At present there are a number of policy challenges which have implications for both Programs. One major consideration is the sizable 'bubble' of an expanded cohort of medical students that will be making its way through the training system for the next five years. Resulting from Federal policy decisions made in the 1990s, 'the figures paint a clear picture: the wave of students flowing into the Australian medical workforce represents substantial growth, and we must plan carefully - now - if we are to ride the wave, rather than being swamped by it.' (Joyce et al 2007:310) Many stakeholders around the country are aware of this approaching wave, from the NSW Medical Student Council which called upon the Federal Government to stop increasing medical student placements until more internship positions have been created (Wallace 2008) to the RDAA which has called for increased investment at the level of internship and vocational training (RDAA 2008), to Schwartz (2008) who has suggested that market forces should be allowed to influence the numbers of medical practitioners.
As Joyce and others point out, the consequences of policy decisions can be felt for decades. Both the UDRH and the RCS Program have required significant infrastructure investment and to ensure that the investment which has already been made is realised, the medical training pathways, including the capacity of State/Territory-funded health services, require urgent consideration to accommodate the projected increase of medical students into the system. This poses a challenge for the RCSs in particular, as they will seek to accommodate a growing demand for clinical placements in rural hospitals, Aboriginal Medical Services, GP surgeries and other health service settings at the same time that pre-vocational and vocational placements are being increased within many of the same settings. However, the expected expansion of medical students through the system will also impact upon the capacity of the UDRHs to maintain the programs of training and support for nursing and allied health while being faced with increasing demands to accommodate placements for a greater number of medical students.
A second policy challenge which faces both Programs is the requirement to deliver on a workforce initiative within an educational setting. Each RCS or UDRH serves two masters, to the extent that they are accountable to their university faculty for delivering educational outcomes (with commensurate reporting and administration) while also being accountable to the Department of Health and Ageing for delivery of a suite of activities designed to support and sustain the rural health workforce (also with its own reporting and administration). Ensuring that the goals are clear and that all parties are cooperating towards a common end should assist to streamline some of the administration requirements of each Program without loss of transparency.
A third policy challenge arises from a long-standing concern of many doctors to develop a dedicated rural training pathway. This dream of integrating the various levels of rural medical training, from student placements through intern and postgraduate years to vocational training, has been on the rural medical agenda for some time and a number of organisations are already exploring options to streamline training pathways. The extent to which RCSs can play a leadership role in this – for instance whether RCSs have the infrastructure available to accommodate oversight of intern and postgraduate years, and whether they should do so – is still to be resolved. Some informants considered that the RCS should continue to focus on its original mandate of delivering the university medical curriculum, while others argued that the RCS structures and facilities are well-placed to become an integrated provider of all levels of medical training. This latter view has been promulgated most recently by the RDAA and the NSW Medical Student Council (RDAA 2008). Regardless of who provides the various levels of rural medical training, as with the previous two challenges it appears clear that urgent dialogue and cooperation are required to develop a pathway which will accommodate the increasing numbers of students who are likely to seek rural pre-vocational and vocational training.
The remainder of this chapter discusses the key strategic issues emerging from the evaluation and makes recommendations for the future. This discussion is grouped into seven themes:
- strategic leadership and vision - including succession planning and structural sustainability;
- program management - including funding levels, parameters and objectives, monitoring and operational expansion;
- maintaining the culture of innovation;
- the capacity of the health system to absorb increased training requirements;
- community impact - including Indigenous health; and
- implications for the local workforce.