Practitioner perceptions of locum access and availability in rural and remote
Queensland
Col White
Frances Parsons
and
Sandra Fergusson
Queensland Rural Medical Support Agency
Queensland Rural Medical Support Agency 2002
This work is copyright. Apart from any use as permitted under the Copyright Act 1968, no
part may be reproduced without prior written permission from the Queensland Rural Medical
Support Agency. Requests and enquiries concerning reproduction and rights should be
directed to the Queensland Rural Medical Support Agency, PO Box 167, Kelvin Grove DC,
Qld 4067.
Suggested citation
White, C., Parsons, F., & Fergusson, S. (2002). Practitioners perceptions of locum access
and availability in rural and remote Queensland. Paper presented at the ARRWAG Third
National Conference Rural and Remote Health, Adelaide.
ABSTRACT
Access to, and availability of locum relief has been long identified as a key factor that
impacts on the recruitment and retention of a well-trained medical workforce in rural and
remote communities. The purpose of the current study was to examine the perceptions of
medical practitioners in rural and remote Queensland as to the adequacy and availability of
locum relief, and their degree of satisfaction with current services available. 206
practitioners responded to the survey and although all questions were not applicable to all
respondents, analysis of valid responses indicated that 56.9% were dissatisfied with their
access to, and availability of locum relief. Data further indicated that over 88% of
respondents believed that access to locum relief influenced their decision to remain in rural
practice. Further analyses indicated that degree of remoteness impacted on practitioners
appreciation of locum relief with results suggesting that perceived importance of access to
locum relief increases significantly in line with changes in the degree of remoteness/isolation.
Data also indicated that 56.8% of respondents were unable to take the amount of recreation
leave they desired in the preceding 12 months. The impact of locum costs on their ability to
take adequate recreation leave and/or attend education and training activities was also seen as
somewhat to very important by 82.2% of respondents in relation to recreational leave and
75.4% in relation to education and training. A number of significant differences between
private practitioners and Queensland Health employees in regard to access to, and
appreciation of locum relief services are also discussed.
1
INTRODUCTION
Access to, and availability of locum relief has been long identified as a key factor
which impacts on the recruitment and retention of a well-trained medical workforce in rural
and remote Australia.1,2,3,14 The Kamien Report in 1987 found that difficulty in obtaining
locum relief was rated as an important issue for 55% of his sample and in a subsequent
review of stayers and leavers in rural practice, the ultimate pressures to leave for rural doctors
in both Queensland and Western Australia were found to be the constancy of after hours
work and difficulty in obtaining locum relief.3 Subsequent studies undertaken in Australia
throughout the 1990’s have tended to suggest that practitioners in rural and remote location
tend to work harder than their urban colleagues, require a broader range of clinical skills and
have more difficulty in accessing continuing medical education (CME) and obtaining locum
relief. 2,4,5,6,7
Research over the past 10 to 15 years has tended to suggest that the key issues facing
rural general practice are largely related to the isolation resulting from geographical problems
and the resultant "burn-out" and stress, the lack of availability of adequate and accessible
quality continuing medical education, and the lack of availability of locum cover.8,14,15,16 The
problems encountered by rural and remote medical practitioners in accessing adequate locum
relief has not been unnoticed by government and other relevant health authorities. Indeed a
number of initiatives including the Rural Locum Relief Program (RLRP) have been instigated
by the Department of Health and Aged Care (DHAC) to alleviate actual and potential
deficiencies in locum support for rural and remote medical practitioners.
However, in a current review of the RLRP, the Locum Relief Review Group have
noted a number of impediments to the provision of adequate locum services to rural and
remote practices.9 These include the recognition that the economics of general practice add
to the complexity of provision of locums services and that practices can achieve economies of
scale by employing four or more practitioners. For a large majority of rural and remote
practices, this is not a viable choice and the review group acknowledges that regional, rural
and remote areas have a much higher proportion of small and solo practices compared with
metropolitan areas.10 The review group also acknowledges that factors that could compound
the shortage of locums, particularly in regional, rural and remote areas include:

Higher turnover of doctors in regional, rural and remote areas;

Unfilled permanent positions, particularly in public hospitals;

Provider number restrictions;
2

GP’s in more remote areas may need greater support from locums as they are often on
call 24 hours a day, seven days a week and are often the only GP in the area;

Increased importance of Continuing Medical Education – this can often take GP’s
away from their practice and they may need locum support to cover their absence;

Increasing number of part-time GP’s, which may impact on the total availability of
the workforce;

