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Practising psychiatry in New Zealand’s rural areas:incentives, problems andsolutions

Trevor Lau, Shailesh Kumar and David Thomas

Objectives: To identify challenges faced by psychiatrists working in New Zealand’s non-metropolitan areas and identify strategies that NewZealand psychiatrists use to overcome some of these challenges.

Method: Ten psychiatrists attending the RANZCP New Zealand Branchconference in 2000 participated in a focus group. They identified positiveand negative aspects of working in New Zealand’s non-metropolitan areasand possible solutions to problems.

Results: Ten main themes were identified. These focussed on professionalchallenges of practising psychiatry in rural areas. Social and economic fac-tors did not rank highly. The solutions generated included expanding thelocal psychiatric workforce, modifying workload or work pattern of exist-ing psychiatrists, utilising differing models of service delivery, and enhanc-ing professional development.

Conclusions: This is the first study that has reported on challenges of, and some solutions to, practising psychiatry in New Zealand’s non-metropolitan areas. Difficulties identified and solutions generatedwere similar to those found in rural areas of other developed countries. It is important that a widely-accepted nomenclature (“rural”, “provin-cial”, “urban” psychiatry) be developed. More research is suggested intothe characteristics of New Zealand’s specialist psychiatry workforce andinto the efficacy of any solutions implemented.

Key words: New Zealand, provincial psychiatry, rural psychiatry, serviceprovision.

In developed countries, the relative lack of psychiatric services inrural areas has attracted much attention. In Australia, the uneven dis-tribution of psychiatrists has been subjected to rigorous scrutiny.1 In

a 1993 survey, only 7% of all psychiatrists in South Africa worked inrural areas which were reported to have 6.4 psychiatrists per millionpopulation.2 Informal evidence suggests that a similar state of affairsexists in New Zealand,3 but systematic studies are lacking. An exam-ination of 1994 workforce data concluded that there was no urban-provincial difference in shortages of psychiatrists.4 Since then, thehealth sector has experienced major restructuring and there is a lack of data on the current situation.

From the available literature,5 three strategies for improving servicedelivery to rural areas overseas can be identified:

1. Attracting more psychiatrists to rural areas with incentives orthrough bonding contracts;

Trevor LauRotorua Hospital, New Zealand.

Shailesh KumarUniversity of Auckland and Lakeland Health, New Zealand.

David ThomasSchool of Medicine, University of Auckland, New Zealand.

Correspondence: Dr Trevor Lau, Lakeland Health Ltd, PrivateBag 3023,Rotorua, New Zealand.Tel: 64-7-3497971Fax: 64-7-3497883 Email: laut@lhl.co.nz

RURAL PSYCHIATRY

2. Providing psychiatric training to other health pro-fessionals, such as general practitioners and men-tal health nurses;

3. Using modern telecommunication methods toaccess psychiatric resources located in urban areas(i.e. telemedicine).

The likely effectiveness of these strategies has notbeen tested in New Zealand. It is not clear whetherthese strategies would address the issues relating tothe shortage of psychiatric services in rural areas.The purpose of this paper is to identify concerns thatpsychiatrists have about providing psychiatric ser-vices in rural areas of New Zealand. A qualitativeparadigm was selected as being better able to identifysignificant themes on a topic in which there hasbeen little previous research.6–9

METHOD

Sample recruitment

An open invitation was extended to psychiatristsattending the RANZCP conference in Rotorua, October 2000 to participate in a focus group.

Sample characteristics

The sample consisted of ten self-selected psychi-atrists who provided services to small town (provin-cial) and rural areas of New Zealand. Nine of theparticipants were male, and one female. Their meanage was 50 years (range 40 to 62 years). Seven des-cribed themselves as European, one as Sri Lankan,one as Indian, and one as African. Eight held theFRANZCP and one the MRCPsych, while one had nospecialist qualification. They had practised psych-iatry for an average of 21 years (range 12 to 30years). Three described themselves as working in psy-chogeriatrics and one in each of general psychiatry,rehabilitation psychiatry, child psychiatry and com-munity psychiatry.

