Where to next for rural general practice policy and research in Australia?

The available evidence from the past 20 years of government interventions can inform future priorities

Australia is in a critical period of rural workforce policy reform. The Australian government is responding to a surge of domestic and international doctors, while addressing the pervasive problem of geographic and specialty maldistribution.1 There is renewed commitment to strengthen rural health policy and further develop a well skilled, adaptable rural general practitioner workforce. GPs underpin resilient, healthy rural and remote communities and are essential for a coordinated and efficient health system.2 This article seeks to inform future directions and research priorities by reflecting on 20 years of policy activity and outcomes.

National data provide conflicting scenarios of Australia’s current GP distribution. Australian Institute of Health and Welfare data, derived from self-reported work hours, indicate that rural supply is equal or above that in major cities (Box).3,4 Department of Health data, derived from Medicare billing, instead suggest poorer supply with increasing remoteness.5 These analyses are hampered by considerable limitations, including poor differentiation of consulting room general practice from on-call hours, procedural activity and hospital work.6 They poorly account for factors which increase with remoteness, including salaried activity, high workforce turnover and use of locums, poorer population health status, and reliance on international medical graduates (IMGs). This compromises accurate perspectives of national GP supply and distribution.

An extensive range of policy, advocacy and research activity has occurred with respect to rural general practice over the past 20 years (online Appendix 1). Policies have covered four key areas: education and training; regulatory; financial incentives; and support for rural practice (online Appendix 2).

Education and training

Substantial undergraduate medical education and training reforms include increasing undergraduate Commonwealth supported places; increasing enrolment of rural background students to 25%; and increasing opportunities for training in rural areas to a minimum of 1 year for 25% of students. Evidence is growing of the compound benefit of rural background (rural interest) and rural training for increased rural uptake; nevertheless, most current rural GPs have metropolitan backgrounds.7-10 Regionally based undergraduate training, with highly targeted selection of rurally oriented students, also demonstrates substantial rural GP return.9 However, more nuanced evidence of the impact of these measures on GP distribution to smaller rural and remote areas remains lacking.

Increasing focus is being given to strengthening pre-vocational and vocational pathways for junior doctors. Historically, the Postgraduate General Practice Placements Program provided 10–13 weeks’ rural general practice exposure for pre-vocational doctors. New integrated regional training hubs, although not specific to general practice, will enable increased rural training pathways beyond undergraduate programs. Further, building on rural community internships, new programs enabling junior doctors’ exposure to rural general practice are under development. However, there remains limited evidence to inform optimal structures for pre-vocational training facilitating rural general practice uptake and retention.

With respect to vocational training, rural general practice became differentiated from general practice as a specialty following the establishment of the Australian College of Rural and Remote Medicine in 1997 and the introduction of the Royal Australian College of General Practitioners’ Fellowship in Advanced Rural General Practice. Currently, half of GP registrars are required to train rurally; however, continued use of a weak rurality indicator provides poor impetus for registrar training to occur beyond large regional centres. Longitudinal research suggests good 5-year retention following rural training, especially for registrars with rural backgrounds,11 with 2016 Australian General Practice Training Program data indicating 5-year rural retention of 42% for all rural pathway registrars.12 Recent transfer of GP registrar selection to the Colleges presents a major opportunity to develop evidence-based selection, to improve future rural GP workforce distribution. The Remote Vocational Training Scheme, which provides distance supervision and education for GP registrars in remote practice, has reported strong success, although coverage is small.13

GPs practising advanced skills are essential in smaller rural and remote communities, where specialists are commonly lacking.14 Proceduralists are more likely to stay in these communities than non-procedurally active GPs.15 However, there is sparse evidence of effective interventions to stimulate advanced practice. The promised national rural generalist pathway needs to support the formation of rural generalist professional identity, largely based on experience in Queensland,16 showcasing well integrated hospital training, a curriculum prioritising remote and rural contexts, and well remunerated employment supporting substantial retention.

Regulatory strategies

Since 1997, the requirement for IMGs to work in districts of workforce shortage to access Medicare billing has greatly affected rural workforce capacity, with IMGs comprising 40–50% of the rural GP workforce. Complex issues with registration, recognition of pre-existing skills and qualifications, and inadequate professional support factors influence lower professional satisfaction of IMGs. Few interventions have addressed these issues.17 New legislation replacing 457 visas with temporary skill shortage visas, to take effect in March 2018, flags potential future reduced immigration of IMG GPs through annual review of the Skilled Occupations List.

