Methodological issues in medical workforce analysis: implications for regional Australia

Social Inequality: Utilisation of general practitioner services by socio-economic disadvantage and geographic remoteness

OBJECTIVE

To examine the association between socio-economic status (SES) and GP utilisation across Statistical Local Areas (SLAs) that differed in their geographic remoteness, and to assess whether Indigenous status and GP availability modified the association.

DESIGN

Retrospective analysis of Medicare data for all unreferred GP consultations (1996/97) for 952 SLAs comprising the six Australian States. Geographic remoteness was ascertained using the Area Remoteness Index of Australia (ARIA), and SES was measured by grouping SLAs into tertiles based on their Index of Relative Socioeconomic Disadvantage score.

MAIN OUTCOME MEASURE

Age/sex standardised rates of GP utilisation for each SLA.

MAIN RESULTS

In SLAs classified as 'highly accessible', rates of GP use were 10.8% higher (95% CI 5.7-16.0) in the most socio-economically disadvantaged tertile after adjustment for Indigenous status and GP availability. A very different pattern of GP utilsation was found in 'remote/very remote' SLAs. After adjustment, rates of GP use in the most socio-economically disadvantaged tertile were 25.3% lower (95% CI 5.9-40.7) than in the most advantaged tertile.

CONCLUSIONS

People in socio-economically disadvantaged metropolitan SLAs have higher rates of GP utilisation, as would be expected due to their poorer health. This is not true for people living in disadvantaged remote/very remote SLAs: in these areas, those most in need of GP services are least likely to receive them. Australia may lay claim to having a primary health care system that provides universal coverage, but we are still some way from having a system that is economically and geographically accessible to all.

Geographic distribution of the Australian primary health workforce in 1996 and 2001

OBJECTIVE

To analyse the geographic distribution of medical and non-medical primary health professions in 2001, and to compare this with 1996.

DESIGN AND SETTING

Census data on the number and characteristics of selected health professionals in Australia by remoteness areas (as measured by the Accessibility Remoteness Index of Australia) were obtained from the Australian Bureau of Statistics.

MAIN OUTCOME MEASURES

Number of general medical practitioners, allied health professionals and nurses per capita in Australia by remoteness areas in 2001 and 1996.

RESULTS

In 2001, the number of general medical practitioners per capita in major cities was significantly higher than the numbers in inner regional areas, outer regional areas, and remote areas. This was also true of the number of allied health professionals per capita. The number of nurses per capita did not show the same pattern. From 1996 to 2001, the number of general medical practitioners per capita showed the largest increase in outer regional areas (10%) and no change in remote areas. The allied health professional workforce per capita increased significantly in all regions, while the nursing workforce per capita showed no significant increases.

CONCLUSIONS AND IMPLICATIONS

Supply of all primary health professionals in remote areas remains low, and distribution patterns changed little from 1996 to 2001. The implementation of numerous government health workforce initiatives has coincided with little observable change in geographic distribution of the health workforce up to 2001.

Is rural medicine a separate discipline?

BACKGROUND

The Australian College of Rural and Remote Medicine was established in 1997 to meet what rural doctors perceived as their unmet educational and professional needs. However, the issue of just how different rural practice is from urban practice remains a topic of debate.

METHODS

This paper explores the scope of rural medical practice, through the use of clinical scenarios and a synthesis of the research literature, to determine if rural medical practice is emerging as a distinct discipline in Australia.

CONCLUSION

Rural and remote medical practice is different, and additional, to urban practice, in the context, content and process of care. Three of the four criteria for determining rural medical practice as a distinct discipline exist in Australia. The fourth criteria: sufficient external recognition of rural medicine as a distinct discipline, awaits resolution.

WHAT THIS PAPER ADDS

This paper examines a key issue that has been a source of conflict between the relevant stakeholders for a decade. By placing the differences between rural and urban medical practice within a framework, supported by published work, this paper describes what is required to justify rural medical practice as a distinct discipline for the first time.

Why paediatricians rural out going to the country but support opportunities for change

OBJECTIVES

To determine the knowledge of vacant country specialist positions, the main barriers to filling country specialist positions, the acceptance of hypothetical creative employment models and to gain understanding of what would it take for respondents to accept a country position.

METHODOLOGY

Mailed self-report questionnaires to all 103 Queensland paediatricians and finishing paediatric trainees (response rate 93.1%) to explore reasons for the long-term vacancy of the Staff Paediatrician position at the Mount Isa Base Hospital, North-west Queensland, Australia.

RESULTS

Of the respondents, 87.4% were aware of the vacant position. The lack of adequate locum cover for leave (97.8%), on-call load (92.2%), professional isolation (91.4%), and family commitments (91.4%) were identified as the four most frequently recognized recruitment barriers. Of the respondents, 30.2% said they could be attracted to such a position if they were guaranteed the ability to return to their present post in 2 years, 30.7% said they could be attracted to a rural exchange, and 73.1% suggested the position would be more attractive to new Fellows if at the end of a 2-year period they were guaranteed some Visiting Medical Officer sessions or a temporary Staff Paediatrician position at a tertiary centre. Significantly, fewer of the 30-39-years age group said available job opportunities for their spouse made it impossible for them to consider the advertised position, compared to older age groups (P = 0.003). In response to the question 'What would it take for you to consider such a position?', 22.6% answered a change in employment package, 22.6% a change in family commitments, 16.6% too subspecialized, and 7.1% could possibly consider a locum or exchange in the future.

CONCLUSIONS

Specialist positions, such as the advertised position, are well known, but remain unfilled because they are considered unsustainable. However, the response to hypothetical creative employment models suggests this could be changed, provided specialist training (e.g. paediatric training) is kept general and the younger consultant is given consideration.

