5.3.1 Overview of the achievement of Program parameters

Overall, the RCSs have delivered convincingly when measured against the Program parameters, and in many cases are exceeding the requirements.

The first few years of an RCS's operation require a significant amount of 'gearing up' - construction and/or refitting of buildings, development of local teaching contacts, design of programs, establishment of training places, and development of relationships with the local community. As a result, some of the recently-launched RCSs are yet to operate to their intended capacity in terms of student numbers.

The more established RCSs now have a demonstrable track record, and derive considerable satisfaction from their achievements. Most are particularly proud of the quality of medical education provided to students, which they argue is the same or better than the quality of medical education available in metropolitan clinical schools. RCSs demonstrate this through a range of measures, including:
  • strong academic results for RCS students (who in most universities sit the same exams as their city-based peers);
  • positive responses from students, who speak highly of the individual attention they receive from senior clinicians in hospitals and other teaching settings, and contrast this to being 'three rows back, and the consultant wouldn’t even know your name' in metropolitan teaching hospitals; and
  • increasing demand for RCS places, which the Schools regard as a consequence of the above.
As a result, some established RCSs routinely exceed the 25% requirements in terms of the student numbers or face the challenge of more demand for places than can be met.34 There are some sites that have struggled to meet the quota. The reasons for this are unique to each site but may be related to the local demographics, training capacity of rural localities, the length of time the RCS has been established, or the way in which the RCS Program is promoted to medical students within the host university.

Staffing and recruitment strategies of RCSs have generally been effective, and feedback received in this evaluation validates the Department’s requirement that senior staff live locally. Local origin of people in leadership positions, or their willingness to relocate and join the rural community, has been a key enabler for RCSs to successfully engage rural clinicians in the aims of the Program and to motivate other community leaders to support the initiative and to assist the students during their time in the location.

This community involvement and partnership is evident in all RCSs, with two primary outcomes:
  • ensuring that an adequate number of good quality training places are available which will be sustainable, beneficial for the local community and sufficient for curriculum requirements; and
  • ensuring that students are 'well looked after' during their stay. Community support has been very strong in many locations, as the medical workforce shortage is of great concern to regional communities nationwide.
'I would like to see them over produce. I would like to see the glut back [in] the 70s where you had to be in the top 10 percent to get a job in a hospital, whereas [now] you take the bottom 10 percent of anything you can get. At the moment for me in a really operational clinical sense it is about workforce, boosting up the workforce.' (senior hospital clinician)
It was suggested by some informants within RCSs, universities and other agencies that, due to the level of funding provided, RCSs have not had to be as 'creative and resourceful' as the UDRH Program, in engaging with and developing partnerships across a wide range of stakeholders. However, some RCSs have embraced an expansive understanding of their role in promoting innovation and development within rural health services in addition to their role as providing clinical medical training.

'I think you have got to be innovative in rural and remote health I think because when we need to come up with innovative solutions for local issues and each sort of local issue may be different, so innovation I think is a very important part of the rural clinical school activities.'(RCS administrator)
It is true, however, that RCSs have had the funding to employ staff on competitive salaries or construct purpose-built facilities without necessarily needing to develop collaborative arrangements with other like-minded initiatives; however most RCSs have made efforts to build relationships with UDRHs, AMSs, health services and other health-related organisations such as general practice networks. Overall, the ability of RCSs to provide for their own needs has been beneficial for rural health education or rural communities: on one level the amount of money available through the RCS Program has enabled a high quality of medical education and the development of significant educational infrastructure; on another level the presence of RCSs has also benefited a range of other programs and initiatives, which in many cases have been able to utilise the people and facilities available through the RCS.

Rural clinical schools have also been perceived as promoting rural health within their universities, beyond the initial novelty of new buildings, new staff and new student pathways created by the Program, through demonstrating strong student outcomes and earning respect as equal partners in the university’s medical faculty rather than 'the poor cousin from the country that nobody wanted to know about'. For many, this has been hard won through confronting traditional stereotypes about rural Australia and the quality of medicine practiced in rural communities and patiently demonstrating that clinical teaching in a rural setting can be as effective as in the urban environment.

