The use of education and training programs to influence health workforce distribution has been a major focus of the Health portfolio over more than a decade. This has seen substantial investment in rural training initiatives and increasing engagement with universities and postgraduate training providers delivering targeted government programs designed to achieve health workforce outcomes.
Students play an important role in the supply of health professionals in rural areas. Increases to allocations of Commonwealth supported medical places over the last ten years have been accompanied by measures to address workforce shortages in rural areas.
By the time current medical graduate numbers are forecast to plateau from 2014 onwards (at around 3,800 a year), Australia will have more than doubled graduates over a decade, and almost tripled graduate numbers since 2001.65 Similarly, nursing graduates will have increased from just over 5,000 annually to almost 10,000 in the same period (including international students),66 with similar expansions occurring in the dentistry and allied health disciplines.
Ensuring that this growth in graduates flows through to improvements in workforce distribution is a key challenge which has attracted considerable effort and government investment. Over $820 million has been allocated towards health education initiatives (excluding scholarships) over the forward estimates, representing the largest ongoing component of the Health Workforce Fund.
The main strategies used to influence health professionals in such a way as to achieve supply and distribution outcomes centre on the professional entry education stage. Policy and programs targeted at this period are based on evidence which suggests that students who: (1) come from a rural background and/or (2) spend time training in a rural setting will be more likely to pursue a rural career upon qualification.
Targeted investments in rural medical education initiatives aim to increase the proportion of rural students entering university to study medicine and to provide opportunities for large numbers of medical students to undertake extended rural training placements.
A number of stakeholders are now seeking to build on these initiatives by establishing medical school courses either fully located in rural and regional areas, or providing a substantial component of training outside major metropolitan areas.
There have also been substantial investments in prevocational and vocational training for doctors, which have been designed to increase training capacity and expand medical education into new areas such as primary care, rural hospitals and private health care settings. In particular, vocational training for GPs is structured to a large extent to help achieve supply and distribution outcomes, with incentives (many linked to Medicare access) available to encourage rural practice.
Measures for nursing and allied health education designed to affect workforce supply and distribution are not as well developed. In part, this is because the Commonwealth historically has had a far less direct role in the employment and funding of these categories of the workforce. Allied health, dentistry and nursing stakeholders are calling for substantial new investment in training in their disciplines, both on equity grounds and to address predicted shortfalls in the rural workforce.
Government influence on supply and distribution begins with student selection. The most important supply control is the cap placed on Commonwealth supported medical places in Australian universities. This cap is intended to maintain control of the medical training pipeline in order to manage the number of medical graduates seeking internships, generally in the public health system. This cap is controlled by the Minister for Tertiary Education and the Department of Industry, Innovation, Climate Change, Science, Research and Tertiary Education (DIICCSRTE), which regularly seeks advice from the Department of Health and Ageing (DoHA) on medical student numbers.
Most Australian medical schools receive Government funds under the Rural Clinical Training and Support (RCTS) program. The RCTS program provides recurrent funding (supported by capital funding, now provided from other Commonwealth sources) to establish clinical training schools in rural areas. The program provides targeted funding to participating Australian medical schools in a number of key areas including: rural student selection; the enhancement of support systems for students and rural medical educators; and the provision of structured rural placements for all Australian medical students.
Since 2009-10 the RCTS program has been a component initiative within the larger Rural Health Multidisciplinary Training (RHMT) program, which is part of the Health Workforce Fund.
The RCTS program targets include the following requirements: 25% of Australian medical students are to undertake a minimum of one year of their clinical training in a rural area (defined as ASGC-RA 2–5) by the time they graduate; 25% of Commonwealth supported medical students are to be recruited from a rural background; and all Commonwealth supported medical students must undertake at least four weeks of structured residential rural placement in an ASGC-RA 2–5 region. There are currently 17 universities participating in the RCTS program.
