4.5.1 Enabling factorsA number of key factors were identified which had led to the achievements of the UDRHs to date. While
each UDRH had its unique characteristics of local geography, personalities, and confluence of circumstances, several foundational characteristics appear to be required for the UDRH to reach its objectives. These are outlined below.
LeadershipSeveral of the UDRHs are still lead by their founding Directors, providing a sense of stability and continuity both within the individual site and amongst the Program nationally. Because of the broad nature of the UDRHs the leadership within the national Program is accordingly diverse, including both clinicians and non-clinicians. This diversity has contributed to the different ways in which UDRHs have operationalised their remit in their local regions. In many ways, the perceived visionary leadership of the UDRHs, particularly with an emphasis on multidisciplinary, community-based team practice, has attracted those with similar views regarding the primacy of a multidisciplinary primary care approach to rural health services. This approach, grounded in a population health philosophy, has created the culture of networking and relationship-building which has characterised the work of the UDRHs.
' 'The boss' is the main reason I came [to the UDRH]. [the Head] is visionary, provides leadership, is supportive, has created a culture of teamwork rather than competition.' (UDRH staff member).
It was also noted that the character of the leadership influences the culture and focus of the organisation.
'In other UDRHs people are not always given that respect and allowed to run with things; the environment at [this UDRH] is quite unique, different from other UDRHs; there's a flatter structure, it's much more team based; there’s a willingness to work together and support each other, lots of training on working together as a team, making sure we're all linked in; the strength is the management style.' (UDRH staff member)
The heads of each UDRH form the executive board of their peak body, ARHEN, and through this body the combined UDRHs have contributed to advocacy for rural health services at a national level.
A majority of staff who were consulted exhibited enthusiasm, passion and outstanding commitment to their own work and the work of the UDRH. Indeed, as one Department Head commented,
'We tend to find the staff first, and then create a job description… It's the quality of the staff that makes it work.'
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Vision and strategic planningThe vision of transformation of the rural health workforce has been a sustaining driver for many working within the UDRHs. Small but real successes, such as the retention of a nurse or psychologist within the community, or the ability of a physiotherapist to undertake graduate studies while remaining in practice in the country, are celebrated as evidence of the UDRH contribution to the provision of rural health services and, by extension, to the quality of life for people living in rural communities.
UDRHs depend upon the development of community, regional and national relationships for their survival. Their limited core funding requires UDRHs to seek outside opportunities to achieve the objectives which have been set for the Program. These have taken the form of partnerships with local health services and other health service agencies, applications for grant funding from a range of funding bodies, links with community groups and health professionals, and contractual arrangements with State/Territory-funded health agencies. This has been named as some as the catalyst for innovation, and a contributing factor to improved population health services and research.
Supported information technologyThe establishment of high-quality, cutting-edge videoconferencing technology in regional, rural and remote locations has been one of the greatest enablers, and also one of the most significant achievements, of the UDRH Program. Facilities which allow videoconferencing mean that distance learning opportunities can be provided to people hundreds of kilometres away from the lecture theatre, or that academic supervision can be given for individuals undertaking research projects in remote locations. Increasingly lectures are also available as podcasts so that students can access them at their leisure. Access to the internet and electronic access to university library resources have also facilitated health practitioners’ ability to undertake continuing studies or research while remaining in practice. These same facilities have also made the option of rural placements and training more attractive to students.
Crucial to the success of the IT in facilitating UDRH programs, however, is the support provided by dedicated, full time IT staff, the presence of whom minimises the frequency and impact of inevitably occurring difficulties (e.g. with video conferencing, and internet connections). The IT facilities are also costly to install and require ongoing investment and maintenance to ensure that the capacity of the system meets the requirements of providing distance learning and other communication opportunities to rural and remote Australia. The full potential of the IT resources has not yet been realised, with UDRH-university linkages only being as good as the current band width allows.
4.5.2 Limiting factors
FundingA number of staff spoke of the UDRHs as 'fragile' due to the restricted funding of the UDRH Program, with one staff member indicating that a number of positions and program opportunities would be lost in the next year, because of the inability to stretch the current funding to cover the increasing costs of employing staff. Other UDRHs have acknowledged the difficulty and have increased their efforts to create partnerships and innovative projects which allow for sharing of resources with other agencies. All UDRHs, however, have indicated that the ability to continue to provide the range of projects and opportunities will be compromised in the future without a real increase in the funding for the Program.
There are two additional consequences of the limited funding which arise: the inability of the UDRHs to provide an adequate level of resourcing and support for the increasing number of students who undertake placements, and the potential for staff burnout in light of increasing demands on UDRHs without a corresponding ability to employ staff to meet those requirements.