Bonded medical places (BMPs) were implemented in 2004, constituting 25% of all domestic medical student places. Acceptance of a BMP initially required a rural return-of-service equal to the length of the medical course. In 2016, this commitment reduced to only 1 year. This policy shift towards less coercion and increased reliance on individual choice of rural practice by domestic graduates increases risks for supply in less attractive communities and warrants monitoring.

Restrictions in accessing Medicare billing also apply to graduating international students of Australian medical schools. A report found that 78% of IMGs secured Australian internships,18 but their decision making, pathways to rural general practice and levels of satisfaction are poorly understood.

Financial incentives

A range of financial incentives encouraging GPs to work in rural communities have been introduced within a context of progressively lower relative Medicare rebates for services by GPs compared with other specialists, and a freeze in Medicare indexation since 2013. These have eroded the financial attractiveness of rural general practice with lower proportions of recent medical graduates choosing general practice (30%) compared with those of the 1970s and 1980s (50–52%).7

Rurally focused financial incentives have included course fee reimbursement for working rurally (now defunct); Practice Incentives Program payments with scaled rural loadings; and rural recruitment and retention incentives. Retention grants have been considered favourably, with positive effects on rural GP morale, although retention effectiveness was not directly assessed.19 Nevertheless, research reveals that only two-thirds of rural GPs are influenced to stay by incentives,20 and incentives of up to 130% in addition to annual earnings ($237 000 in 2008) are required for the least attractive jobs and locations,21 highlighting the likely inadequacy of current retention incentives ($60 000 per annum maximum).

Support for rural practice

Evidence shows that rural GPs, particularly those with advanced skills, have longer total and hospital hours of work, more on-call and after-hours call-outs, and difficulties accessing locums and taking leave.6,22 Recent research suggests that after-hours incentive payments are inherently biased against small rural practices, with poorly targeted Medicare rebates related to urban overuse.23 Locum programs were also found to be poorly targeted and to have restricted reach,24 despite evidence that guaranteed locum relief may be a more effective stimulus for rural general practice than either retention incentives or skills loadings.19

With the planned introduction of Health Care Homes, research-informed policy is needed to support sustainable practice models for rural GPs and reduce reliance on large financial compensation for unattractive conditions (eg, about $73 000 to compensate for an increase in the frequency of on-call work, from 1 in every 10 days to every second day).20

What must happen?

Our review highlights 20 years of considerable national policy investment and limited accompanying evidence about its effectiveness, providing important context for current rural GP workforce reforms. The adequacy of current national supply and distribution of GPs remains difficult to judge based on current measures.

The extent of policy activity in the four areas reviewed has varied greatly, although balanced and targeted investment in all of educational, regulatory, financial and practice support is needed to enable a robust rural general practice workforce into the future. Governments face critical decisions about how to better target interventions specifically to general practice in small rural and remote communities.

The challenging employment conditions of rural and remote GPs and issues faced by IMGs are well established, but very little targeted policy intervention has followed. Interventions could be facilitated by research that more strongly focuses on solutions that improve conditions for satisfactory and sustained rural and remote employment, including research about workable practice models that reduce individual burden.

There have also been areas of strong policy activity despite limited evidence. Early educational policy intervention to promote rural practice via rural immersion in undergraduate medical training is only now reinforced by strengthening research. However, such policy is also undergoing rapid reform, for example the BMP policy. New programs of research are needed to inform effective rural generalist training and mechanisms to support geographic distribution of domestic students via choice. Given that evidence is lagging in such areas, policy development should proceed cautiously to mitigate the potential negative effects on the rural general practice workforce.

In conclusion, in spite of the rapid and ongoing policy implementation in rural general practice, there is limited evidence of its effectiveness, rarely extending to smaller, more remote communities. To overcome current policy challenges, there is an urgent need for targeted research-informed policy on vocational rural generalist training, advanced skills practice, migration, sustainable practice models, and specific interventions that target greatest need. A national research program to address this agenda is a priority investment for all stakeholders.