There is debate about the effectiveness of the 25% rural origin target in influencing workforce distribution, with some studies suggesting students from a rural background are up to three times more likely than urban students to become rural doctors, while others have suggested this factor has only limited impact on career choice.67 The demographic profile of the student cohort examined in these studies appears to have had some impact on the results, with older cohorts of graduate entry medical schools less likely to show rural origin as a factor in ultimate choice of practice location. Regardless, evidence continues to show the importance of rural origin as a predictor of career choice in many cases, and it is suggested that this 25% target should remain in place and be closely monitored.
The recent Senate Community Affairs Reference Committee inquiry into the Factors affecting the supply of health services and medical professionals in rural areas recommended that the definition used for the RCTS program should be tightened on one hand, while adding a classification to measure ‘rural mindedness’ on the other, the latter to enable urban students to access preferential rural entry schemes at medical schools.68 While the intent of such a recommendation is laudable, measuring how “rurally inclined” a particular student may be seems to be a highly problematic concept which would potentially be open to gaming by students who are participating in a highly competitive process. While there could be merit in tightening the data definitions currently used for this target, there are also risks and potential costs in terms of upgrading existing data collection systems used by medical schools.
At this stage it is suggested that the key focus should be on ensuring all medical schools have strategies in place to achieve the current target, noting that in 2011 six of the 17 medical schools participating in the RCTS program appear to have failed to achieve their 25% quota.69 Overall however, the yearly national intake across Australia is around 25%, with 23.6% of domestic medical students reported as having a rural background in 2011.70 RCTS preliminary program data indicates that almost all participating universities have met this requirement in 2012 and that the national average is above the 25% quota.
Evidence captured by monitoring student exam results and evaluation surveys suggests that rural placements have the potential to provide a better learning experience than that of the urban campus, due to the close contact between student and supervisor in the rural setting.71 Such placements are in high demand among students and it is important to note that recent studies by the University of New South Wales, Sydney University, Flinders University and the University of Western Australia appear to show strong linkages between students completing long-term rural placements and the choice of a rural postgraduate training pathway. The University of Queensland has also undertaken a ten year longitudinal study into its rural training program, which has demonstrated that around 40% of graduates were currently working in non-urban locations.72
Despite these useful studies, the RCTS program would benefit from an enhanced evidence base and a more consistent and systematic approach to monitoring rural career choices of participating students. There are many cases of experiences in rural clinical schools leading to a career in rural medicine, as well as some regionally based outcome evaluations conducted by individual universities, but long-term data is not yet available for large numbers of graduates at the national level.
The nature of the RCTS program has led to some positive outcomes in terms of increased rural health service delivery. It has also encouraged innovative models of education which are tailored to the unique communities in which they are delivered.
A consistent theme in recent studies of the RCTS program has been the suggestion that longer placements generate better outcomes than those conducted over a shorter period. A recently published study by Playford and Cheong, through the University of Western Australia, suggested that the “longer students are supervised in rural settings, the better.”74
The primary barrier to achieving longer placements appears to be the mandatory nature of the current RCTS program target, requiring all domestic medical students to complete at least four weeks of rural placement. Feedback from stakeholders, backed by the various academic studies, suggests that requiring all students to undertake a rural placement when some will have no interest whatsoever in rural health is counterproductive and only serves to place unnecessary strain on rural clinical training capacity.
Short term rural placements may have value as an introduction to further rural training, provided the students are willing. Later-year elective placements in remote areas and Aboriginal and Torres Strait islander communities also appear to be effective, provided students are well prepared in terms of cultural competency and have well supported access to clinical training. Considerable efficiencies could be introduced to the RCTS initiative by removing the mandatory nature of multitudes of short-term placements and, instead, focusing resources on quality longer placementsfor students with a demonstrated interest in rural health, as well as focusing on better coordination with other sectors of the training pipeline.
