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84 Making General Practice Attractive: Encouraging GP attraction and Retention KCE Reports 90 Recruitment issues and recent (2003-2007) policy development in France Regional disparities in the availability of physicians and other health professionals, termed "recruitment issues", are also present in European countries, such as France, UK 175 , Norway, and Germany. In France, recent reports (Rapport Descours (2003) 176 , IRDES (Bourgueil et al 2006 177 ), Rapport Juilhard (October 2007) 178 ) address these issues. The Rapport Descours (2003) 176 , concerned with health professions, and the Rapport Juilhard (October 2007) 178 , more concerned with physicians, propose general measures. These suggestions are similar to what can be learned from developed countries with a history of (rural) physician shortage, e.g. US, Australian 154 , 161 and Canadian initiatives 168 . In France, Bourgueil et al (2006) 177 observe many State and Regional legal levers to entice physicians into practicing in shortage areas. Most of these opportunities are financial and fiscal; some of them are not applicable, due to lack of enforcement legislation. Medical residents do not know them. In their survey of regional committees of the "Observatoire national de la démographie des professions de santé" (ONDPS), Bourgueil et al 2006 179 propose a "pipeline strategy". In October 2007, a French Government proposal to limit the choice of practice location by newly graduated physicians resulted in medical residents going on strike. As in Ontario 174 , such measures are seen as highly unpopular. Interns and residents Unions and French analysts (Yann Bourgueil, Libération, 6/10/2007 180 ) criticized the project, arguing that they would be no more effective than US NHSC programs, since they address recruitment issue but not attraction and retention issues. Moreover, focusing on practice location choice deters policymakers and stakeholders from discussing more essential questions: the missions of primary care and general practice, its place in the health system, its organisation and financing, and its interdependencies with specialized medicine and hospitals. New generations of medical graduates are trained by academic hospitals, so this is a euphemism to say that primary care is not well known among medical students. The issue is worsened by the context of feminization of the medical profession and personal aspirations emphasizing a better balance between private and professional life. Bourgueil concludes that the primary care system should be made more coherent and more visible. 5.2.1.3 Retention: creating incentives and more satisfaction to make general practice stable In industrialized countries, literature about retention is also almost entirely dedicated to distributional issues, i.e. the geographical inequities existing in the availability of GPs, especially, but not exclusively, between rural and urban areas. Policies used to address this issue are economic incentives, physician preparedness to work in rural areas through medical education, continuing medical education, locum relief, increasing GPs job satisfaction (or not dissatisfying GPs), and various other programs. ECONOMIC INCENTIVES It may be surprising that recruitment strategies proved to be effective retention strategies. Pathman et al 2004 181 studied the effectiveness of loan repayment and obligated service. Compared with young non-obligated GPs, physicians serving obligations to state programs practiced in demonstrably needier areas and cared for more patients insured under Medicaid and uninsured (48.5% vs. 28.5%, P
KCE Reports 90 Making General Practice Attractive: Encouraging GP attraction and Retention 85 loans of graduates and practitioners in exchange for service) and direct financial incentives (funds for residents and practitioners in exchange for service). In Quebec (Canada), a well-known economic incentive is the increase of fee rates (fee tariff) by 15% for physicians practicing in rural regions, and a decrease by 30% for those who practice in university regions 168 . This incentive is also operating in most other Canadian provinces, with variable adjustments. In UK, specific allowances and deprivation payments (increase in capitation rates) also exist for GP practicing in underserved, either urban or rural "designated" areas, i.e. where there is a ratio of GPto-population lower than 1:3000. This a compensation for higher workload and poorer working conditions, rather than a retention incentive. PREPAREDNESS As shown above, preparedness by medical education would be seen as a retention, rather than a recruitment policy 109 . LOCUM RELIEF A common factor associated with rural practice is the lack of access to locum relief programs. In Australia, Locum Relief Programs were developed to address the problems of significantly higher workloads and fewer holidays for rural GPs compared to their metropolitan counterparts. Generally, research into locum relief programs measure GP attitudes towards the service provided, instead of trying to show a effect on recruitment or retention. In Australia, the inadequate access to locum relief has been addressed since the mid 1990s, with the introduction of a national Rural Locum Relief Program 154 . The program was established to provide locum coverage and give greater support for junior practitioners who would not otherwise work in rural areas. In Canada, locum relief programs also exist in most provinces 168 . The problem is that locum relief supposes an adequately staffed workforce. Implementation and effectiveness are challenging. For example, locum looks appealing from the viewpoint of GPs who benefit from a temporary relief. However, things may not be all rosy from the viewpoint of GPs providing locum services. Which GP would accept to build a career on something very far from ideal, and would relinquish a stable environment, continuity of care and close physician-patient relationships? In our opinion, providing locum services is not appealing in the long-term for highly qualified professionals and cannot be satisfying for those who did not choose it. CONTINUING MEDICAL EDUCATION (CME) One of the key strategies to retain GPs in rural areas is to increase on-going medical training accessible to rural GPs 182 . Continuing medical education (CME) addresses the professional needs of GPs by providing postgraduate studies to develop clinical skills, and socialization issues. Although CME does not appear to significantly impact on recruitment, the positive evaluations by rural GPs suggest that CME does influence retention, but there is no evidence to support these claims 154 . INCREASING GPS JOB SATISFACTION (OR NOT DISSATISFYING GPS) In organizational psychology, job satisfaction is an immediate antecedent of personnel turnover intention and behavior 183 and therefore a predictor of retention. The difficulties with literature on job satisfaction is to deal with factors common to every workers (e.g. stress), which do not add much to knowledge for the present project, or with highly context-dependent determinants of job satisfaction, which are not transferable to other settings and contexts. Part of literature on job satisfaction is devoted to empirical testing of theoretical models, which does not usefully contribute to the present literature review (e.g. the methodologically nice study by Landon et al. 122 ). Finally, most studies on job satisfaction are surveys, in which doctors are asked why they are satisfied or not or why they stay or leave general practice. This approach may lead to "self-serving bias" in attribution theory, i.e. people only partly understand the reasons behind their behavior.
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