The patterns, determinants and measurement of rural and remote primary health care workforce turnover and retention
thesisposted on 2017-02-23, 02:38 authored by Russell, Deborah Jane
Health workforce supply and geographical maldistribution are amongst the most important issues affecting the provision of accessible primary health care services and improving the equity of health outcomes for populations living in rural and remote areas throughout the world. It is crucial that policymakers attempting to redress these issues have accurate and timely information so that workforce planning and policy-making is well-informed. In particular, it is critical that policy interventions effectively optimise the turnover and retention of the existing rural and remote primary health care workforce, as these are frequently a scarce and valuable resource. The aim of this research, therefore, is to understand the patterns, determinants and metrics of rural and remote Australian primary health care workforce turnover and retention, with a view to developing appropriate indicators and benchmarks to support rural and remote health service workforce retention and inform rural and remote health workforce policy-making. The research of this thesis takes a quantitative approach to investigate rural health workforce turnover and retention. Firstly, five metrics, well suited for measuring turnover and retention in rural and remote Australian contexts, are identified. These include simple metrics, such as turnover rates and retention rates, as well as metrics requiring more advanced analytical capabilities, such as survival probabilities and proportional hazards ratios. These metrics, particularly those calculated using survival analysis, are applied to five different Australian rural and remote primary health care workforce datasets to explore how rural primary health care workforce retention differs according to profession, geographical location, population size and a range of other financial and economic, professional and organisational, educational and regulatory, and personal and family factors. The empirical findings are then used to derive tentative benchmarks for length of stay of primary health care professionals that differ according to profession and geographic location. This research reveals substantial and significant differences in rural and remote Australian primary health care workforce retention according to profession and geographical location and population size. Doctors and allied health professionals have approximately 1.80 times the risk of leaving a rural or remote health service at any point in time compared with nurses and Aboriginal health workers. Substantial differences in retention are evident within the allied health professions. Podiatrists, for example, are more than twice as likely to leave compared to occupational therapists (Hazard Ratio 2.13). The risk of rural and remote GPs leaving small communities (population size<5,000) also increases with increasing geographical remoteness (Outer regional Hazard Ratio 1.33; Remote Hazard Ratio 2.65, compared to Inner regional GPs). Additionally, the research of this thesis reveals that a range of professional and organisational variables are strongly associated with rural primary health care workforce retention. These include practice ownership, hospital appointments and undertaking advanced procedural activities (for GPs) and grade of employment (for Allied Health Professionals). Income source, health workers’ age group, country of primary training and regulatory restrictions on practice location are each strongly associated with retention. The research also proposes tentative benchmarks for the retention of rural Australian primary health care workers that differ according to profession and geographical location. The median survival of rural NSW GPs is predicted according to geographical location and population size, coastal location, country of primary medical degree, and certain workload characteristics. Aside from better understanding rural and remote PHC workforce retention patterns and determinants, the research of this thesis has extensive and broad-ranging policy implications. At the most fundamental level, the use and demonstration of how best to measure retention in the rural and remote PHC context is critical for informing future research, for future evaluation and monitoring of retention interventions, and for the collection and management of workforce data. Importantly, the new empirical knowledge generated by this research has also highlighted the need to modify national workforce retention policy to take both geographical location (remoteness) and population size into account when targeting retention incentives, as was recommended by the 2013 “Review of Australian Government Health Workforce Programs”. Further, the findings suggest that strengthening and expanding rural generalist pathways providing advanced procedural training and up-skilling of rural and remote GPs may support their long-term retention, as may the funding and support of rural and remote hospital infrastructure. Retention of Allied Health Professionals in rural and remote communities can be supported by developing specific rural and remote career pathways. Finally, coercive recruitment mechanisms can be expected to be associated with higher retention whilst the coercion is in place, but a substantially increased risk of leaving once the period of coercion ends. Mitigating the risk that PHC workers fulfilling return-of-service obligations may exacerbate retention of rural and remote PHC workforce in the longer term is likely to require careful matching of individuals to the location in which they fulfil their obligations and ongoing investment in vocational training and professional support programs.