Notwithstanding the above, voluntary schemes such as the John Flynn Placement Program (JFPP) have demonstrated that non-compulsory short-term options for rural training are popular with students. At present 1,200 students participate in the JFPP each year, with placements conducted primarily during the university vacation periods. Selected medical students are placed into a rural community for two weeks per year for four years to encourage engagement with the local community and to allow the student to experience life as a rural doctor. The program is defined less around the clinical aspects of being a practitioner in a rural area and more about the lifestyle and community opportunities which being a doctor in such a community can offer.
The JFPP placements in this sense are quite different to other university placements funded under the RHMT program in their focus on community experiences. Program outcomes data suggests that this initiative is having a positive impact and is a valuable, complementary strategy to the rurally based clinical training under the RCTS program. There may be the potential for administrative efficiencies, through aligning the management of the RCTS program and JFPP and it is suggested that the universities (through existing UDRH and RCTS networks) should have the opportunity to collectively tender for the management of the JFPP which is currently under the auspices of ACRRM.75 However, it is recommended that the program should be maintained as a separate funding stream within the larger RHMT initiative.
University management of all components of the RHMT program could address the lack of consistency across programs and training pathways at the undergraduate level. Such inconsistency can currently result in discrepancies in the degree of access students have to sufficient, high-quality training experience in rural areas – compromising the intent of the RHMT program. That is, payments to supervisors under the JFPP may be undermining goodwill that UDRH placements rely upon in delivering placements without direct financial incentives. Both ACRRM and the universities are competing to secure placements for their students in a limited pool of rural supervision resources. Removal of the four-week clinical placement requirement from the RCTS program may also reduce the pressure on supervisor capacity in this domain.
The University Departments of Rural Health (UDRH) Program establishes a university presence in rural areas and offers clinical training opportunities for medical, nursing and allied health students and offers research and educational opportunities for students and health professionals in rural areas. There are 11 UDRHs nationally, funded as part of the larger RHMT program.
UDRHs are managed under funding agreements with a single host university, but often support student placements from multiple universities. The Combined Universities Centre for Rural Health in Geraldton, for example, has partnership arrangements with six different tertiary education providers in Western Australia. These partnerships are effective ways of meeting the needs of a broad range of students, but can be complex to manage and bring associated costs.
Feedback from stakeholders, as well as the analysis of program performance to date, suggests that the network of multidisciplinary UDRHs has significant potential to provide enhanced education services including in areas such as re-entry courses for rural and remote nurses seeking to re-start their professional careers and in other postgraduate training fields. This is detailed further in Chapter 7 on nursing workforce development.
However, UDRHs have argued for many years that funding restrictions inhibit their ability to provide a greater range of training and educational support services. The geographic scope of the UDRH network is limited, with only one UDRH covering all of WA and areas of other states including southern NSW, southern QLD and the Riverland region in SA not benefiting from a UDRH presence. While some UDRHs have accessed HWA funding, this has not been consistent across the network.
Once again, many examples exist of students choosing a rural career on the strength of an experience at a UDRH but long-term data do not yet exist. As outlined below, the majority of UDRH placements are fairly short-term in nature and it is likely that some universities are using their UDRHs as coordinating institutions to meet the mandatory rural placements targets for medical students. This may not be the best use of precious UDRH resources.
A related benefit of both the RCTS program and the UDRH program is the infrastructure support they provide to rural centres and their ability to reduce professional isolation. The work of the Mount Isa Centre for Rural and Remote Health is an excellent example of this, providing a focus for local recruitment and training, particularly of Aboriginal and Torres Strait Islander staff, and providing noneconomic incentives for health professionals, including medical staff, to live and work in the district. These are important centres and provide many benefits to the towns in which they are established. The programs have been supported by significant Government capital works investments in rural areas, which provide teaching and office space, clinical rooms, student and staff accommodation, libraries and laboratories.
Nevertheless there is a continuing need for multidisciplinary student accommodation to support rural placements which are a key strategy to overcome rural workforce shortages long term. Current accommodation limits for students undertaking placements remain as a barrier to achieving program targets and while a total of 530 beds for students and staff are provided through the UDRH network, this is not sufficient to cover the needs of the large numbers of participating students.76 For example, there are particular issues in sourcing adequate accommodation in Mt Isa due to the impact of the mining boom on the local property market.
