There is ample evidence that ill health is associated with both poverty and rurality [4, 8]. Accordingly, those from rural areas will have a higher need for GP services. However, the results of this study has shown that in 2004-05 those in regional areas visited a GP fewer times, on average, than those in major cities. This indicates that there may be a shortfall in demand and those in regional areas do not have the utilisation of GP services they require. Indeed, it is shown that if those in regional areas had the same utilisation of GP services as those in major cities, they would actually have a higher number of average GP visits per year. It is estimated that there is a shortfall in demand of around 5.7 million GP visits annually for those in regional areas.
This paper does have limitations which must be noted. Firstly, it is assumed that demand is fully met in major cities. While GPs in major cities have traditionally worked shorter hours than their counterparts in rural areas in Australia (indicating that they may be less likely to be overworked), there is less of a difference in younger cohorts, with younger GPs in rural areas working only marginally more hours than their major city counterparts . Within Australia there is debate over what is considered an 'adequate' number of GP visits. For example, the Australian Medical Workforce Advisory Committee has used the number of services in major regional areas as a benchmark figure; however this has been disputed on the basis that there was not good evidence that people who live in major cities received more health care visits than would be ideal . If demand is not fully met in major cities, then the figures presented in this paper underestimate the shortfall in utilisation experienced by those in regional areas, as currently those in major cities have the best access to GP services. Secondly, the inequality associated with aboriginality has not been assessed. This is largely a data limitation, as the 2005 NHS does not identify responders who have Torres Strait Islander or Aboriginal heritage. This is a limitation as it is well documented that Indigenous Australians have a far lower health status and life expectancy - 11.5 years for males, and 9.7 years for females, than their non-Indigenous counterparts, and mainly reside outside major cities (only 31% of the Indigenous population live within major cities) [17, 18], and thus have a particularly high need for access to GP services. Thirdly, as indicated in the methods sections some variables, such as income, health and number of GP services had to be collapsed into fewer categories to allow a sufficient number of records in each cell. Thus, it was not possible to estimate service utilisation specifically for smaller subgroups such as those living in very remote areas. Finally, it is assumed that if additional services are provided in rural areas, these will be taken up by the rural population. However, it should be noted that there are other barriers to the utilisation of health care services, such as cultural constraints, trust in health care systems, and availability of transport to services [19–21].
Those in regional and rural areas have far poorer health status than their urban counterparts . In spite of this they currently do not have the same utilisation of GP services as those in major cities. Thus, there is a large shortfall in meeting the health care needs of those in rural areas - geographically the most ill group of the Australian population. This confirms the view raised in 1971 by Julian Tudor Hart that those with poorer health receive less access to medical care than those with better health . While the costs of health care have been noted to be a barrier for 6% of the Australian population in seeking GP services, previous studies have found no difference between cost being a barrier to GP service vists between those in rural areas and major cities .
The National Reform Agenda calls for a health care system that is effective and efficient and focuses on preventing chronic disease in order to improve the health of Australians . However, the current distribution of health care services will not allow for this goal to be met, as those from low socioeconomic groups and regional areas - who are the most ill in society, do not have adequate utilisation of health care services to meet their need. Continuing to not meet the needs of those who are most in need will hinder the overall improvement of the health of the Australian population, and may increase the inequalities between those with a high socioeconomic status and those with low socioeconomic status [25–27].
Current workforce planning focuses on the number of GPs per capita or per age/sex population [28–30]. As a result, workforce plans strive to increase GP numbers to provide the same number of GPs to all Australians according to simple demographic parameters which do not reflect demand or need for GP services. Those in regional areas have a greater need or demand for access to GP services than those in major cities.
Australian models of 'demand' have tended to be treated simply as the services currently supplied. The distribution of services by age and sex has then been used as the basis for projecting future 'demand' [10–13]. The limitation of this approach is that existing unmet demand is not defined, and current inequalities resulting from the misdistribution of the health workforce are implicitly assumed to continue. Sometimes, in the absence of estimates of demand, workforce requirements are based on other proxy measures such as a study of the radiology workforce which relied on vacancy rates, radiologist to population ratio, and reports of work over-load as indicators .
There is a real need to pursue policies that deliver affordable services to disadvantaged areas. Currently polices which promote service delivery of this type include establishing rural clinical schools and schools in less well served areas such as in western Sydney to train doctors within underserved areas. This has the advantage of attracting students who come from disadvantaged areas, who know and understand the area in which they are likely to work . Bonded medical places have been another approach which ensures that new medical places go to students who agree to spend at least part of their career practicing in an underserved area . Incentives to increase bulk billing are also important to ensure affordable access to services provided in rural areas in particular . Internationally, motives to attract health professionals to low socio-economic areas have included incentive salaries for health professionals who practice in disadvantaged areas . Another option for very small and remote communities where it is difficult to recruit GPs, is models of funding which allow the 'cashing out' of Medicare subsidies to cover a viable health service model that may feed other types of multidisciplinary and multipurpose services.