Retention policies for allied health professionals in rural areas : a survey of private practitioners

Introduction: Retention of rehabilitation therapists (RTs) in rural areas is a growing problem in rural Australia. Current literature demonstrates that private allied health professionals in general remain longer in rural areas than those working in the public sector. However, govemment focus to enhance retention has been on those employed in the public sector, offering private practitioners little incentive to stay rural. There has been an absence of policy commitment to attracting private professionals to rural areas or offering rural practitioners options for mixing private and public service. This study aimed to explore the thoughts and perceptions of private RTs in rural areas conceming their incorporation into broader rural health policies and concomitant programs. Methods¡ An online survey was sent to a purposively chosen sample of RTs in rural Victoria. Participants were selected from publicly available internet listings and were contacted via email. Possible participants were limited to those who had an email address and to those on three available professional lists (physiotherapy, occupational therapy and speech pathology). The survey consisted of 2gquestions: eightrelated to the perceived place that practitioners in rural areas occupy; eight related to their professional practice; seven related to retention policies; two related to education and training; and four were demographic questions. Results: A total of 72 RTs completed the survey and were included in the analysis (407o response rate). The overwhelming majority of respondents were in favour of having partnerships between private and public practice in rural and regional areas and of govemments developing programs to facilitate such partnerships. In Total,267o of respondents currently worked in some form of @ K O'Toote, AM Schoo, 2010. A licence to publish this material has been given to ARHEN http://www.rh.org.au The InternatÌonal ElectronicJournd of Rurel end Rernote Health Research. Educ*lon Practlce and Pollcy partnership with public agencies. There was also a reasonable response to the use of government incentives to retain and attract private practitioners to rural and regional areas. Conclusions: The results of this research indicate that many private RTs in Victoria perceived their greater involvement in the delivery ofpublic health in rural areas in a positive manner.


Introduction
Services to rural areas are treated as just that, 'services'.
However, the role of services can be more than just 'provision of service' because more often than not services bring with them infrastructure and professional personnel. Professionals can be, and often are, major assets for economic, social and cultural sustainabilityt-6. The problem is that professionals are often 'visitors' to rural areas and their retention and recruitment is difficult for a range of reasonst-t3.
Governments do develop policies and programs to support allied health in rural Australia, such as the Australian Federal Government's Rural Allied Health Undergraduate Scholarship Scheme, Rural Allied Health Clinical Placement Grants, and the past Rural Private Access Program. In Victoria a suite of local, regional and state-wide workforce projects have been initiated by the Department of Human Services. These include the 'Region of Choice', 'Mentoring Works' and 'Statewide Allied Health 'Workforce Education Program' that aim to attract and retain health professionals in rural areas. However, the retention of allied health practitioners (AHPs) is still problematic and, with the exception of medical practitioners in the primary healthcare setting, govemments predominantly focus on the 'public sector' when developing rural health policies. The general focus on retention policies for rural and regional AHPs in Australia has been 'employment' of personnel in preexisting structures of public delivery (eg hospital or community health setting). This has been reinforced by workforce studies that focus on managing allied health professionals within public health hierarchical structures la-I 8.
These studies focus almost exclusively on public sector employees. The role of private AHPs is rarely mentioned. Professionals need flexibility in the way they pelform relevant tasks and apply their skills in rural areas. The need for 'flexibility' is a common attribute among professionals in rural settingsle. The application of rigid rnanagement controls, especially under strict funding guidelines, will often clash with this need for flexible arrangements in rural settings20. The issue of more flexible funding models for rural health has been raised in the literature by researchers looking for altemative models of management or funding, in order to establish clinical leadership and improved rural career optio ns20-22 . The focus is still very much on restructuring funding models for the public sector. Research has shown that private AIIPs generally remain longer in rural areas than those working in the public sectorl2'23 '24. Little recognition is given to re-thinking models that help to integrate the private sector into the allied health workforce policy mix. However, before policy-makers consider changes to the present system, analysis is required of what private practitioners think about their own role in broader policy for retention ofpractitioners in rural areas.
This article reports on the thoughts and perceptions of an important group of private AHPs in rural areas using data from a survey about inclusion into a broader rural health policy and programs. The focus of this article is on 'rehabilitation therapists' (RTs; physiotherapy, occupational therapy and speech pathology)2s. For the purposed of this discussion, the term 'public' means health services that belong to the state, and 'private' refers to services that are 'for profit' outside of the state. llhe lilernational Electronic Journd of Rural €nd Remotè Health Rasearch, Educ*lon Practlce end Pollcy Method Participants The targel group for the surveys included private RTs working in rural and regional areas of Victoria. Because the project is exploratory and funding was limited, only those private RTs who had an email address were chosen. Email addresses were obtained from lists on the intemet, and were thus limited to RT professions that made such lists publicly available (physiotherapy, occupational therapy and speech pathology). The number of email addresses obtained was 198, of which 14 were returned as invalid or rejected by spam protectors. Of the remaining 184, 72 surveys were completed (407o). This completion rate is considered a good response rate for online surveys26.

Instrument
The survey consisted of 29 questions: eight related to the perceived place occupied by RTs in rural areas; eight related to their professional practice; seven related to retention policies; two related to education and training; and four were demographic questions (Appendix I). The questions in the survey were drawn from previous research into the retention of allied health practitioners in rural areas2o't5'". The survey was constructed using an online survey program (Zoomerang).