RCTS placements also impact on the availability of reasonably priced hospital accommodation as many universities have contracts with hospitals for their accommodation, which gives preference to RCTS students. However, students from one discipline should not need to be prioritised over others due to space restrictions. Insufficient reasonably priced options can currently result in accommodation budgets being exceeded where demand outstrips supply, such as during the JFPP/RCTS placement cross-over periods. Further, there is a risk that the current lack of a designated funding source for investments in new capital projects is limiting the capacity of universities to support clinical training placements.
The RCS and UDRH programs were evaluated in 2008 by Urbis Pty Ltd, with generally positive findings in terms of their ability to meet key program targets and their potential to provide a positive impact on rural workforce distribution, both in terms of attraction of new professionals and the retention of existing staff.77 This evaluation did raise a number of challenges for these programs in achieving their ultimate workforce aims, some of which are discussed below.
There are many similarities between the RCTS and UDRH programs and it has often been suggested that the two programs should be merged to create a more integrated and multidisciplinary rural training platform. Some universities, such as Melbourne, Newcastle and Monash, have effectively already integrated their RCSs and UDRHs, primarily because of the physical co-location of the two programs. However some medical schools (University of Queensland, University of New South Wales, and the University of Notre Dame) do not have a UDRH and may struggle to meet combined program targets without substantial additional funding.
There is also a view amongst some UDRH stakeholders that the multidisciplinary nature of their program could be lost to a focus on medical training if the program was integrated with the RCTS. Nevertheless, there could be administrative savings from further consolidation. This should be considered on a case-by-case basis and supported where stakeholders agree on the potential benefits.
In particular, research activity between the RCTS and UDRH programs appears to be an area in which there are significant opportunities to benefit from economies of scale and the expertise of a wider group of research-minded rural professionals. Rural health research is included in the parameters/objectives of both programs, yet there is no national strategy to coordinate these efforts and the selection of new projects for research investment appears to be quite ad hoc. More core funding appears to be spent on research by the UDRHs, and some units have significant and internationally recognised expertise in this area. Notwithstanding this, some research funded under both programs has been described as boutique in nature, with limited value in terms of developing evidence-based national workforce development programs.
The Australian Rural Health Education Network (ARHEN) has developed an informal ‘Research Leaders Network’ within the UDRH program, which has the potential to provide a greater focus for collaborative work across different sites. Objectives of the network include promotion of UDRH research activity and uptake of findings by government across the rural health sector, facilitation of collaborative research interests (potentially via publication on the ARHEN website), developing future research capacity within the UDRH network and building research leadership in rural health scholarship. The network may take a leading role in identifying potential research projects, gaps and issues in the health and education field.
It is recommended that the ARHEN network, in consultation with individual UDRHs, is the ideal platform to reach agreement on an appropriate maximum proportion of the UDRH’s core operational grant to be committed to research. Further, support from this network, in the form of rural health research stewardship, should also serve to produce a more coherent, better directed body of work in this area. Without leadership of this kind, there is the potential risk that investment in research is reducing the focus on multidisciplinary training. It is important that a consensus is reached with stakeholders on the right balance between training and research activities in the context of limited UDRH budgets.
Rural education strategies for allied health
At present, the UDRHs are very active in coordinating rural clinical placements for allied health students, with pharmacy, physiotherapy, dentistry, occupational therapy, dietetics and oral hygiene students among those regularly placed. A number of UDRHs, such as the Broken Hill UDRH, have recently pioneered a new service learning model aimed at strengthening clinical training.
The model is based on the principles of improving community access to health care while providing enhanced student learning, and involves students providing services to patients under supervision in carefully controlled clinical environments. The model therefore has the potential to increase the capacity of a region to support more students on clinical placements while delivering necessary services to underserviced population groups.
The following case study provided by ARHEN describes the service learning model.
