3.22 Recruitment and retention of staff

Key facts

Why is it important?

There is a growing recognition of the array of factors that affect the health status of Aboriginal and Torres Strait Islander people, including differences in the social determinants of health, availability and accessibility of culturally appropriate health services, and other biomedical, behavioural, and environmental factors (DoH 2013).

The capacity to recruit and retain non-Indigenous staff who are culturally competent is essential for health services to deliver appropriate, continuous and sustainable health care for Indigenous Australians. Staff recruitment and retention are particularly important in rural and remote areas to ensure Indigenous Australians in these areas have access to health professionals for their health care needs (Humphreys et al. 2009). Almost two-thirds of Indigenous Australians live in Regional and Remote areas, and Indigenous Australians make up 30% of the total population in Remote areas (ABS 2018).

Indigenous Australians are under-represented in the health workforce. One way of supporting culturally appropriate and safe health services is for the government to support a skilled Indigenous Australian health workforce (see measure 3.12 Aboriginal and Torres Strait Islander people in the health workforce). Indigenous Australians respond better to health care when it is delivered in a culturally safe and appropriate way. Indigenous health professionals have a strong capacity to deliver culturally responsive care in addition to any clinical care they may also be delivering and can improve the cultural security of health care and reduce discharge against medical advice (Taylor et al. 2009). An Indigenous health workforce also helps to strengthen the cultural capability of the broader health teams and organisations in which they work. While the Indigenous workforce plays a vital role in the provision of culturally appropriate services, it is the responsibility of the health care system to ensure that mainstream health services are culturally competent through high-quality professional development and training, appropriate management when cultural respect is lacking, and staff developing awareness of their own unconscious bias (AHMAC 2016).

Findings

What does the data tell us?

Medical practitioners

In 2017, there were 97,257 medical practitioners registered in Australia (excluding provisional registrants), 88% of whom were employed as clinicians (Table D3.22.1). Many of those not working in medicine were overseas, retired or on extended leave. The supply of employed medical practitioners working as clinicians increased between 2005 and 2017 (from 298 to 383 full-time equivalent—FTE—per 100,000 population) (Table D3.22.15).

The supply of medical practitioners was not uniform across the country; it was greater in Major cities (450 FTE per 100,000) than in Outer regional areas (291 FTE per 100,000), although it differed by type of medical practitioner (Table D3.22.13).

While general practitioner (GP) rates were similar across geographic areas, the supply of clinical specialists declined with remoteness. There were 177 FTE per 100,000 in Major cities compared with 24 FTE per 100,000 in Very remote areas (Table D3.22.14, Figure 3.22.1). Access to specialists for those living outside metropolitan areas is primarily provided through outreach clinics, visiting specialists, or telehealth (AIHW 2016a). A 2014 study reported that 19% of specialist doctors provided outreach and three-quarters of these were metropolitan-based (O’Sullivan et al. 2014). Specialist access is also provided through Commonwealth-funded Indigenous primary health care services (AIHW 2018).

In 2016, 58% of GPs working outside metropolitan areas were males; this increased to 62% in Very remote areas (Table D3.22.22).

Figure 3.22.1: Employed medical practitioners, FTE per 100,000 population by main area of practice and remoteness area, 2017

Source: Table D3.22.14. AIHW analysis of National Health Workforce Data Set.

A national survey of the rural workforce in November 2016 found that of the 8,329 GPs working in rural Australia, an estimated 48% had been in their current practice for fewer than 3 years (56% in Remote areas and 58% in Very remote areas) (Table D3.22.4, Figure 3.22.2).

A 2015 study on GP mobility found that GPs working in small communities and those in rural locations for fewer than 3 years are most at risk of leaving rural practice. Younger rural GPs were also more likely to leave rural practice than were older rural GPs (McGrail & Humphreys 2015).

Figure 3.22.2: Proportion of GPs in rural and remote areas, by length of stay in current practice and remoteness, 30 November 2016

Source: Table D3.22.4. Medical practice in rural and remote Australia: Combined Rural Workforce Agencies National Minimum Data Set report as at 30 November 2016.

A 2007 study identified that doctors who were satisfied with their current medical practice said they would remain in rural practice for longer than those who were not satisfied (11.5 years compared with 8.2 years). GPs content with their lives as rural doctors intended to remain in rural practice 51% longer than those who were not content (11.8 compared with 7.8 years) (Alexander & Fraser 2007).

