  |
|
|
||||
|
||||||
| Journal of the New Zealand Medical Association,
02-April-2004, Vol 117 No 1191
|
||||||
|
New Zealand Rural General Practitioners 1999
Survey—Part 3: rural general practitioners speak out
Ron Janes and Anthony Dowell
Rural general practice in NZ is facing increasing
difficulties with retention and recruitment,1
and the rural GPs in the current workforce are
stressed.2,3 The key issue, identified by the
rural GPs themselves, is a significant workforce shortage which in turn leads to
heavy workloads, frequent on-call duty, and lack of rural locums to enable time
off for professional development and
holidays.4,5 The workforce shortage was also an
important issue in 1986, when the last national survey of rural GPs was
done.6
In November 1999 the Health Funding Authority (HFA) adopted
the Rural GP Network’s Rural Ranking Scale (RRS) for defining
‘rural’ GPs entitled to claim a rural bonus
payment.7 Only GPs scoring 35 points or greater
(maximum 100 points) were considered ‘rural’ and entitled to apply
for a ‘rural bonus’ payment. With a
clear definition of a ‘rural GP’, and the availability of a database
of NZ rural GPs compiled by one of the authors (RJ; unpublished data), the
opportunity existed to directly survey the entire rural GP workforce and ask
them to comment on the state of NZ rural general practice. Initial quantitative
data from this survey have been published.8
This paper provides further information to inform policy
makers about the scale and depth of current difficulties, and details the
solutions suggested by the rural GPs themselves.
MethodsAn anonymous postal
questionnaire was used to collect information from rural GPs. Our previous paper
describes the methods used (questionnaire development, distribution and data
analysis), and presents initial quantitative data on the rural GP
respondents.8
The participant information sheet stated:
‘Basic information about rural general practice
and rural GPs in New Zealand is desperately needed to assist with lobbying for
improved working conditions (training, locums, CME, etc). The attached
questionnaire is designed to collect that information’
The questionnaire included an open-ended question that
asked rural GPs ‘for any further comments or suggestions about rural
general practice’. The database for this paper consisted of the
transcripts of the written responses, which were read multiple times by one
author (RJ), and then purposefully analysed for themes about rural general
practice. The analysis consisted of intentional collation of raw data into
common themes and sub-themes in a systematic manner. After this analysis, key
concepts were further refined.
ResultsResponse
rate Questionnaires were sent to 559 rural and semi-rural GPs—417
were returned completed (an overall response rate of 75%). Of the 417 completed
questionnaires, 74 had RRS scores of less than 35 points, and 5 had not
completed the RRS. This provided 338 appropriately completed questionnaires, of
which 138 contained written responses to the open-ended question asking
‘for any further comments or suggestions about rural general
practice’. The demographic data of the 138 rural GPs providing written
responses were similar to those of the 338 rural GP respondents.
Qualitative data The
following are outlines of the three main themes that were read from the
data
The three key sub-themes
identified for each category above were:
(Supportive quotes
from the rural GPs are cited in the text.)
Positive
aspects of rural general practice
The
job
The core work of rural general practice was described as
interesting and rewarding by many rural GPs. There was the challenge of
providing the full spectrum of care from birth to death, and of using emergency
skills with critically ill patients. Furthermore, they reported that patient
continuity of care was greater in rural areas, and there was the opportunity to
get to know the person and their family. As well, in rural areas, they felt they
were valued and respected members of the community. All of this contributed to a
high degree of job satisfaction.
‘The practice population and the medical
challenges are both interesting and rewarding and I would recommend rural health
care to anyone’
Support for the
job
There were several comments from rural GPs that mentioned
local continuing education initiatives, which made keeping up-to-date with
health information easier. Other GPs mentioned support they received from
specific organisations, such as their local Independent Practitioners
Association, the Rural GP Network, the Goodfellow Unit, or the Northern Rural GP
consortium. The assistance from part-time GPs (mainly female or older
semi-retired GPs) was especially valued by those GPs fortunate enough to enjoy
their support.
‘I am very lucky to have a long-term locum who
does a fairly regular 4/10, and full-time for my holiday (I cover her for her
holidays)’
(No
respondent stated that income was a positive factor in their work as a rural
GP.)
Unique
factors about the job
Positive comments acknowledged that each rural area is
unique—and that some rural areas, where it was more attractive to live,
had no rural GP workforce shortages.
‘(Town) is a slight enigma as far as rural health
goes, in the fact that there is always a plentiful supply of doctors wishing to
work part-time or full-time here’
Negative
aspects of rural general practice
The
job
While the core work of rural general practice was described
positively, rural GPs were almost unanimous in condemning their excessive
workload. Specifically, they described the ‘double jeopardy’ of a
heavy daytime workload followed by a night or weekend on-call. Indeed, doctors
were planning to leave their practice because of its effect on them and/or their
family.