Key features of this model include:
- redesigning the short-term UDRH student placements to accept groups of students from different disciplines for extended placements (e.g. six to eight students from a feeder university for periods between 6 to 12 weeks and longer);
- consulting with local communities and regionally based service providers about their key health issues and creating placement opportunities in both health and other sectors, including school education, aged care and disability services, and welfare agencies; and
- negotiating with parent universities to align their educational objectives with the service learning and placement opportunities identified locally.
Appropriate supervision and a supporting environment is a crucial part of this model to offset any impact this may have on local clinicians and service organisations.
The need to enhance supervision support has cost implications for UDRHs pursuing this more comprehensive placements model. Nevertheless, further adoption of this training model has the potential to enhance outcomes for nursing, dentistry and allied health training delivery in rural and remote areas and warrants further investigation.
It has also been suggested that universities participating in the RCTS program could play a greater role in supporting multidisciplinary training. This would substantially expand the rural training network and cover a greater geographic area than currently supported by the network of 11 UDRHs. While there would be major cost implications if the RCTS model were to be genuinely applied across allied health and nursing, at the very least the rural infrastructure supporting the 17 universities participating in the RCTS program (both in terms of physical, intellectual and social capital) should be leveraged to support training for other disciplines beyond medicine.
The RCTS program parameters currently provide that universities should:
“…provide support for the development of multidisciplinary training placements and the provision of interdisciplinary learning opportunities for students (most likely through the provision of access to physical training facilities, placement coordination services and access to established rural community support networks).”78
Access to placement support and facilities could be particularly beneficial for allied health students undertaking regional placements. Program reporting information suggests that some universities have begun to adopt a more multidisciplinary focus, but that achievements have been variable and hard data on the level of support provided is not consistently available. This issue warrants further exploration in discussion with universities. This is one area where greater integration between the RCTS and UDRH initiatives could be particularly beneficial.
The following table outlines UDRH placement support activity across the health disciplines in 2011.
Source: UDRH Program, Consolidated Reporting data, Department of Health and Ageing, 2011.
|Placements of 2 weeks duration or more||Total weeks of student training||Average placement period (weeks)|
|Undergrad – medicine|
|Undergrad – nursing|
|Undergrad – allied|
|Undergrad – total|
|Postgrad – total|
While this placement support function represents a significant level of activity, to date most UDRHs have primarily focused on short-term placements, involving linking nursing and allied health students with local clinicians and health services in a coordinating role. While these placements provide students with valuable exposure to the realities of rural health service provision, as outlined above, recent research has suggested that placements of a longer duration (eight weeks or more) are more likely to generate sustained interest in rural careers.79 It is likely that these findings will apply equally to placements in nursing and allied health.
While investments targeted at university level are essential, it would be remiss to ignore the fact that higher education pathways do not begin only when students commence tertiary education. In fact, choice of future career path often starts with information and options available to students in the later years of their secondary education. It has been argued that, in general there is not a strong level of encouragement and resourcing for school leavers to take up an allied health career. However the choices for rural students are arguably better in this area given that more universities offer allied health courses in rural regions and, once accepted, there is some support for rural allied health students while at rural universities.
It has also been suggested that current university rural origin entry targets for medicine should be extended to the allied health disciplines. The 25% target was originally introduced in medicine as it sought to align with the estimated rural population level at the time. The concept has some merit, given the evidence linking rural career choice to rural origin. However, because of the high numbers of allied health courses and the large number of allied health and nursing students in the tertiary education sector, the costs of pursuing, monitoring and administering such a target could be significant. It is also more difficult to monitor targets in terms of student numbers due to the demand-driven funding model for non-medical Commonwealth supported places (CSPs).
If this option were to be pursued the likely costs would need to be quantified and discussed in detail with relevant universities to determine what implementation arrangements would be needed in order to make targets achievable. Consultation with the Education Portfolio would also be necessary. Further, it should be noted that a 25% target across such a diverse study body may not be appropriate in all cases and this will need to be considered in the context of administration costs and the capacity of universities to recruit rural students in these proportions.