Other health professionals

In 2017, the number of employed psychologists was lowest in SA2 areas that have a high proportion of Indigenous Australians in the population. There were 37 per 100,000 in areas with 20% or more Indigenous Australians in the population, compared with 131 per 100,000 in areas with less than 1% (Table D3.22.17). The pattern was similar for pharmacists (60 compared with 116 per 100,000 respectively) (Table D3.22.18). The areas used are based on the Australian Statistical Geography Standard.

Looking at FTE rates at a national level can mask variation in the supply of the health workforce at small local area levels. Calculating supply at the small local area level using Statistical Area 2 (SA2) and AIHW’s Geographically-adjusted Index of Relative Supply (GIRS), found that there were 39 SA2s with GIRS scores of 0–1 (higher probability of workforce supply challenges). Of these, the majority (23) were in Very remote areas, along with 7 in Remote areas, 6 in Outer regional areas and 3 in Inner regional areas.

GIRS scores were calculated for GPs, nurses, midwives, pharmacists, dentists, psychologists and optometrists, and these scores showed that between 3% and 15% of the Indigenous population in these professions lived in areas with low relative workforce supply. GIRS scores of 0 to 1 occur most often for midwives (15%), optometrists (13%), pharmacists (12%) and least often for nurses (3%) (Figure 3.22.3). Nearly 20% of Indigenous Australians lived in areas facing a supply challenge for at least one health profession, compared with 3% of the non-Indigenous population (AIHW 2016b).

Figure 3.22.3: Proportion of population living in areas of lowest relative clinical workforce supply, by Indigenous status and profession

Note: For midwives, the GIRS score was calculated for women aged 15–44.

Source: AIHW. Spatial distribution of the supply of the clinical health workforce 2014: relationship to the distribution of the Indigenous population. Cat. no. IHW 170. Canberra: AIHW; 2016.

Indigenous primary health care organisations

As at 30 June 2018, there were 5,060 FTE health (clinical) staff and 3,329 FTE administrative and support staff positions within Commonwealth-funded Indigenous primary health care organisations. The vacancy rate was 7% for health positions and 2% for administrative and support staff positions (Table D3.22.11).

In the period 1999–00 to 2017–18, there was an increase of 402% in the number of FTE staff in these organisations (Table D3.14.47). Despite this growth, the vacancy rates for health positions and administrative and support staff positions changed little between 2000 and 2018 (Table D3.22.12, Figure 3.22.4).

Figure 3.22.4: Proportion of FTE vacant positions in Aboriginal and Torres Strait Islander primary health-care organisations, by position type, at 30 June 2000 to 30 June 2018

Source: Table D3.22.12. Service Activity Reporting, Drug and Alcohol Services Reporting and AIHW Online Services Report data collections.

As at 30 June 2018, vacancies in Commonwealth-funded Indigenous primary health care organisations were highest for nurses (86 FTE), followed by Aboriginal health workers (55 FTE), Aboriginal health practitioners (42 FTE) and social and emotional wellbeing workers (42 FTEs) (Table D3.22.11).

The proportion of health/clinical staff positions that were vacant ranged from 9.3% in Remote areas to 3.7% in Inner Regional areas. For administrative and support positions, vacancies were highest in Remote areas (5.6%) and were 2.5% or less elsewhere (Table D3.22.23, Figure 3.22.5).

Figure 3.22.5: Proportion of FTE vacant positions in Indigenous primary health-care organisations, by remoteness area and position type, 30 June 2018

Source: Table D3.22.23. Service Activity Reporting, Drug and Alcohol Services Reporting and AIHW Online Services Report data collections.

In 2017–18, 71% (141 services) of Commonwealth-funded Indigenous primary health care organisations reported that recruitment, training and support of Indigenous staff was a major challenge. In Remote areas, this was as high as 81%. Among all staff, retention and turnover were reported as a challenge by 54% of organisations; the proportion was highest in Remote (73%) and Very remote areas (75%) (Table D3.22.25).

In the Northern Territory, where the majority of services are located in Remote or Very remote areas, recruitment, training and support services was a challenge for 84% of services, and staff retention and turnover was reported as a challenge by 79% of services (Table D3.22.24).

Aboriginal health workers and Aboriginal health practitioners

Aboriginal and Torres Strait Islander Health Workers (ATSIHW) and Practitioners (ATSIHP) play essential roles in ensuring culturally appropriate care for Indigenous Australians. ATSIHP are required to be registered with the Australian Health Practitioner Regulation Agency and are included in the National Health Workforce Data Set. To be eligible to apply for registration as an ATSIHP, a person must provide evidence that they are of Aboriginal and/or Torres Strait Islander descent, identify as an Aboriginal and/or Torres Strait Islander person, and are accepted as an Aboriginal and/or Torres Strait Islander person in the community in which they live or did live. The number of registered and employed ATSIHPs increased from 451 in 2015 to 547 in 2018 (DoH 2019).