Sample work environment

Four of the participants worked in a rural area, threein a semi-urban area and three did not specify. Theaverage service catchment area contained a popula-tion of 77,000 (range 15,000 to 145,000). The servicein which participants worked employed between 2.0 and 7.0 FTE psychiatrists (mean 4.1) and had, onaverage, one current psychiatrist vacancy (range 0 to1.5 vacancies).

Data collection

A three-hour focus group was facilitated by one ofthe authors (DT), a health researcher experienced inrunning focus groups. The other authors attended asnon-participant observers. Written consent wasobtained from all participants for the sessions to berecorded and transcribed. The three-hour session was

divided into three phases, with a short refreshmentbreak after the first two phases.

Phase 1: The participants identified challenges andspecific difficulties facing psychiatrists who provideservices in small towns and rural areas of NewZealand, what factors attracted or deterred psychi-atrists from practising in these areas, and strategieswhich might be used to improve service delivery insuch areas. This generated a list of twenty distinctthemes which were written on a whiteboard so theycould then be discussed and elaborated on by theparticipants.

Phase 2: After any ambiguity in the meaning oflabels used for the twenty items was clarified, theparticipants then made ratings on a scale of 0 to 10,10 being most important. The ten most importantthemes were identified from the list. The analysiswas based on the grounded theory approach whichuses inductive generation of hypotheses from empir-ical data.10

Phase 3: Each participant then grouped the themesinto two groups, the most important five and thenext most important five. From this grouping, theten themes were ranked in order of importance.This procedure is similar to the “Delphi tech-nique”.11 The ten themes, identified as mostimportant by participants, were discussed in orderto identify possible solutions or practices thatmight help address the challenges or difficultiesnoted in each of the themes. The solutions were tobe based on personal experience. Finally, a draft ofthis report was circulated to all participants fortheir feedback which was incorporated in the finalversion of the report.

RESULTS AND DISCUSSION

This is the first study from New Zealand that hasdescribed not only the challenges of practisingpsychiatry in non-metropolitan areas but has offeredsome innovative solutions felt to be effective in over-coming these challenges. As well, the attractive fea-tures of non-metropolitan psychiatry were examined.

Twenty broad themes were recorded by the authorsfrom discussion in the first phase of the focus group.The ten most important themes identified by partici-pants are outlined in Table 1, in order of the frequencyof “importance” ratings given by participants.

Being a sole psychiatrist and having to be a general-ist is an issue that has been reported as a challengein practising psychiatry in rural areas by previousauthors. Sole psychiatrists are not only expected tofulfil multiple roles (training multi-disciplinary staff,mental health team leadership, strengthening fami-lies, mental health promotion and prevention,research dissemination, influencing key communityfigures, encouraging policy changes), but also toA

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deliver psychiatric care for an extensive variety ofconditions (among them intellectual disability,seizure disorders, substance abuse, dementia).12,13

The multiple conditions treated by a generalistpsychiatrist in rural areas are frequently dealt withby more specialised psychiatrists in urban areas.

The problems of personnel retention, shortage ofskilled mental health staff, limited access to hospitalbased services, lack of funding for psychiatric ser-vices and frequently being on call, have beenreported by previous authors as problems with prac-tising rural psychiatry.5,12,14 Limited opportunities toobtain second opinions, having no collegiate sup-port and few opportunities to participate in continu-ing medical education or quality assurance activitiesarise due to professional isolation.5

Managing clinical risk also appeared high on the listand is underpinned by the fact that once a risk isidentified, managing it effectively is challenging,given the limitations of local resources and timeconstraints on the treating psychiatrist. In addition,attempting to access the more specialised servicesavailable in larger centres can be cumbersome.

