available to encourage the retention of senior doctors in rural and regional Victoria. Doctors who have worked for a minimum of seven years in rural and regional public hospitals would receive an additional annual payment of $5000, payable from a fund held by the Government so that hospitals’ budgets are not put under additional pressure.

More doctors in rural and regional public hospitals

Research by Humphreys, Jones, Jones & Mara (2002) identifies the importance of professional factors as determinants of retention and length of practice in rural areas. The key problem for rural doctors is inability to get time away for recreational leave and family considerations, and for emergency relief and relief to complete CME programs.

With the current shortages in several medical specialties, hospitals are finding it harder and harder to attract and retain specialist medical staff. Rural hospitals often find themselves needing to stretch their budgets to attract or retain specialists, as the shortages mean that salaries in rural and regional areas are often higher than in urban areas.

To avoid such strains on hospital budgets and to maintain a balanced mix of services in country Victorian hospitals, a central pool for specialist rural location allowances would help country hospitals attract staff without compromising other services.

In the absence of good on-call arrangements and professional support, the unrelenting nature of the demand for after-hours care imposes an excessive workload, with negative effects on health and well-being. We need more doctors in rural and regional Victoria to ensure the broader rural medical workforce does not burn-out or leave rural practice due to its demands.

Procedural GP VMO allowance

The Ministerial Review of Public Hospital Medical Staff noted a current deficit of at least 50 GPs with procedural skills, such as obstetrics, anaesthetics and surgery.1 Such VMOs are vital to ensure the future of smaller rural hospitals, and need additional support.

The Victorian Government already provides training support for the State’s 275 GP proceduralists, and provides support for training. However, additional support and recognition is needed. AMA Victoria recommends that GP proceduralists receive an additional loading of $5000 per annum as recognition of their value to rural health care in Victoria. As these doctors provide support to the system as a whole, the recommended loading should be paid from a central pool rather than from small hospital budgets.

Rural towns are dependent upon GP proceduralists to ensure the continuing health and sustainability of local communities. Research has shown that the existence of a procedural GP workforce is at breaking point. 2 Significant investment and support is required to ensure the invaluable skills of GP proceduralists are not lost on country towns.

Adjustment allowances

The Forster Report (2005) of the Queensland health service recognised that more flexibility was needed to secure young specialists returning from work overseas and who were wanted to work in the public sector, as often they were unable to do so because of inadequate available resources. Inflexible budget arrangements lead to an inability to employ young specialist staff on meaningful contracts.

Entry to the public hospital specialist workforce in Victoria has customarily been through the allocation of a small number of sessions so as to help establish a viable practice. However with increased competition and focus from other states on this workforce cohort a more systematic strategy is required.

The Forster Report suggested a range of options including:

a phased retirement and succession process where senior medical practitioners move to part-time work and offer support and mentoring to a younger clinicians moving into the senior post;

guaranteeing younger medical practitioners a permanent position or sessional work upon their return from working overseas.

The ability of rural and regional health services to attract hospital specialists without divesting the services of existing specialists is minimal. Budgets are not large enough or flexible enough to allow for transitional arrangements. Thus a common pattern is for a specialist to give notice of retirement, the hospital advertising for a replacement, but not being able to have a handover period or the training opportunities. This lack of flexibility also can result in long term vacancies, as the health service is not able to take advantage of new opportunities before the outgoing specialist has gone.

All political parties should consider setting up a flexible funding pool that may be accessed by health services from time to time to assist the establishment of new specialist and mentoring roles across regional Victoria to improve access for patients.

Continuing medical education (CME)

Doctors in training in rural areas need increased CME allowances to account for the additional costs on CME, such as travel, and to improve the quality of services ($3.2 million over four years).

Continuing medical education is vitally important to the ongoing survival of a rural medical workforce. Opportunities to learn about new developments in medicine and new types of treatment and care are invaluable opportunities that should not just be afforded to metropolitan areas.

Locum support services

Every doctor deserves a break from practice, either for continuing medical education, family leave or recreational leave. Data demonstrate that locum support is a vital predicator of rural attraction and retention.

The proposed locum support service would provide a subsidy to every medical practitioner in rural and regional Victoria to subsidise a locum for two weeks. The subsidy would be available as a rebate to either individual medical practitioners or their employer who pays the cost of attracting a locum.

The state wide service could be run by the Rural Workforce Agency Victoria and Divisions of General Practice.

Rural practice ICT support

We need health ICT that addresses the needs of patients and doctors. The Victorian Government’s substantial investment in HealthSMART has failed to deliver IT systems in hospitals that communicate with IT systems in general practice and private specialists practices.

Recognising that rural Victorians have greater health needs, and that rural medical practitioners are under pressure, all political parties should support the immediate ICT integration of rural hospitals and rural private practices.

A grant should be made available to assist rural medical practitioners integrate practice computer systems with hospitals. This grant would be payable to private practitioners who choose to integrate their computer systems and participate in electronic patient management systems. The incentive package is designed to promote private practitioners integrate with hospital IT systems.