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88 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90 5.3.3 Retention Practice location is also strongly influenced by the preferences of GP spouse, especially when a choice has to be made between urban and rural area. Spouse pay attention for themselves and their family to aspects such as job opportunity, community links, community environment, housing, services, schools, and leisure. The main policies used to attract GPs in rural area are economic incentives to support starting general practice (grants, subsidies, loans) : • Funding medical schools for expansion or maintenance of health professions education and training (e.g. US Title VII funding) is moderately effective. As far as we are informed, cost-effectiveness of such programs was not evaluated. • Subsidies (grants) for starting family practice are used to sustain rural healthcare workforce (Australia, Canada), but it is not sure if they are effective or cost-effective. Young French GPs judged such initiatives irrelevant. • Financial support to medical students (grants, loans) in exchange for a period of service in underserved areas (US federal National Health Service Corps and similar state programs) is moderately effective, at least in the short-term. Surprisingly, it was found that loan repayment in exchange of obligated service was an effective retention policy. Cost effectiveness was not evaluated. Another recruitment strategy is to use "recruiters". For example, the Robert Wood Foundation's Southern Rural Access Program (SRAP) consists in the use of granted recruiters to assist rural communities in assessing healthcare needs and recruiting primary care providers. Other initiatives exist to give young graduates an administrative support for locating/opening their own family practice. Three factors arise from the review of literature for the retention of GPs, both in rural or undifferentiated areas. The difficult working conditions (e.g. workload, flexibility of working schedules) and work-family balance (e.g., to save time for personal and family life and leisure) influence the decision to quit the profession, in particular in rural areas but policies in this field have still to be implemented and evaluated. Low income is a second factor. In the literature, general practitioners working in rural areas felt being less favored than their urban counterparts. But, economic retention incentives, such as increasing fee rates for physicians practicing in rural regions (Canada), and specific allowances and deprivation payments (UK) does not seem to be effective in the long-term. GPs may feel inadequately compensated for higher workload and poorer working conditions or environment. Another, but broader, economic incentive is community development that could play a role in retention of the GPs. Some GPs suffer from a lack of professional support (e.g., specialty support, educational opportunities, and support from local hospitals or community health staff) or a lack of community support for private life (e.g. availability of leisure and cultural activities, quality of school for the children, spouse’s well-being). Many other programs and policies have been developed but their effectiveness has not been tested yet. Salaried practice, continuing medical education, locum relief, and professional development putting "inactive" GPs back into practice, delaying retirement, and community integration are among those programs. Implementation and effectiveness are also challenging. Providing immigrant visa to International Medical Graduates (IMGs) in exchange of a variable period of obligated service is effective, at least in the short-term, but this however raises issues of discrimination against IMGs and ethical issues.
KCE Reports 90 Making General Practice Attractive: Encouraging GP attraction and Retention 89 6 CHAPTER 6: WHAT ARE THE POLICIES TO BE IMPLEMENTED IN BELGIUM TO IMPROVE ATTRACTION, RECRUITMENT AND RETENTION OF THE GENERAL PRACTITIONERS: A STAKEHOLDERS’ ANALYSIS 6.1 INTRODUCTION The previous chapter identified in the international literature the policies influencing attraction, recruitment and retention of general practitioners. However, the transferability of such policies in Belgium may be questionable. For example, many policies target urban/rural medical densities differences. Although those differences exist in Belgium, they may be not that important than in the US. This last part of the study identifies policies that could be implemented in Belgium to improve the GPs’ career. The stakeholders will appraise them. What makes good policies can be assessed following different perspectives. Broadly, two paradigms are contending : the rationalist perspective and the pluralist theory 191 .The former states that decisions are made through a rational process by considering all the options and their consequences especially on the costs 192 . According to the latter perspective, rationality involves many considerations (and not only costeffectiveness) and power is widely distributed into the society so that no one has enough power to enforce a specific solution whatever its cost-efficiency in solving the problem. As figure 1 suggests, policies do not get onto the agenda according to some logical series of stages but when the 3 streams of problems-identification, solutions and political power intersect 193 . Figure 1: Kingdon’s three stream model of agenda setting Source Adapted from Kingdon (1984) This pluralist paradigm applies to primary care in Europe. Governance in primary care is strongly rooted in self-regulation and mechanisms of network interaction 2 .
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