Lack of trainees was also reported as a significantproblem of working in rural areas. Trainees notonly provide intellectual stimulation from teach-ing but also share the workload by triagingpatients. Other investigators who report similarproblems suggest that compulsory rotation oftrainees from larger academic centres to rural onesmight be a solution.5

The group reported an anti-psychiatry culture(described by some participants as an “anti-medical”attitude) in rural communities, and among ruralGPs, as a significant barrier to delivering psychiatriccare to rural populations. These attitudes have also been reported by others, who have associatedit with the stigmatisation that frequently occurs in close-knit communities where news travelsfast.14,16,17

As evident from the above discussion, the groupremained focussed on professional challenges inpractising psychiatry in rural areas. It is notable thattwo other principal factors, social and economic,reported to affect the decision to practice in ruralareas were briefly mentioned but did not assume ahigh importance for our subjects.18 Examples ofsocial factors included availability of educationalfacilities for children, availability of recreationalfacilities, partner’s career, privacy issues, distancefrom family members, and ease of integration intothe wider community. Economic factors encompasssalary and incentives.

In contrast to challenges, some positive aspects ofpractising in rural areas were mentioned (Table 2).These included opportunities for working with care-givers outside mental health, being a generalist, lowercost of living and less “politics” in service delivery.

Solutions suggested

The participants were asked to propose ideas thatthey had found effective in ameliorating the tenmain problems (Table 1). The solutions are presentedin Table 3. Because of time constraints, only seven

Table 1: The top 10 emergent themes from the focusgroup, in decreasing order of importance

1. Being a sole psychiatrist and having to be a generalist

2. Difficulties in retaining psychiatric staff

3. Professional isolation

4. Managing risk in clinical practice

5. Problems with on-call rosters: Busy and frequentlybeing first on-call

6. Being non-hospital based

7. Lack of psychiatric trainees

8. Anti-psychiatry attitudes in rural communities andamong GPs

9. Shortage of funding

10. Shortage of skilled mental health staff

Table 2: Factors identified as making practising inrural areas attractive

1. Opportunity to work with non-mental health caregivers

2. Opportunity to develop personal relationships withpatients and the community

3. Close to nature and scenery

4. Opportunity to be a “real generalist”, variety of practice

5. Flexibility in work practice and ability to switch roles

6. Cohesion with colleagues in the team and shared senseof achievement

7. Greater opportunity to see patients in their homesurroundings

8. Lower cost of living

9. Less stress and politics

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Table 3: Suggested solutions to the challenges of practising psychiatry in rural areas

Problem Solutions tried or suggested

1. Being a sole psychiatrist 1. Generate critical mass of psychiatrists

and having to be a 2. Locum cover (e.g. from USA, but identified as expensive), having rotating relievers

generalist 3. Outreach programs from larger centres

4. Build relationships with general practitioners and nurses

5. Make peer-supervision a priority

2. High staff turnover 6. Attract overseas psychiatrists with lifestyle factors, targeting those who are not so mobile(e.g. with young families)

7. Active recruitment, offering attractive packages

8. Matching the nature of service delivery in rural areas (outpatient based) with the traditionalmode of working of immigrant psychiatrists. Psychiatrists from USA or South Africa are moreaccepting of first on-call models

9. Relax New Zealand Medical Council registration requirements for overseas psychiatrists

3. Professional isolation 1. Making CME mandatory to facilitate increased funding and more money for training

2. Telemedicine

3. Mandatory 1:1 supervision, attendance at peer reviews, conferences

4. Credentialling

4. Managing risk in 1. Changing rigid protocols which have been developed in response to external pressuresclinical practice (e.g. risk assessment scales)

2. Better supervisory channels

3. Make use of peer review, credentialling, evidence-based practice

5. On-call rosters 4. General practitioners joining on-call roster, care will need to be taken of competence andavailability

5. Have psychiatrists be on-call for one continuous week-long period instead of severalevenings in the course of any given week

6. Using non-psychiatrists such as crisis service nurses to triage

6. Lack of trainees Rotating relatively senior trainees from urban centres, who may need positive trainingexperiences and incentives for doing rural runs