Selected demographic, social and work characteristics of the Australian general medical practitioner workforce: comparing capital cities with regional areas

The aim of the present study was to compare selected characteristics of the Australian general medical practitioner workforce in capital cities and regional areas. Data were derived from the 1996 Census of Population and Housing. Characteristics included age, sex, full- or part-time work, place of birth and change in residential address. Analyses were performed for each state and territory in Australia, the statistical division containing each capital city and all other statistical divisions in each state and territory. Of the 26,359 general medical practitioners identified, 68% were male. More female than male general medical practitioners were aged < 45 years (74 vs 52%, respectively; P < 0.0001). The proportion of general medical practitioners aged < 35 years was higher in capital cities (30%) than regional areas (24%; P < 0.0001). Overall, 32% of the general medical practitioner workforce was female and almost 50% of those aged < 35 years were female. The proportion of female general medical practitioners was higher in capital cities than regional areas, by up to 30%. While 13% of male general medical practitioners reported part-time work, 42% of females also reported part-time work and these figures were similar in capital cities and regional areas. Approximately 40% of the Australian general medical practitioner workforce was born outside Australia and while fewer migrants have entered in recent years they were more likely to be living in regional areas than the capitals. The census provides useful medical workforce data. The regional workforce tends to be made up of more males and is older than in capital cities. Monitoring trends in these characteristics could help to evaluate initiatives aimed at addressing regional workforce issues.

Associations between rural background and where South Australian general practitioners work

OBJECTIVE

To determine the association between rural background on practice location of general practitioners (GPs) (rural or urban).

DESIGN

Comparison of data from two postal surveys.

SUBJECTS

268 rural and 236 urban GPs practising in South Australia.

MAIN OUTCOME MEASURES

Association between practice location (rural or urban) and demographic characteristics, training, qualifications, and rural background.

RESULTS

Rural GPs were younger than urban GPs (mean age 47 versus 50 years, P < 0.01) and more likely to be male (81% versus 67%, P = 0.001), to be Australian-born (72% versus 61%, P = 0.01), to have a partner (95% versus 85%, P = 0.001), and to have children (94% versus 85%, P = 0.001). Similar proportions of rural and urban GPs were trained in Australia and were Fellows of the Royal Australian College of General Practitioners, but more rural GPs were vocationally registered (94% versus 84%, P = 0.001). Rural GPs were more likely to have grown up in the country (37% versus 27%, P = 0.02), to have received primary (33% versus 19%, P = 0.001) and secondary (25% versus 13%, P = 0.001) education there, and to have a partner who grew up in the country (49% versus 24%, P = 0.001). In multivariate analysis, only primary education in the country (odds ratio [OR], 2.43; 95% CI, 1.09-5.56) and partner of rural background (OR, 3.14; 95% CI, 1.96-5.10) were independently associated with rural practice.

CONCLUSION

Our findings support the policy of promoting entry to medical school of students with a rural background and provide an argument for policies that address the needs of partners and maintain quality primary and secondary education in the country.

Inequitable distribution of general practitioners in Australia: analysis by state and territory using census data

The objective of this study was to describe the distribution of general practitioners in each State and Territory, stratified by statistical division and adjusted for estimated community need. The location of general practitioners was obtained from the 1996 Census of Population and Housing. Community need was estimated from crude death rates supplied by the Australian Bureau of Statistics. On average there are 920 people per full-time general practitioner in Australia. Three States are relatively oversupplied by up to 5% (Australian Capital Territory) and the rest are relatively undersupplied by up to 12% (Western Australia). Adjusted for estimated need, the Australian Capital Territory is oversupplied by 71% compared with all of Australia, while Western Australia is undersupplied by 15%. More marked differences occur within the States, with the statistical division containing each capital city in each State that is relatively overserved. The greatest oversupply is in Sydney, where 33% fewer people share a full-time general practitioner than the whole of New South Wales (adjusted for need, oversupply in Sydney is 63%). Relative undersupply is greatest in Queensland, with 133% more people sharing each general practitioner in the north-west statistical division compared with the whole State. The distribution of general practitioners between and within States and Territories is unequal and inequitable. In each State, capital cities tend to be relatively oversupplied compared with more rural areas. While these data do not inform the absolute level of service needed in a community; they do suggest that strategies to redress the inequitable distribution are required.

Inequitable distribution of general practitioners in Australia: estimating need through the Robin Hood Index

OBJECTIVE

From Census data, to document the distribution of general practitioners in Australia and to estimate the number of general practitioners needed to achieve an equitable distribution accounting for community health need.

METHODS

Data on location of general practitioners, population size and crude mortality by statistical division (SD) were obtained from the Australian Bureau of Statistics. The number of patients per general practitioner by SD was calculated and plotted. Using crude mortality to estimate community health need, a ratio of the number of general practitioners per person: mortality was calculated for all Australia and for each SD (the Robin Hood Index). From this, the number of general practitioners needed to achieve equity was calculated.

RESULTS

In all, 26,290 general practitioners were identified in 57 SDs. The mean number of people per general practitioner is 707, ranging from 551 to 1887. Capital city SDs have most favourable ratios. The Robin Hood Index for Australia is 1, and ranges from 0.32 (relatively under-served) to 2.46 (relatively over-served). Twelve SDs (21%) including all capital cities and 65% of all Australians, have a Robin Hood Index > 1. To achieve equity per capita 2489 more general practitioners (10% of the current workforce) are needed. To achieve equity by the Robin Hood Index 3351 (13% of the current workforce) are needed.

CONCLUSIONS

The distribution of general practitioners in Australia is skewed. Nonmetropolitan areas are relatively underserved. Census data and the Robin Hood Index could provide a simple means of identifying areas of need in Australia.