Procedure
Ethics approval for the survey was granted by Deakin University, Victoria, and consent by respondents was assumed if the survey was returned. A URL for the survey was included in the email and sent to participants. Data from completed surveys went directly into a database so that all responses were anonymous and conf,rdential. The sample was purposive rather than representative, because the study design was intended to be exploratory rather than definitive'

Results
Of the 72 respondents 66 reported their occupation: 23 were speech pathologists, 22 were physiotherapists and 2l were occupational therapists, The overwhelming majority of respondents who reported their sex were lemale (777o, n=55). The majority (52o/o, n=3I) were aged between 36 and 50 years, while 28Vo (n=17) were 35 and below, and 20Vo (n=I2) \ilere over 50 years. Of those who reported the number of years working in rural/regional areas (n=53),64Vo had worked for 10 years or less. One respondent had worked for 38 years in rural/regional areas. Of the 60 who reported where they began their careers, 63Vo (n=38) reported rural and 377o (n=22) indicated urban. The overwhelming majority (n=50, 797o) began their careers in the public sector, 1 l7o (n=7) began in non-government organization (NGO) sector, while only l07o (n=6) began in the private sector.
More than a quarter of the rural private RTs (n=19) reported working in partnership with the public sector for part of the time. The majority of those practitioners worked as clinical practitioners in the public sector (on a salary) and their hours of work varied from 2 to 38 per week. The individual who indicated 38 hours also worked another 16 hours in private practice. Others (n=5) reported that they also acted in an advisory role for the public sector. A smaller number (n=11) worked in the NGO sector in a clinical as well as an advisory role. Thirty practitioners also worked in a voluntary capacity for one or more sporting organizations, welfares groups, charities or schools. Their activities varied among clinical, advisory, governance or training roles' There was a considerable number (n=45) who indicated that they worked with practitioners of other than their own profession' This varied from cross referrals to team work with other practitioner groups both within and without their own professions.
Of the 65 who answered the question 'Is there benefit for rural or regional health professionals having partnerships between private and public practice in rural and regional O  A total of 62 respondents answered 'yes' to the question 'Do you think governments need to develop programs in rural and regional areas to facilitate partnerships between private, public and community practices?' When asked whether governments should facilitate such partnerships, the response was varied. There was a general feeling that such facilitation would be beneficial as long as it did not involve increased paperwork and regulation.
Respondents were then asked whether they agreed or not with the propositions outlined (Table l). The RTs agreed to more funding for public and community institutions, more availability of resources (such as availability of practice rooms at local places), and extra programs to assist professionals in the public sector to develop a private practice in rural/regional areas.
The respondents also made a number of general and particular suggestions about ways to assist private RTs to sustain their practices in rural areas. Some of these included: . educational support, for example lower costs for access to or use of local in-house public However there was some caution from those who replied 'no' to the question. They said that it depended on whether there was a shortage of specific professionals in the area.
They generally wanted more policy recognition for existing practitioners so retention problems could be overcome. In this respect there was support for more scholarships and grants to attract practitioners into the existing private practices. There was some hesitation about government support for setting up clinics that had their home base in large urban centres like Melbourne. Such an approach was seen as a way of channelling funding into urban clinics while sustaining minimal practice in rural areas.
When the respondents were asked about the major barriers to working in rural areas there was a range of responses ( Table 2). Many of the issues had been foreshadowed in previous questions but the leading barriers were seen as cost, small numbers of available clients, lack of access to professional training and the low socio-economic status (SES) of many of their clients.
When respondents were asked whether having a private practice widened their social network in their loca¡ion,527o (n=31) indicated that it did. This included mixing with other business people in the area, and especially for women through business training. For those in small towns the business was an entrée into social networks as the professionals in the public facilities were generally in larger regional centres. There was also the opposite reaction from the 48Vo (n=29) who felt their social network was limited because many of the local population were clients, either through their private practice or in partnership with public facilities.  There were 55Vo (n=32) who felt that they had a positive role to play in local economic development. This included their role in hiring people to work for them, investing and spending money in the locality, contributing to other local developments as community members and providing an essential service to the locality that makes it more attractive for others to invest in the area. In their professional role many considered themselves to be the means for keeping local people healthy through primary health care, and supplying rehabilitation processes, which both add to the vitality of the local area and create a better environment for economic development.
When asked to comment further, there was some indication that public perceptions of private RT practice in rural and regional areas was not always very positive. For example: Philosophical perspectives can have a negative impact (ie workers in public sector may believe that private practitioners are only in it for the money).
Private practice professionals need to make a profit and this does not always sit well with the pubLic purse.
There is often the perception that we are nøking oodLes of money from the fees we charge, however nothing could be further from the truth. . Other rural and regional areas?
17. In client management do you work closely together with other private practitioners in your local area but outside your profession? (Yes, No) Can you explaín?
18. Is there any benef,rt for rural and regional health professionals having partnerships bet¡r'een private and public practice in rural and regional areas? (Yes,

No)
Can you indicate what those benefits might be?
19. Do you think governments need to develop programs in rural and regional areas to facilitate partnerships between private, public and community 22. Do you tbink that there should be government incentives for allied health professionals in metropolitan areas to establish private practices in rural and regional areas? (Yes, No) Can you suggest some ways that this could be addressed? 23. What do you think the barriers are fo¡ allied health professionals establishing private practice in rural and regional areas? 24. Any other comments about private allied health professionals in rural and regional areas? 25. Was there any emphasis placed upon how to run a business in your education for your profession? (Yes, No) More funding for public and community institutions in ruraUregional areas to hire vate orolessionals for services in the Dublic sector More availability ofresources for cooperation between private, public and community rooms at local Dublic