Current proposals for new and expanded medical schools
One recommendation from the recent Senate Community Affairs Committee inquiry was that: "...the Commonwealth government explore options to provide incentives to encourage medical students to study at regional universities offering an undergraduate medical course".80
While incentives to encourage medical students to attend rural universities are certainly consistent with the view that time spent training in rural areas encourages the uptake of a rural career, there are few universities teaching whole medical courses in what could be considered rural areas, generally extending from a major regional centre out to surrounding areas:
- James Cook University (Townsville);
- the University of Newcastle and the University of New England (Tamworth and Armidale);
- Deakin University (Geelong); and
- the University of Wollongong (Wollongong).
Medical places at those universities are already in high demand and appear likely to be filled irrespective of whether an incentive exists for students to attend, so this recommendation has very limited application.
Existing rurally based medical schools are well established and have been operating over-subscribed training programs for a number of years. However, there have been proposals in recent years seeking support for the establishment of new rural medical schools.
To date, proposals for new medical schools have not been supported by the Government, primarily on the basis that sufficient clinical training capacity does not exist to accommodate new CSPs in medicine. This position recognises feedback from medical education stakeholders that training capacity at the undergraduate and prevocational training levels is currently under severe pressure due to the rapid expansion of medical school places over the last decade. The potential benefits to rural and regional areas of having a medical school based in those locations has not necessarily been contested, but the timing of proposals during a period where all medical school places have expanded rapidly appears to be a major issue.
The growth in medical student numbers during the past ten years has placed significant stress on the clinical training systems which caters to both university students (who typically spend the final two years of their degree in clinical environments) and interns. Beyond the internship years, the medical training pipeline remains constricted because access to specialist training is also limited.
The medical training pipeline begins to narrow when medical students begin their clinical training years and remains narrow through to the completion of specialty training. Until the future of the medical training pipeline becomes clearer, for example through the planning work being undertaken by HWA,81 it is likely that the Commonwealth will find it difficult to support any increases in medical CSPs. It has been argued that new CSP approvals will not create a demand on clinical training for some years and are required now because the growth in medical graduates declines after 2015. Critics of the proposal respond that:
- clinical training capacity may remain tight for many years and may become even tighter in some jurisdictions due to financial constraints; and
- the expansion of clinical training capacity in many jurisdictions may not keep pace with the expected growth in graduates to 2015, meaning that some jurisdictions may take several years to be able to provide training opportunities for the current number of expected graduates.
While there is a growing body of evidence to suggest that extending rural training experiences for as long as possible could enhance workforce outcomes, it is unlikely that existing programs would be able to continue to operate sustainably if any new medical schools are established in the short to medium term. This would have flow on implications for the ability of these current medical schools to support clinical training needs for existing CSPs.
Yet, evidence does indicate that current rural programs are having the desired impact despite containing metropolitan training components. The University of Sydney, in its submission to this review process, has pointed to promising signs with approximately 20% of graduates from their rural program taking up rural postgraduate training positions, where they are available.82 Further time and evaluation is needed to determine the true strength of arguments from both sides.
Rather than the cost and other pressures of entirely new medical schools, some stakeholders have made requests for support of other innovative education and training models based on enhancing existing training programs to provide longer rural training experiences. Each of these models would require significant upfront and recurrent funding. However, there is some merit in these proposals and they are worthy of further consideration and possible testing in the mix of different education and training models. The following two case studies outline the proposed approaches to expanding existing medical school programs.
Such proposals have merit in terms of the potential outcomes that could be generated by offering students a comprehensive rural medical education experience. Recurrent funds from the existing RCTS program grant could be used to contribute some funding support for these sorts of proposals. Existing infrastructure and training networks could be leveraged to support student training. This type of model has the potential to be significantly more cost-effective than establishing a new rurally based medical school. Detailed scrutiny of the costing model for this type of proposal is required to ensure value for money. It is not suggested though that any support should involve new CSPs, in keeping with current policy settings and the acknowledged pressure on health system clinical training capacity.