'RCSs are now seen as a godsend - 10 years ago they would have been seen as a threat'.(RCS Head)
There are examples of RCSs building a significant research agenda (e.g. Flinders University in the Riverland, University of Western Australia and Notre Dame University, University of Sydney in Orange, University of Tasmania). However, research has not been a major focus for many RCSs, particularly those still in the establishment phase. Some schools have taken the view that their contribution should focus on the local impact of population health issues, or undertaking population health analyses which contributes to the local health system planning and investment. In other areas, like the Riverland under the Flinders University RCS, a more substantial research program has been developed, strengthened by the creation of a position dedicated to generating a ‘research culture’, which is seen as valuable in and of itself.

5.3.2 Issues arising in the achievement of the objectives

As noted earlier, RCSs have identified a series of key achievements, and most people involved with the RCS Program are enthusiastic about participating in what is perceived to be a very positive step in rural health education in Australia. However, there are three broad areas of consistent concern across RCSfunded universities.
  • Shortages in the current (and immediate future) health workforce, difficulties in recruiting some specialists (for example psychiatrists), and limitations in State/Territory hospital and health care systems impose natural limits to the number of long-term student placements that can be accommodated without jeopardising the quality of the educational experience.
This is an important issue, as all RCSs are presently operating with a growth philosophy (looking both to recruit new training sites and to expand the number and/or duration of student placements in existing training sites) and the number of medical students nationally is also increasing steadily (see Figure 5 below).
  • Preceptor burnout has been mentioned by many, particularly with regard to rural general practitioners, as a risk to the Program, particularly in the next five years until the expected increase in rural practitioners begins to be evident. 'The problem is being asked to be the solution', that is, those practitioners who are already overworked due to the shortage of doctors are being asked to assist in addressing the workforce shortage through increased teaching and supervisory roles.
  • RCSs do not operate with the economies of scale which metropolitan clinical schools enjoy. Withoutongoing Federal funding, universities would need to significantly downsize (or in some cases dismantle) their rural clinical programs and revert to running short term placements only (e.g. through RUSC).
Details regarding the implementation of the Program are found in section 5.4.

Figure 5 - Commencing medical students in Australia (Domestic and International) 2000-2010

5.3.3 Contribution to national rural health workforce priorities

In summary, there are some promising signs but no definitive answers to whether RCSs in Australia have (or have not) yielded higher rates of rural practice among participating students. However, there is evidence of positive attitudinal shifts towards rural training and practice. Some studies have suggested that an increasing number of students are seeking rural internships (Playford et al 2008, Wilkinson et al 2004), although these figures should be approached with caution as it is not clear to what extent this will translate into career decisions: Health Workforce Queensland (2008) reports that only 4.29% of former medical students from the two Queensland universities are working in RRMA 4-7.

There is also anecdotal evidence, from this evaluation, of workforce benefits from the RCSs through the attraction and retention of clinicians involved in teaching and supervision. Workforce outcomes are discussed in greater detail in section 5.4.1.

This evaluation has found some evidence of RCSs directly improving the range or quality of health care services in rural Australia; there are a number of instances where particular specialties that were previously not available in the community have become available because of a successful appointment by the RCS, sometimes as a joint appointment with the local area health service or UDRH. There is some evidence of a contribution by RCSs to the national research agenda, although this varies from place to place. It is often identified through the provision of critical institutional infrastructure brought to regional locations (for example, enabling access to research libraries and resources). It is generally agreed that the priority of the RCSs in their establishment phase has been to create a credible rural teaching infrastructure, and that the building of a research focus is the next priority as the RCS site matures.

34 At some of the more established RCSs (eg University of Sydney, University of Queensland) positive word of mouth communication among students has reportedly resulted in demand for RCS places from students who have no inclination towards rural practice, but are simply interested in the enhanced training opportunities available in regional locations.