Unattractive working conditions and associated burn-out;

Paperwork and legislative restrictions, e.g., difficulty in obtaining visas for
Temporary Resident Doctors (TRD’s).
The purpose of the current study was to examine the perceptions and needs of medical
practitioners in rural and remote Queensland as to the adequacy and availability of locum
relief and degree of satisfaction with current services available. As a major component of its
recruitment and retention strategies, the Queensland Rural Medical Support Agency
(QRMSA), currently provides 5 full time equivalent contracted overseas doctors who are
used for locum tenens in rural and remote Queensland. Additionally, the QRMSA maintains
a backup service of 32 urban GP’s who are available for short term locum tenens under our
‘City Docs Go Bush’ program. Despite the availability of this subsidised locum service, data
compiled by the QRMSA suggest that approximately a quarter to a third of requests for
locum relief remain unfulfilled over any six-month period of time. For example, in the
financial year ending June 2001, the QRMSA locum services provided 243 locum placements
for a total of 3,268 days. These placements satisfied 73.9% of total requests.
This shortage of locums tends to suggest that many general practitioners in rural and
remote areas not are accessing sufficient leave and therefore may experience high levels of
burnout that will impact on retention in these areas.
Data as provided by respondents is reported ‘as received’. However, it should be
noted that issues pertaining to locum provision and relief are often more pertinent to isolated
rural and remote practitioners and responses may be slightly biased. In effect, provincial and
large rural practices often have the advantage of economies of scale, and issues in regard to
locum availability and relief may be less important or cognisant.
METHOD
A seven page questionnaire was distributed by mail to 759 non-specialist, rural and
remote medical practitioners in RRMA’s 4 to 7 identified in the QRMSA database in late
November, 2000. The questionnaire was multi-faceted in that it sought to explore
3
practitioner’s needs, usage and perceptions of QRMSA’s CME program, Information
Technology, and current locum programs. It is practitioner’s perceptions of locum usage and
access that comprised the last page of the questionnaire which forms the basis of this paper.
The overall response rate was reasonable in that 206 of the 759 contacted (27.14%)
completed and returned the survey. No financial or other inducements were offered for the
return of the survey, and respondents returned the survey at their own expense. Completion
and return of the survey was voluntary and no follow up contact was undertaken to increase
response rates. While aware of potential biases such as self selection in the methodology
utilised, we would contend that a response rate in excess of 27% of a finite population (total
number of non-specialist medical partitioners in rural and remote Queensland) provides a
reasonable baseline for deriving inferences.
RRMA is a Commonwealth Index developed in 1994 by the then Department of
Primary Industry and Energy and Department of Human Services and Health.11 It is based
primarily on Statistical Local Areas (SLA’s) and attempts to measure and designate locations
by degrees of remoteness and accessibility to services. This index has seven levels with the
designation, other remote centre (RRMA 7) being the most isolated and/or lacking access to
services and facilities.
Table 1 details the RRMA category and gender composition of the respondents
expressed in frequencies and percentages. The last two columns of this table provide total
Queensland numbers of rural/ remote medical practitioners for RRMA categories and gender.
Examination of this table suggests that while the gender composition of respondents is very
similar to the statewide distribution, the number of respondents in RRMA category 4 are
somewhat under represented and categories 5 to 7 are somewhat over represented compared
to the statewide distribution of rural and remote medical practitioners. It is felt that the under
representation of practitioners in RRMA 4 may be due to a relatively large number of general
practitioners and resident medical officers in RRMA 4 locations such as Hervey Bay,
Maryborough, Caloundra, Noosa Heads etc., many of whom do not readily self identify as
being a rural medical practitioner.
4
Table 1: RRMA and gender distribution of respondents
RRMA Category
Frequency
Percent
Total Qld
Total Qld
Frequency
Percent
RRMA 4
53
25.7
268
35.31
RRMA 5
102
49.5
325
42.83
RRMA 6-7
51
24.8
166
21.87
Total
206
100.0
759
100.00
Male
148
71.8
539
71.01
Female
58
28.2
220
28.99
Total
206
100.0
759
100.00
Gender
A common feature of mail survey/questionnaires is that respondents often do not
answer all questions and/or provide answers that are unanticipated, confusing or complex for
the researcher. Additionally, not all questions are applicable to all respondents. The problem
of how to deal with missing responses is always a contentious issue with no one correct