Rural training pathway – post university
Training doctors in rural areas is a key part of the strategy to ensure that there is a measurable increase in the supply of health services to communities in the long term. However, the appropriate structures do not yet exist to fully integrate and complement all of the education and workforce initiatives developed for this purpose.
All medical graduates need to complete an internship to gain general medical registration. Under current models, the intern year tends to be spent in larger population centres where traditional teaching hospitals are located – rotations in medicine, surgery and emergency medicine are compulsory but not available everywhere. Therefore the ability to influence the distribution of interns is limited by this requirement.
In addition, the employment of interns and junior doctors has previously been the sole responsibility of states and territories (described in more detail in Chapter 3). It has only been fairly recently, with a large increase in medical student numbers, that state and territory governments have been willing to consider expansion of intern training in the private sector, due to the valuable public hospital workforce provided by interns and junior doctors.
The lack of rural internships was one of the major risks identified in the 2008 evaluation of the RCS and UDRH programs to achieving the outcomes of the Government’s investment in rural training.83 This issue was also a predominant discussion point during the Rural Health Education roundtable conducted as part of this review. Exact figures on available intern placements in rural and regional Australia are not known but it is clear that despite the approximately 800 medical students graduating from an RCTS annually, only a small proportion are able to access a rural internship, despite a preference to do so.
Stakeholders have also cited the lack of a clear pathway from undergraduate rural training into employment as a rural doctor (post-fellowship) as a key reason why students who are interested in rural health are regularly lost to the metropolitan health system during this crucial decision point in their career, as they enter paid employment as doctors and commence their vocational training. However, addressing this issue and increasing capacity of the system overall is not dependent only on creating new rural internships in traditional settings.
There could be merit in exploring more structured investments in networked intern places, involving a combination of acute care and primary care training within a range of settings in a particular region (e.g. private, community or Aboriginal Medical Service). This type of approach has the potential to build stronger links between trainees and communities and could be a more cost-effective way of enhancing intern training capacity while continuing to support a focus on training in primary care (for instance, internships funded by the Commonwealth Government could require a rotation in primary or community health care, in addition to the mandatory rotations required by the Medical Board). Recent announcements of Commonwealth funding for private sector intern training positions in a number of jurisdictions have set a precedent for this type of approach.
At the national level, this new approach could be based on adoption of the successful Specialist Training Program (STP) model, through which health care settings (often through consortia arrangements) apply to support networked training posts involving multiple settings providing different parts of an accredited position. This often involves linkages between the public and private sectors and in many cases is a better reflection of how graduates will work once they finish their training.
Under this type of arrangement the host setting is responsible for negotiating accreditation arrangements, building and maintaining partnerships with other health settings within their training network and then recruiting a suitable registrar to fill the training position. This model is well developed and is currently supporting 750 registrar training positions (growing to 900 by 2014). STP funding is directed to successful applicants through larger agreements between the Department and each specialist college, providing a direct linkage between health care providers and educational institutions.
If each of the current medical training initiatives were functioning to deliver their ideal intended outcomes, the following pathway into careers in rural medicine would exist:D
This model recognises that students of urban origin may be equally likely to choose a rural career, if the right training conditions exist to encourage that choice. Equally, it is acknowledged that periods of metropolitan training may be desirable at different points in the continuum to ensure educational quality. Specialist training would include general practice.
Figure 4.1 below demonstrates the integration of networked intern training along the new rural pathway to vocational registration from the student perspective. These arrangements may be of particular interest and benefit to students who are bonded under the current Bonded Medical Places (BMP) and Medical Rural Bonded Scholarship (MRBS) schemes. While it is not possible to quarantine individual training places for named individuals, the availability of such a pathway would simplify the process for those practitioners wishing to study and remain in rural areas. It should be noted that the current state-based systems of intern allocation would require adjustment in response to this approach. Or it may be considered necessary to develop a complementary but discrete application and allocation system for students commencing as interns on the rural pathway if changes to the current systems are not viable.
