BackgroundResidents of remote communities in Australia and other geographically large countries have comparatively poorer access to high-quality primary health care. To inform ongoing policy development and practice in relation to remote area health service delivery, particularly in remote Indigenous communities, this review synthesizes the key findings of (1) a comprehensive study of workforce turnover and retention in remote Northern Territory (NT) of Australia and (2) a narrative review of relevant international literature on remote and rural health workforce retention strategies. This synthesis provides a valuable summary of the current state of international knowledge about improving remote health workforce retention.Main textAnnual turnover rates of NT remote area nurses (148%) and Aboriginal health practitioners (80%) are very high and 12-month stability rates low (48% and 76%, respectively). In remote NT, use of agency nurses has increased substantially. Primary care costs are high and proportional to staff turnover and remoteness. Effectiveness of care decreases with higher turnover and use of short-term staff, such that higher staff turnover is always less cost-effective. If staff turnover in remote clinics were halved, the potential savings would be approximately A$32 million per annum. Staff turnover and retention were affected by management style and effectiveness, and employment of Indigenous staff.Review of the international literature reveals three broad themes: Targeted enrolment into training and appropriate education designed to produce a competent, accessible, acceptable and ‘fit-for-purpose’ workforce; addressing broader health system issues that ensure a safe and supportive work environment; and providing ongoing individual and family support.Key educational initiatives include prioritising remote origin and Indigenous students for university entry; maximising training in remote areas; contextualising curricula; providing financial, pedagogical and pastoral support; and ensuring clear, supported career pathways and continuing professional development.Health system initiatives include ensuring adequate funding; providing adequate infrastructure including fit-for-purpose clinics, housing, transport and information technology; offering flexible employment arrangements whilst ensuring a good ‘fit’ between individual staff and the community (especially with regard to cultural skills); optimising co-ordination and management of services that empower staff and create positive practice environments; and prioritising community participation and employment of locals.Individual and family supports include offering tailored financial incentives, psychological support and ‘time out’.ConclusionOptimal remote health workforce stability and preventing excessive ‘avoidable’ turnover mandates alignment of government and health authority policies with both health service requirements and individual health professional and community needs. Supportive underpinning policies include: Strong intersectoral collaborat...

BackgroundThe geographical maldistribution of the health workforce is a persisting global issue linked to inequitable access to health services and poorer health outcomes for rural and remote populations. In the Northern Territory (NT), anecdotal reports suggest that the primary care workforce in remote Aboriginal communities is characterised by high turnover, low stability and high use of temporary staffing; however, there is a lack of reliable information to guide workforce policy improvements. This study quantifies current turnover and retention in remote NT communities and investigates correlations between turnover and retention metrics and health service/community characteristics.MethodsThis study used the NT Department of Health 2013–2015 payroll and financial datasets for resident health workforce in 53 remote primary care clinics. Main outcome measures include annual turnover rates, annual stability rates, 12-month survival probabilities and median survival.ResultsAt any time point, the clinics had a median of 2.0 nurses, 0.6 Aboriginal health practitioners (AHPs), 2.2 other employees and 0.4 additional agency-employed nurses.Mean annual turnover rates for nurses and AHPs combined were extremely high, irrespective of whether turnover was defined as no longer working in any remote clinic (66%) or no longer working at a specific remote clinic (128%). Stability rates were low, and only 20% of nurses and AHPs remain working at a specific remote clinic 12 months after commencing. Half left within 4 months.Nurse and AHP turnover correlated with other workforce measures. However, there was little correlation between most workforce metrics and health service characteristics.ConclusionsNT Government-funded remote clinics are small, experience very high staff turnover and make considerable use of agency nurses. These staffing patterns, also found in remote settings elsewhere in Australia and globally, not only incur higher direct costs for service provision—and therefore may compromise long-term sustainability—but also are almost certainly contributing to sub-optimal continuity of care, compromised health outcomes and poorer levels of staff safety. To address these deficiencies, it is imperative that investments in implementing, adequately resourcing and evaluating staffing models which stabilise the remote primary care workforce occur as a matter of priority.

Objective: To compare cancer incidence and survival for the Northern Territory (NT) Indigenous population with that of other Australians, and to assess NT Indigenous incidence time trends. Methods: Cancer registry data were used to calculate cancer incidence rate ratios (NT Indigenous to total Australian), the average annual change in NT Indigenous cancer incidence and the relative risk of cancer death after diagnosis of cancer (NT Indigenous to combined Western Australian and Tasmanian cases) for 1991–2001. Results: For NT Indigenous people, incidence rates were high for cancers of the liver, gallbladder, cervix, vulva and thyroid and, in younger people only, for cancers of the oropharynx, oesophagus, pancreas and lung, but low for cancers of the colon and rectum, breast, ovary, prostate, bladder, kidney, melanoma and lymphoma. Incidence rate ratios ranged from 0.1 for melanoma to 7.4 for liver cancer. Incidence increased for breast and pancreatic cancers. Survival was low for almost all specific cancers examined, and for all cancers combined (relative risk of death 1.9, 95% Cl 1.7‐2.1). Conclusions: Compared with other Australians, NT Indigenous people have higher, and increasing, incidence for some cancers (particularly smoking‐related cancers) and lower survival for most. Implications: Cancer has a greater impact on NT Indigenous people than other Australians. Well‐established cancer risk factors should be more effectively tackled in Indigenous people and known effective screening programs more effectively implemented. Research is urgently required into the reasons why survival from cancer in NT Indigenous people is so much lower than in other Australians.

Background Attracting and retaining sufficient health workers to provide adequate services for residents of rural and remote areas has global significance. High income countries (HICs) face challenges in staffing rural areas, which are often perceived by health workers as less attractive workplaces. The objective of this review was to examine the quantifiable associations between interventions to retain health workers in rural and remote areas of HICs, and workforce retention. Methods The review considers studies of rural or remote health workers in HICs where participants have experienced interventions, support measures or incentive programs intended to increase retention. Experimental, quasi-experimental and observational study designs including cohort, case–control, cross-sectional and case series studies published since 2010 were eligible for inclusion. The Joanna Briggs Institute methodology for reviews of risk and aetiology was used. Databases searched included MEDLINE (OVID), CINAHL (EBSCO), Embase, Web of Science and Informit. Results Of 2649 identified articles, 34 were included, with a total of 58,188 participants. All study designs were observational, limiting certainty of findings. Evidence relating to the retention of non-medical health professionals was scant. There is growing evidence that preferential selection of students who grew up in a rural area is associated with increased rural retention. Undertaking substantial lengths of rural training during basic university training or during post-graduate training were each associated with higher rural retention, as was supporting existing rural health professionals to extend their skills or upgrade their qualifications. Regulatory interventions requiring return-of-service (ROS) in a rural area in exchange for visa waivers, access to professional licenses or provider numbers were associated with comparatively low rural retention, especially once the ROS period was complete. Rural retention was higher if ROS was in exchange for loan repayments. Conclusion Educational interventions such as preferential selection of rural students and distributed training in rural areas are associated with increased rural retention of health professionals. Strongly coercive interventions are associated with comparatively lower rural retention than interventions that involve less coercion. Policy makers seeking rural retention in the medium and longer term would be prudent to strengthen rural training pathways and limit the use of strongly coercive interventions.