answer. However, for the purpose of this study, it was decided to concentrate chiefly on
valid responses and comment only where missing responses appear to be excessive
RESULTS
An initial question sought to determine respondents usual source of locums. Results
are displayed in Table 2. These indicate that for respondents in this survey, QRMSA,
Queensland Health and own practice are the most common sources of locums.
Table 2: Usual source of locums as reported by respondents
Source
Percentage
QRMSA
39.7%
Commercial agencies
17.3%
Division
12.1%
Other practices
3.5%
Queensland Health
26.4%
Own Practice
23.7%
Other
11.6%
Note: Totals in excess of 100% due to some respondents nominating more than one locum source.
Satisfaction with, access to, and availability of Locums provided by QRMSA and
other agencies were also measured on a five-point scale ranging from very satisfied to very
dissatisfied. One of these points was labelled, Irrelevant to cater for respondents who did not
utilise locums. Results for other agencies were collapsed and the degree of satisfaction
expressed with QRMSA and other agencies are displayed in Table 3.
5
Table 3: Number and percentage of respondents satisfied with access to, and availability of locums
sourced by:
Agency
Number
Percent
QRMSA
63
92.6%
Other Agencies
47
73.1%
While these results may be seen by some as somewhat biased, it is more probable that
the vetting and quality control procedures implemented by QRMSA has resulted in the
employment and placement of high quality, experienced locums compared with other
placement agencies. For example, all locums employed by QRMSA undertake a one week,
supervised orientation program in a rural practice prior to their initial placement.
The survey further sought respondent’s perceptions as to whether access to locum
relief positively impacts on their decision to remain in rural practice. Data presented in Table
4 suggests that over 88% of respondents believe that access to locum relief influences their
decision to remain in rural practice. The question was not applicable for 54 respondents and
13 responses were missing.
Table 4: Access to locums positively impacts on my decision to remain in rural practice
Frequency
Percent
Valid Percent
Cumulative
Percent
Valid
Strongly Agree
65
31.6
46.8
46.8
Agree
58
28.2
41.7
88.5
Disagree
11
5.3
7.9
96.4
Strongly Disagree
5
2.4
3.6
100.0
Total
139
67.5
100.0
Further analyses demonstrated that the impact that locums have on a doctors decision
to remain in rural practice is greater the further remote his/her location as displayed in Table
5.
6
Table 5: RRMA by Access to adequate locum relief positively impacts on my decision to remain in rural
practice
Agree/Strongly Agree
Disagree/Strongly
Disagree
RRMA 4
RRMA 5
RRMA 6-7
Total
Count
26
8
34
Percentage
76.5%
23.5%
100.0%
Count
61
7
68
Percentage
89.7%
10.3%
100.0%
Count
36
1
37
Percentage
97.3%
2.7%
100.0%
Count
123
16
139
Percentage
88.5%
11.5%
100.0%
The degree to which respondents agreed or strongly agreed that access to adequate
locum relief positively impacts on my decision to remain in rural practice was 76.5% for
RRMA 4, 89.7% for RRMA 5, and 97.3% for RRMA 6-7. The difference in percentages
were statistically significant between RRMA 4 and RRMA 6-7 (t=3.14;p <.005), and between
RRMA 4 and RRMA 5 (t=2.40;p <.05).
A further question sought to gauge respondent’s satisfaction with access to, and
availability of locum relief. Results as detailed in Table 6 indicate that while 43.1% of
respondents are satisfied, 56.9% are dissatisfied. For 62 of the respondents, the question was
not applicable while 14 responses were missing.
Table 6: Access to, and availability of locum relief are satisfactory
Frequency
Percent
Valid Percent
Cumulative
Percent
Valid
Strongly Agee
8
3.9
6.2
6.2
Agree
48
23.3
36.9
43.1
Disagree
47
22.8
36.2
79.2
Strongly Disagree
27
13.1
20.8
100.0
Total
130
63.1
100.0
These results tend to be somewhat biased through the inclusion of Queensland Health
employees who tend to express a higher degree of satisfaction compared with private
practitioners as outlined in Table 7. Satisfaction with access and availability of Locum Relief
is 38.0% for Private GPs/Registrars and 61.1% of Qld Health Employed doctors.
Dissatisfaction with access and availability of Locum Relief is 62.0% amongst Private
GPs/Registrars compared with 38.9% of Qld Health Employees.
7
Table 7: Doctor Type by Satisfaction with Access & Availability of Locum relief
Doctor type
Access & Availability of Locum relief
Total
satisfactory
Private GP /Registrar
Qld Health Employee
Strongly Agree/
Strongly
Agree
Disagree/disagree
Count
35
57
92
Percentage
38.0%
62.0%
100.0%
Count
22
14
36
Percentage
61.1%
38.9%
100.0%
Count
57
71
128
Percentage
44.5%
55.5%
100.0%
The difference between Private and Queensland Health doctors’ satisfaction with access and
availability of locum relief is statistically significant (t=2.30;p <.05).
One of the consequences of poor access to availability of locum relief is reflected in