Part-time doctors were reluctant to work full-time because
of the concern of the effects of overwork. They clearly identified the following
components of their excessive workload, which were further aggravated by the
general shortage of rural GPs:
‘On a bad day, I feel trapped by a very
heavy workload, disruption to family life and the need to spend a lot of time
after work doing letters and chasing up things for patients’
‘I
have commenced in rural general practice relatively recently. As a consequence
of the demands my work places on me, my family and I do not enjoy the quality of
life I once aspired to. I intend working very hard over the next 6–12
months to reverse this situation. If I am not successful in improving our
quality of life, I firmly intend to leave rural general
practice’
‘(I) feel overloaded
with red tape (ACC/AITC, etc) computers, on-call, college demands (MOPS) and
increasing patient expectations. At the same time, the financial incentives are
falling year by year as expenses rise. Audit for MOPS is always difficult’
‘After 14 years of
1:1 and 1:2 call it is time to change—for the sake of myself and my
family’
‘Biggest problem is
lack of locums to get holidays, etc. Other problem include increased paperwork
and other non-paid administration. Decreasing income doesn't
help’
‘We need help with
locums! Locums don't want to do call! Rural general practice would be OK, except
for the call’
‘Lack of GPs in
surrounding areas, which means we have to cover, no locums
available’
Support for the
job
Overwhelmingly,
rural GPs felt they were unsupported: their role was undervalued, their work
poorly paid, and their specialty lacked a defined career pathway. All of these
factors were felt to be directly contributing to the workforce crisis and
causing practice ownership to be more of a trap, than an asset.
‘So far, the message
is that we are moderately useless, worthless, and doing a job that is not
appreciated because we are working 24 hours a day and are not supplying as good
a service as the towns do with their efficient city surgeries and after hours
clinics. There is no-one speaking strongly in support of the experienced rural
doctors’
‘Central
bureaucracy appears to have objective of denigrating general practice/family
medicine = problems with Obst./changes to ACC Provider Certification/prospect of
nurse prescribing/ encouragement of alternative medicine’
‘I earn as much here
full time as I did in an affluent city practice working 3 days a week and part
time hospice work and practically no on call. There are nights on call I don't
even earn enough to cover the rent I pay to stay here’
‘Unfortunately our
incomes are falling and overheads increasing, making the long-term outlook
bleak’
‘My investment in my
practice has been reduced to a worthless asset/liability as it is impossible to
attract anyone to the area’
‘Investing my money
for needed IT developments in a business, which may be unsaleable, would be
unwise’
Unique factors of
the job
This sub-theme highlighted that some difficulties were
unique to either certain individuals or certain localities. Individuals with
specific problems included: older and retiring
doctors, foreign-trained doctors, female
GPs, and GP couples. Older and retiring doctors reported having to work beyond
when they would have preferred to reduce or stop practising, because of the
inability to find a replacement. They also lamented that their practice had
almost no value. Some reported just wanting to find someone to care for their
patients.
‘I
am retiring in 6 weeks whether or not I get a replacement. I have been trying
for two years to try to sell or give my practice away - I have a tentative
long-term locum arriving who may or may not stay. He is offered entry at NO
COST’
Foreign-trained doctors reported a number of difficulties,
mainly to do with the registration process.
‘Problems with initial registration - Having to
travel to (large urban centre) costing $450 airfare for interview which lasted 5
minutes. Leaving family only 2 days after arriving in New Zealand. Could these
documents not be sighted by someone more locally’
Female GPs described a number of unique difficulties, which
were further aggravated if their partner was a GP. (These problems unique to
female GPs are dealt with in a separate paper on gender differences in NZ rural
general practice in this issue.9)
Locality-specific problems related to either the financial
disincentive of working in some low socioeconomic areas or how the rural ranking
scale has negatively impacted on some rural localities.
‘Huge
unpaid debt. It is not unusual to get up in the middle of the night to someone
with $200–$300 debt who has no intention of paying. This is
demoralising’
‘There are many
truly rural doctors who have very responsible onerous on-call work but, because
of the 'remote orientated' questions of the rural ranking scale, miss out. They
are still stressed with rural doctor stresses, have no access to after hours
clinics etc but are largely ignored by 'remote' rural doctors and urban doctors
alike. The rural GP network is dominated by remote GPs. The ranking scale is
secretive and inappropriate, and does not cover the scope of rural practice
stresses’
Suggested
Solutions for Rural General Practice:
The rural GP respondents suggested a range of solutions to
improve working conditions.
The
Job
Solutions to make the workload manageable
included:
The two key suggestions
were to:
Solutions here
included:
Support
for the job
Solutions to support
rural GPs included:
‘I
seem to need an RNZCGP 'case worker' to work more closely with me to achieve
accreditation’
(This comment is included specifically, to
acknowledge that the College has since started just such a programme to assist
members complete their accreditation.)
Unique factors
about the job
Suggested solutions here included:
DiscussionThis is the first NZ study to
directly survey all active rural GPs for their opinions on the state of rural
practice. The results support the previously published quantitative data from
this questionnaire study,8 and expand upon
them. While the survey results were collected 4 years ago (December 1999 to
March 2000), the stability of rural healthcare continues to be fragile, with
workforce shortages still common in many localities.