A defining characteristic of UDRHs has been their innovation in approaching research, training and partnerships. One way of approaching the limitations of funding might be to develop a separate pool of innovation funding, which would allow those UDRHs who are seeking to grow and develop to apply for additional, competitive funding to support research and development in partnership with State- or Territory-funded and private health services, community organisations, and other agencies. Creating a separate pool of funding which could be accessed (by competitive application) to increase their revenue might relieve some of the pressure felt by some UDRHs who are eager to explore new models of service delivery and population health responses, but are constrained by the lack of resources to do so. It was noted by several informants that the time required simply to find and then apply for alternative sources of funding is costly, so the availability of a dedicated innovation pool might also ease the pressure of seeking other funding sources.
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The need to provide financial support, accommodation and/or bursaries for students is an additional limiting factor which impacts on the operation of UDRHs. Students who travel from the city to the country for short-term placements often leave family and work commitments behind; in addition, due to the short-term nature of placements many students continue to pay rent or mortgage payments for their urban accommodation. Students sometimes face a significant cost in undertaking a rural placement. Most UDRHs have sought to provide some form of accommodation or at the least a bursary for students. In some areas, particularly those experiencing a mineral boom or population growth, accommodation is in short supply and prices have risen astronomically in recent years, as have associated costs of petrol and food. This provides a strain on both the UDRH and the individual students. Addressing the costs incurred by nursing and allied health students (which are not usually faced by medical students due to the greater level of resources available) might assist in ensuring that the placements are positive experiences which can influence later career decisions.
Disciplinary silosThere is an increasing understanding of the positive impact of multidisciplinary teamwork in health services, and of the benefits of interprofessional education. Breaking down disciplinary silos, that is, integrating training in various health disciplines has been identified by many informants as a benefit of the UDRHs. A strongly community-based, population health approach to rural health care services is evident within all UDRHs. The fact that UDRHs assist with placements and training for all health disciplines ensures that there is a range of perspectives, and cultures, regarding the provision of health services. Many participants stated that creating a strong, multidisciplinary workforce was an important goal for the future of rural health care. Others spoke of the opportunities which UDRHs provided for students from various disciplines to interact with and learn from each other, inculcating at an early stage the idea that health care provision could (and should) be multidisciplinary.
However, the size and scale of medical education (including the considerable material support available for medical students) ensures a continuing perception that medicine is the primary focus of health care services - to the detriment of nursing and allied health care disciplines. This is markedly more evident in UDRHs which are co-located with established RCSs There are a number of reasons for this continuing perception:
- Although numerically the number of nursing and allied health students is greater than the number of medical students, medical students generally undertake longer term placements and are therefore more visible within the community;
- The funding of medical students is so disproportionate to the support available to nursing and allied health students as to perpetuate the perception that medicine is commensurately more important than any other discipline.
- The funding provided to UDRHs (which have a multidisciplinary mandate) is significantly less than the RCSs (which have a single disciplinary focus on medicine). Importantly, this extends to the ability to fund or otherwise support clinicians who have academic or supervisory roles.
- The fact that rural placements are mandated, and quotas issued, by medical programs, whereas they are not by other health disciplines, appears to impact on the importance placed on medical placements.
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Dependence on State/Territory health servicesWith their multidisciplinary focus, the UDRHs relate closely to State- or Territory-funded health services, hospital-based services, and local private providers who may also work within the public health system.
The ability of State or Territory health systems to provide placements for students, particularly nursing students, is critical in the aim of training students outside of the metropolitan teaching hospitals. One particular challenge is the widespread reliance on locum doctors or agency nurses, which does not provide the stability or continuity needed for teaching and supervision.
'There's an explosion of agency staff - it's attractive for them and they earn a lot but there is resentment from staff nurses and less commitment from transient staff - it's hard on the permanent staff.' (UDRH nursing academic)
The recent Report on the audit of health workforce in rural and regional Australia (Department of Health and Ageing 2008b) found that on the whole nurses were evenly distributed across the nation, there were distribution variations in some rural and remote locations, and underrepresentation of some specialties, such as midwifery and mental health nursing. The audit also noted that there was a shortage of clinical educators available to teach and supervise within public hospitals.
The ability of the health system to accommodate increased numbers of students is a key factor in ensuring that the investment in the UDRH Program leads to a return through creating additional rural practitioners. However, as will be discussed in the next chapter, these workforce initiatives are interdependent upon the larger health system, with the UDRH needing to work with health services to provide training placements, and health services needing to gain rural-ready clinicians.
Difficulty in recruitingUDRHs recognise that they themselves are contributing to the rural health workforce by recruiting and
retaining health academics and clinicians. The presence of university infrastructure in rural settings has been noted by many as a positive influence on a local community, by encouraging students to see the possibility of a rural health career, by providing opportunities for local health professionals to continue their education, and by indicating a commitment on the part of the university and the government to the viability of rural communities. However, the UDRHs face the same difficulties in recruiting and retaining staff as do the health systems they are seeking to support.
'We are very 'fragile' in terms of staffing, but having staff here contributes to the local workforce, if we weren't here, people with an interest in academia wouldn’t have stayed.' (UDRH staff member)