Wright and others (Wright et al. 2019) used census data on self-reported employment to estimate the number of Indigenous health workers in Australia in 2006, 2011 and 2016 (using the Australian and New Zealand Standard Classification of Occupations category of ‘Indigenous health worker’, which is intended to capture both ATSIHW and ATSIHP). They found that the overall number of Indigenous health workers increased from 1,009 in 2006 to 1,347 in 2016. However, this growth was not commensurate with growth in the Indigenous population over this time, meaning that the number of Indigenous health workers per 100,000 Indigenous population fell from 221 in 2006 to 207 in 2016. Growth in the number of Indigenous health workers was concentrated in older workers (aged 45 and over), while there was a decline in the number of workers aged 44 and under. The lack of proportional growth and the ageing of this workforce raises concerns about recruitment and retention into the future.

What do research and evaluations tell us?

Jongen and others (2019) noted that the capacity of Aboriginal Community Controlled Health Services (ACCHSs) to meet the needs of Indigenous Australians relies on the skills, motivation and experience of its workforce. ACCHSs already implement workforce-development strategies while also facing challenges to maintain a strong and stable workforce (Jongen et al. 2019). Challenges and strategies for ACCHSs include improving workforce conditions, increasing remuneration, building strong leadership through clear communication and strong management and supervision, improving professional development opportunities using training and career progression pathways, and supporting teamwork through meetings, mentoring and support. Conway and others (2017) also noted the importance of improved support for Indigenous health workers; the inclusion of Indigenous health workers in decision-making within the health care setting, ‘champions’ to support Indigenous health workers in the implementation of chronic disease care self-management programs, and adequate Indigenous representation in allied health and management positions (Conway et al. 2017).

A senate inquiry into factors affecting the supply of health services and medical professionals in rural areas has identified a complex interplay between environmental, personal and work-related factors (Senate Community Affairs Committee Secretariat 2012). These include access to professional development and career progression, remuneration, heavy workloads, on-call hours, loss of anonymity, social barriers and professional isolation, opportunities for spouses and children, and access to appropriate, affordable and secure accommodation.

A growing trend towards medical specialisation was identified as reducing generalist training pathways and affecting the supply of GPs in rural and regional areas—the area of medical practice most required in these areas (Senate Community Affairs Committee Secretariat 2012). Conversely, rural lifestyle, diverse caseloads, autonomy and community connectedness have been cited as motivation incentives for allied health professionals to work in remote and rural areas (Campbell et al. 2012).

A study of drug and alcohol workers found that Indigenous workers experienced above-average levels of job satisfaction and relatively low levels of exhaustion; however, they also experienced lower levels of mental health and wellbeing and greater work–family imbalance. The report highlighted the importance of workforce-development strategies that focus on culturally appropriate, equitable and supportable organisational conditions, including addressing stress, salaries, benefits and opportunities for career and personal growth (Roche et al. 2013).

Implications

Recruitment and retention of GPs, nurses and allied health professionals are significant issues for health services located in rural and remote Australia. Ongoing support for rural and remote GP vocational training opportunities and the selection of medical students from these areas are critical in addressing these issues (McGrail et al. 2016).

More information is required to develop an understanding of the retention and turnover of staff in Indigenous-specific primary health care services and how this compares with mainstream services. Further understanding of the enablers and barriers of retention would assist in the development and implementation of retention strategies. Succession plans, clear career pathways and support for ongoing professional development in strengthening clinical and non-clinical skills and capabilities are mechanisms suggested to improve recruitment and retention.

Recognition of Aboriginal and Torres Strait Islander health as an identifiable specialty is also important in improving services and retaining highly skilled clinicians to build the capacity of the workforce in Indigenous health. There have been calls for the development of a sub-specialty in Indigenous health for GPs and physicians, supported by medical colleges. This would recognise the unique skills needed to work in Indigenous health and ensure that practitioners would receive appropriate training. The need to improve the attraction of working in Indigenous health has been recognised.

Participation by Indigenous health workers in decision-making in and around health service provision will improve cooperation and collaboration within a health care team (particularly those that include non-Indigenous health professionals) in delivering quality and culturally competent health care (Durey et al. 2012).

