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28 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90 The financial parameters (incomes, debt and the general socio-economic context) also influence the retention in rural areas. Low income (explained by lower reimbursement 67 , 79 , rates and greater numbers of uninsured patients) acts as a brake on the retention 88 , 92 , 114 even if a study pointed that the income was usually not a primary concern for the GP 84 . Nonetheless one study noted that GPs placed in underserved communities just stay long enough to repay their loan obligations 119 . Many facets of the local community play an important role in the retention of the GPs in rural areas. The acceptance of the GP by the local community has positive effects on the retention 84 , 105 , 113 . Some GPs suffer from a lack of professional support e.g., specialty support 67 , 81 , 113 , educational opportunities 67 , support from local hospitals or community health staff 81 . In particular, locum relief, defined as "a physician who substitutes temporarily for another physician" (from the Latin "locum tenens" is frequently cited. 80 , 81 , 91 , 97 , 105 , 113 . Conversely, the availability of relief coverage after hours 105 , a good on-call arrangement, including time off for holidays and for continuing medical education 79 , 105 , 117 , a medical group dynamics 79 , an available diagnostic service 79 are many factors supporting the retention of the GP in a rural area. GOVERNMENTAL, REGIONAL AND LOCAL POLICIES This part is developed in the next section. LIFE SATISFACTION The family has a considerable influence on the retention in rural area. The lack of cultural activities and entertainment 81 , 91 , 105 80 , 81 , 91 and the social isolation of the family have a negative impact on the retention. The partner’s employment opportunities 84 and his/her happiness in the community are also decisive factors 84 , 105 . The lack of anonymity (especially if doctors are hesitate to take a wider role within the community) 105 , 112 and the lack of professional development opportunities 105 are supplementary negative factors that play a role in the retention in rural area. The community support for the personal life retains GPs in rural areas (availability of housing and religious support structures) 105 . A study specifies that the proximity to a city or large regional center is not linked with the retention 117 . 2.3.1.6 Retention in indifferent area Similar factors influence the retention in general practice, independently of the location. They relate to the personal identity, the working conditions and the life satisfaction. More European studies (61%) are available for that part (mostly (88%) from the UK). American studies (31%) and a few Australian studies (8%) were other sources. PERSONAL IDENTITY Demographic factors such as the age, the ethnic origin and the sex affect the retention. GPs older than 55 years would be more satisfied with their work: the satisfaction declines until age 45 and then increases to the age of 60 118 Younger GPs are less satisfied with the amount of responsibility. Three studies show however that the intent to leave the profession is higher with advancing age 118 , 120 . White GPs seem more satisfied with the working conditions 118 . Women are generally more satisfied with their work than men 118 , 121 , However, they retire earlier (5.5 years earlier) than men 122 , 123 . WORKING CONDITIONS Difficult working conditions are also a major brake on retention, as explained in the literature about rural areas.
KCE Reports 90 Making General Practice Attractive: Encouraging GP attraction and Retention 29 The challenge of maintaining high-quality care 34 , of keeping up with a continuously expanding list of recommended therapeutic and preventive treatments 122 and the amount of responsibility play a negative role for the retention 121 . The lack of flexibility in working arrangements 72 , the dissatisfaction (for example in the UK, following the NHS reforms) 61 , 118 , 122 , the heavy workload 65 , 72 , 118 , 124 118 , 121 , the long hours of work are also related to the problem of the GP retention. A lot of stressing agents have also an effect on the intention to leave (e.g., night visits, fear of assault during visits, finding a locum) 121 . Additional factors are linked to the patients with their increasing demands and expectation 65 , 72 . On the other hand, the studies identified some facilitating factors related to the profession. An overall satisfaction 80 , 120 , 121 , the development of the personal abilities 121 , the variety in the job 121 , the recognition for good work 121 , 125 , the positive relationships with the patients 125 are favorable for the GP retention. The local community features are influential. The positive relationships with the local communities 120 and the professional community support that allow adequate time off 80 , training and career development 72 support the retention of the GP. On the other hand, working in deprived areas with lower payments discourages the retention 123 . As a matter of fact, the financial parameters influence the retention of the GP, as noted in the chapters about attraction and recruitment. Many studies present the low incomes 72 , 118 , 120 and the rising practice costs 122 as negative factors. It should be noted that the GPs with higher incomes were less likely to reduce their working time 122 . A study found that the income is not related to the decision of retirement 122 . LIFE SATISFACTION The family is important for the retention: if the GP profession creates an imbalance in the family life, the GP will have a higher intention to leave his/her job 121 . A study further specifies that part-time GPs with an important marital or parental role have less intention to leave their job than full-time GPs 126 . 2.4 SUMMARY: LITERATURE REVIEW ON FACTORS INFLUENCING ATTRACTION, RECRUITMENT AND RETENTION This chapter considers all factors that play a role in the attraction of the future general practitioners and in their decision to start and go on with their practice. Many papers study the situation in North America and in Australia, in particular the factors that influence the work in remote rural areas. Some conclusions might not be applicable to Belgium. Nevertheless, the identification of all factors potentially interacting with the attraction, recruitment and retention in the GP profession are worth being analyzed in the context of this project. This literature review emphasizes the role of extrinsic factors. The most important or influential extrinsic factors that have an effect on the attraction, recruitment and retention were identified as the following ones: • The major role of the medical school (student’s exposure, role model, curriculum…); • The difficult working conditions (heavy workload, the stressful and the non controllable lifestyle, inflexibility of hours, required commitment and on call availability…); • The level of income; • The positive aspects of relationships within the patient. These findings also underline the complexity of the factors interacting in the decisions and the necessity to tackle the problem using a multidimensional approach.
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