7. Anti-psychiatry 1. Offer training packages for general practitioners

attitudes 2. Utilise peer pressure on the GPs not receptive to above

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could be discussed. The solutions were categorisedinto four broad themes:

1. Expanding the local psychiatric workforce

2. Modifying workload or work pattern of existingpsychiatrists

3. Utilising differing models of service delivery

4. Professional development

Some of the solutions suggested to expand the localpsychiatric workforce (such as attracting overseaspsychiatrists, supplementing the local pool of psych-iatrists with non-resident ones who usually work inother centres) are achievable at a local level. Othersolutions proposed (e.g. relaxing Medical Councilguidelines for entry of overseas-trained psychiatrists)would need to be addressed at a national level.

All proposals for modifying the workload or workpattern of existing psychiatrists could be imple-mented at a local level. These included findinglocum cover or using rotating relievers for leave andsickness, changing the on-call patterns, rotatingtrainees from urban centres, involving general prac-titioners in the on-call psychiatric roster, and usingparamedical staff nurses to triage crisis calls.

Involving GPs in delivering psychiatric care is a well-known strategy in addressing the shortage of psych-iatrists in rural areas.19 Different models have beendescribed, such as providing training in psychiatryto GPs,20 implementing liaison attachment modelswherein psychiatrists hold clinics in GP’s surgeries,21

or a combination.22 A difference in preference formodel of service delivery is worth noting – urbanGPs prefer domicillary services whereas rural GPsprefer surgery-based services.23 Participants felt thatinnovations in service delivery were needed andmany described the benefits of telemedicine, whichhas been found useful by previous authors.5,15 Nocorroborative data was available from patientsregarding the acceptability of this method.

Issues related to professional development have beenreported by others as a significant barrier in practis-ing psychiatry in rural areas.24 Some of the solutionsemerging from Australia, including changing themethod of service delivery by the use of distancetechnologies, increasing the local pool of expertiseand instigating outreach programs from urban bases5

may be worth exploring in New Zealand. None ofthe proposed solutions are achievable by psych-iatrists alone. Implementation would depend on fullcommitment by those responsible for managing ser-vice planning and delivery. Furthermore, while nodata exist to evaluate the applicability or benefits ofthe solutions proposed by the group, they are cer-tainly worth further investigation. When replying tothe findings circulated to participants, one psych-iatrist noted that those not living in such centres

failed to appreciate the difficulties in delivering psy-chiatric care in rural areas. This highlights theimportance of provincially based psychiatrists beingallowed to explore their own solutions instead ofhaving external solutions imposed on them.

Methodological issues

While the study sample was not random, all partici-pants had considerable work experience, the minimumlength of time in psychiatric practice being 12 years.The aim of the study was to examine the perceptionsand experience of the participants of the focus group.

No specific definitions of “rural area” or “semi-urban”were given to the participants. There may have beendifferent understandings among participants aboutthe meanings of “rural” and “urban”. Some partici-pants believed that they did not practise “rural psych-iatry” as such, but thought their work site was betterdescribed as “provincial”. The issue of defining whatconstitutes rural or provincial psychiatry is importantfor New Zealand. According to 1996 Census data,25

54% of the population live outside the five metro-politan areas (Auckland, Hamilton, Christchurch,Wellington and Dunedin) which have over 100,000inhabitants. Interesting comparisons may be made inthis respect with Australia, where 28% of the coun-try’s population live in a rural or remote area.26 It isimportant that a common definition be developed asto what constitutes rural psychiatry before furtherwork is undertaken in this regard.

SUMMARY

No systematic studies of the uneven distribution ofpsychiatrists between urban and rural areas of NewZealand were found. Difficulties identified were sim-ilar to those reported in rural areas of other devel-oped countries. No particular factors peculiar to thiscountry emerged. Solutions generated were also verysimilar to those utilised overseas. More research issuggested, particularly into the characteristics ofNew Zealand’s specialist psychiatry workforce andinto the efficacy of any solutions implemented.

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SHRUNK Neil Phillips