The positive aspects of NZ rural general practice, which
were not evident from the quantitative data, emerged clearly from the written
comments: continuity of care, practising the full spectrum of medicine (birth to
death, emergency care), knowing the person and their family, and being valued by
the patients and the community. These positive factors are the reasons GPs stay
in rural areas. These positive factors have been cited by GPs in other countries
as well,10-13 and confirm that rural general
practice is an interesting, challenging, and highly rewarding profession.
Counterbalancing the positive aspects of the job are a
number of negative aspects, chiefly to do with overwork and feeling undervalued,
especially by the funder. Overwork consisted of too much on-call duty and too
many patients needing care. These factors, and especially the stress of on-call
duty, have been catalogued by rural GPs in
NZ1,5,14 and other
countries,10–13 as have the
solutions.4, 10–18
There has
been a rural GP workforce shortage in NZ since at least
1986,6 however rural GPs in this study clearly
felt it was getting worse. These GPs highlight the urgent need to improve the
working conditions of the existing workforce, in addition to promoting
recruitment. Indeed, if recruitment is to ever stand a chance, retention is
critical.19
Regarding retention initiatives, the RNZCGP is providing
extra assistance to GPs struggling to complete accreditation. The
government-funded Rural Locum Support Scheme has started supplying rural GPs
with 2 weeks per year of locum relief, and other funding has been made available
to District Health Boards specifically for retaining rural GPs and improving
onerous on-call rosters. A topic that needs wider discussion and debate is that
of rural GP salaries; suggested by many respondents as one of the potential
solutions to the workforce problem. A contract could guarantee adequate pay,
time-off (holidays and education), and reasonable rosters— with no worries
about debts, arranging locums, or selling practices. This was an option many
rural GPs seemed ready to discuss.
Regarding recruitment initiatives, although designed to
supply short-term locums, the Rural Locum Support Scheme, by internationally
advertising NZ’s attractiveness as a place to work, may assist with
foreign doctor recruitment to permanent posts. Just recently, the NZ Rural
General Practice Network has been awarded the contract to assist with the
recruitment of long-term rural locums. The RNZCGP is working with both
universities and others to develop a career pathway for rural general practice.
The NZ government has increased the medical school intake
(by 20 places) at the universities in both Otago and Auckland, with preferential
admission of rural-origin students to these places. Moreover, these two
universities submitted a joint funding proposal in September 2003 for a 12-week
rural multidisciplinary training experience for all medical students, which will
also include nurses and other health professionals. If approved, this will be an
encouraging development; demonstrating that the NZ government and universities
have recognised their social responsibility20
to train doctors and other health professionals, specifically to meet the needs
of the NZ population.
The results of this study detail the positive factors that
are retaining NZ rural GPs, and these factors should be clearly highlighted in
educational initiatives with medical and other health students. Continuity of
care, knowing the person and their family, and being valued by patients and
communities are more fully appreciated by a prolonged immersion in a rural
training environment. Other advantages of a significant immersion in a rural
setting would include experiencing a balanced alternative to the present
emphasis on urban tertiary hospital placements. Teaching medical students in
rural areas provides a sound generalist educational
experience,21 and ‘in rural communities,
the social forces impinging on healthcare can be more readily defined, while
opportunities for intervention are more accessible to the
students’.22 This type of rural
community-based medical education has been trialled successfully in
Australia.23 Of real concern in NZ, however, is
whether the depleted rural medical workforce has the capacity to take on the
additional challenge of becoming teachers, supervisors, and mentors to these
students.
In conclusion, this study is the first to describe what
rural GPs think about the state of NZ rural practice, and what needs to be done
to improve it. Initiatives that will address their identified concerns have
begun. Restructuring of medical school training, and rural general practice
itself, is essential if young doctors with the appropriate skills and attitudes
are to be attracted in sufficient numbers to live and work in rural areas.
Without these changes, more and more rural areas will be without GPs, and rural
people will have to rely on other options for their medical care.
Author information:
Ron Janes, Associate Professor of Rural Health, Department of General Practice
and Primary Health Care, Auckland University, Auckland, and The Institute of
Rural Health, Hamilton; and rural GP, Wairoa Medical Centre, Wairoa, Hawkes Bay;
Anthony Dowell, Professor, Department of General Practice, Wellington School of
Medicine, Otago University, Wellington.
Acknowledgements: We
gratefully acknowledge research grants from both the ‘RNZCGP Research and
Education Charitable Trust’ and the ‘Wellington Faculty of the
RNZCGP’. We are also indebted to all those rural GPs who took the time to
write comments on the questionnaire. Data from this paper were presented at the
RNZCGP Annual Conference in Rotorua in 2002.
Correspondence:
Associate Professor Ron Janes, PO Box 341, Wairoa 4192, Hawkes Bay. Fax: (06)
838-3729; email: ronjanes@xtra.co.nz
References:
|
|
||||
| | Current
issue | Search journal |
Archived issues | Classifieds
| Hotline (free ads) Subscribe | Contribute | Advertise | Contact Us | Copyright | Other Journals |
|