the difference between the amount of recreation leave wanted and taken by respondents
during 1999-2000. Table 8 indicates that 43.2% of respondents were able to take desired
amount of leave while 56.8% were unable to take the amount of leave they desired.
Table 8: Difference in Recreation Leave taken and desired
Difference in weeks
Frequency
Valid Percent
-4
1
.5
-3
1
.5
-1
2
1.1
0
79
43.2
1
19
10.4
2
33
18.0
3
26
14.2
4
12
6.6
5
7
3.8
6
2
1.1
7
1
.5
Total
183
100.0
For the four respondents who indicated they had taken more leave than they wanted, this data
was checked with the respondent and verified as correct.
Impact of locum costs on the ability to take adequate recreation leave and attend
education and training activities was seen as somewhat to very important by 82.2% of
8
respondents in relation to recreation leave and 75.4% of respondents in relation to education
and training (see Table 9).
Table 9: Impact of locum costs on ability to take adequate recreation leave and participate in education
and training
Recreation leave
Education and Training
Frequency
Percent
Frequency
Percent
Very Important
37
31.4
29
23.8
Important
36
30.5
34
27.9
Somewhat Important
24
20.3
29
23.8
Not Important
21
17.8
30
24.6
Total
118
100.0
122
100.0
Again, the impact of locum costs on both the ability to take adequate recreation leave
(t=-2.92;p < .01) and to attend education and training activities (t=-2.39; p < .05), was
significantly different between private GPs and Queensland Health Employees. There was no
significant difference between doctor type for the impact on ability to take adequate
recreation leave of locum availability, practice location/local facilities, and locum relief
limited during peak times.
DISCUSSION
Results from the current survey are relatively unambiguous. Data provided by
respondents indicates that 56.9% believe that access to, and availability of locum relief is
unsatisfactory. This figure climbs to 62% when salaried Queensland Health employees are
removed from the equation. As a point of interest, it should be noted that Queensland Health
employees comprise approximately 29% of the rural and remote medical workforce in
Queensland. Approximately 9% of these salaried employees have the right to private practice.
Data also suggests that there are significant differences between private practitioners and
salaried Queensland Health employees in relation to their degree of satisfaction with access
and availability of locum relief with private practitioners expressing higher degrees of
dissatisfaction.
The data further suggests that 88.5% of respondents agree or strongly agree that
access to locums positively impacts on their decision to remain in rural practice. This impact
is more pronounced when examining responses by degree of remoteness. Practitioners in
more remote locations were more inclined to agree that access to locums positively impacted
on their decision to remain in rural practice compared to less isolated practitioners (e.g.,
RRMA6-7, 97.3%, RRMA5, 89.7% and RRMA4 76.5%). These differences were
9
statistically significant and suggest that the importance of adequate locum relief increases
with degree of remoteness/isolation.
A further finding was that 56.8% of respondents did not feel that were able to take the
amount of leave they desired in the previous 12 month period. Given previous research
which has shown that overwork and burnout are significant barriers to retaining doctors in
rural and remote practice,1,2,3,9,12,13,16 it would appear that current levels of access to locum
relief are significantly less than ideal.
The impact of locum costs was also seen as important or very important barriers on
the ability of practitioners to take adequate recreation leave or to attend education and
training activities. With the increasing costs of accessing locum services in many rural and
remote locations (in some areas in excess of $3,000 per week) plus other costs such as
accommodation and travel, the practicability of employing locums becomes economic
unviabable.9 This cost effect is again demonstrated when comparing private practitioners
with Queensland Health employees. The cost implications of accessing locum relief are
significantly greater for private practitioners compared with salaried practitioners.
While not designed or intended as a intensive study of locum provision in rural and
remote Queensland, the results of this survey has provided many significant insights into
practitioners perceptions of the adequacy of locum access and availability. A major trend
that has emerged from this survey is that rural and remote practitioners do not believe that
their access to locum relief is satisfactory. Additionally, a majority do not feel that they are
able to take adequate leave for recreation and education/training purposes and that costs
associated with employing locums is a major barrier. Findings also suggest that these
concerns are more paramount for more remote and private practitioners compared with
salaried practitioners supported by Queensland Health.
10
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