Collaboratively designed, implemented and evaluated retention strategies will assist in determining which strategies are most effective at retaining Indigenous Australians in the health workforce (Lai et al. 2018). The National Aboriginal and Torres Strait Islander Health Workforce Plan 2021–2031 was informed by an extensive national consultation process. Consultations identified that improved recruitment and retention of Indigenous Australians requires a culturally safe health and education sector, and in order to successfully grow the Indigenous health workforce, barriers to education, employment and career progression need to be addressed consistently at both the national and jurisdictional level. Attracting and retaining culturally competent non-Indigenous health professionals to work in Aboriginal and Torres Strait Islander health settings as well as Indigenous Australian health workers may help relieve pressure among existing Indigenous Australian health workers (see measures 3.12 Aboriginal and Torres Strait Islander people in the health workforce and 3.20 Aboriginal and Torres Strait Islander peoples training for health related disciplines).

The policy context is at Policies and strategies.

References

• ABS (Australian Bureau of Statistics) 2018. Estimates of Aboriginal and Torres Strait Islander Australians, June 2016. ABS Canberra.

• AHMAC (Australian Health Ministers Advisory Council) 2016. Cultural Respect Framework 2016-2026 for Aboriginal and Torres Strait Islander health. Canberra: AHMAC.

• AIHW (Australian Institute of Health and Welfare) 2016a. Medical Practitioners Detailed Tables 2015. Canberra: AIHW.
• AIHW 2016b. Spatial distribution of the supply of the clinical health workforce 2014: relationship to the distribution of the Indigenous population. Cat. no. IHW 170. Canberra: AIHW.
• AIHW 2018. Australia’s health 2018. Australia’s health series no. 16. AUS 221. Canberra: AIHW.
• Alexander C & Fraser JD 2007. Education, training and support needs of Australian trained doctors and international medical graduates in rural Australia: a case of special needs. Rural and Remote Health 7:681.
• Campbell N, McAllister L & Eley D 2012. The influence of motivation in recruitment and retention of rural and remote allied health professionals: a literature review. Rural and Remote Health 12:1900.
• Conway J, Tsourtos G & Lawn S 2017. The barriers and facilitators that indigenous health workers experience in their workplace and communities in providing self-management support: a multiple case study. BMC health services research 17:319.
• DoH (Australian Government Department of Health) 2013. National Aboriginal & Torres Strait Islander Health Plan 2013-2023. Canberra: Commonwealth of Australia.
• DoH 2019. Health Workforce Data Summary Statistics. 
• Durey A, Wynaden D, Thompson SC, Davidson PM, Bessarab D & Katzenellenbogen JM 2012. Owning solutions: a collaborative model to improve quality in hospital care for Aboriginal Australians. Nursing Inquiry 19:144-52.
• Humphreys J, Wakerman J, Kuipers P, Wells R, Russell D, Siegloff S et al. 2009. Improving workforce retention: Developing an integrated logic model to maximise sustainability of small rural & remote health care services document on the Internet]. c2009 [cited 2014 Nov 17]. Canberra: Australian Primary Health Care Research Institute.
• Jongen C, McCalman J, Campbell S & Fagan R 2019. Working well: strategies to strengthen the workforce of the Indigenous primary healthcare sector. BMC health services research 19:910.
• Lai G, Taylor E, Haigh M & Thompson S 2018. Factors affecting the retention of Indigenous Australians in the health workforce: a systematic review. International journal of environmental research and public health 15:914.
• McGrail MR & Humphreys JS 2015. Geographical mobility of general practitioners in rural Australia. The Medical Journal of Australia 203:92-7.
• McGrail MR, Russell DJ & Campbell DG 2016. Vocational training of general practitioners in rural locations is critical for the Australian rural medical workforce. Medical Journal of Australia 205:216-21.
• O’Sullivan BG, Joyce CM & McGrail MR 2014. Rural outreach by specialist doctors in Australia: a national cross-sectional study of supply and distribution. Human Resources for Health 12:50.
• Roche AM, Duraisingam V, Trifonoff A & Tovell A 2013. The health and well-being of Indigenous drug and alcohol workers: results from a national Australian survey. Journal of Substance Abuse Treatment 44:17-26.
• Senate Community Affairs Committee Secretariat 2012. Community Affairs References Committee: The factors affecting the supply of health services and medical professionals in rural areas. (ed., Senate Standing Committees on Community Affairs). Canberra: SSCCA.
• Taylor KP, Thompson SC, Wood MM, Ali M & Dimer L 2009. Exploring the impact of an Aboriginal Health Worker on hospitalised Aboriginal experiences: lessons from cardiology. Australian Health Review 33:549-57.
• Wright A, Briscoe K & Lovett R 2019. A national profile of Aboriginal and Torres Strait Islander Health Workers, 2006-2016. Aust NZ J Public Health 43:24–6.