A rural training pathway already exists for general practice under the AGPT, administered via General Practice Education and Training Limited (GPET). However, as identified above, the missing link is the availability of rurally-based internship positions through which rurally trained medical students can transition directly to vocational GP training.
In the other specialties, this lack of rurally-based intern positions is further hampered by limited rural training opportunities for specialist trainees in pursuit of fellowship of one of the specialist medical colleges. Innovative strategies for supporting rural specialist training have already been trialled via the STP, through which up to 50% of new places are targeted towards rural and regional areas.
Extending this approach to allow settings (such as local health networks or private hospitals) to apply for a combined intern and registrar training position should be possible, although it would require an enhanced level of coordination in the accreditation process between the specialist colleges and the jurisdictional postgraduate medical councils.
Figure 4.1: New rural training pathway from the student perspectiveD
A similar system to the networked intern training described above could be explored for supporting a competitive rural intern application process, with possible extension into the metropolitan private sector (as currently occurs within the STP). Funding arrangements would need to be developed in more detail, with consideration given to whether the existing STP model of providing funding through colleges will be appropriate to support intern training.
In some cases more direct arrangements with health care settings may need to be developed with appropriate administrators and fund holders identified by the Commonwealth. Available evidence indicates that it would not be suitable for the Commonwealth to contract directly with settings. Advice is that such a direct funding approach was attempted in the early stages of the STP implementation but was abandoned in favour of college management due to limited capacity within the Department to administer a large number of contracts of this type. This kind of administrative congestion is also seen currently with the management of contracts for the Medical Rural Bonded Scholarship and Bonded Medical Places schemes within the Department, which are not resourced to ensure effective tracking and are unsustainable in the long term.
Under this new model, rather than facilities applying directly for funding as per the STP, regional training providers, in collaboration with their Local Area Health Network, private hospital and/or Medicare Local would bid for Commonwealth funded training positions. These positions may represent an internship year or they may encompass an ongoing funding commitment across the intern and vocational training years to ensure access to a rural specialist training pathway. Nominated rural hubs would take on the role of primary allocations centres, with rotations between rural sites, not out from metropolitan settings.
The importance of contractual security over the long term is vital to the success of this model. Facilities which are recruiting interns and specialist trainees are understandably reluctant to commit to supporting positions in the face of short-term funding only. Anecdotally it is also more difficult to attract individual practitioners to permanently relocate often not only themselves but spouses and children without guarantee of ongoing employment. Subject to performance, a trainee under this proposal could be offered a contract for up to six years, equal to the length of their vocational training. This also provides sustainability for intern positions within the same network which require time intensive supervision, usually provided by registrars tiered under a consultant in a pyramidal supervisory structure.
There is the potential for rural clinical schools to play an academic support and coordination role to assist in this process, providing a link between students, health service providers and medical education providers in rural areas. The likelihood of rural training pathways being successfully developed and maintained depends heavily on collaboration between these multiple organisations with involvement at various stages of training. Regional training providers and associates must also undertake early engagement (ideally facilitated by the local RCTS training coordinator) with the relevant postgraduate medical education council in order to obtain the necessary accreditation.
HWA’s Integrated Regional Clinical Training Networks (IRCTNs) could also play an important role in developing these arrangements. With a total of 27 regional networks established, and three broader coordinating IRCTNs in place, the establishment of this new coordination structure presents a significant opportunity. In 2010, the PricewaterhouseCoopers/Phillips KPA Mapping Clinical Placements report for HWA was hesitant to recommend Medicare Locals as suitable hosts for IRCTNs due to their (at the time) fledgling status.84 Arguably, their status as independent legal entities, clearly distinguished from the governance of Local Health Networks, makes them suitable for this role. UDRHs and regional training providers of the GPET network share this independent governance model. It may be timely to review the capacity of Medicare Locals and other regional entities to participate in this new rural training pathway model.
Alternatively, the specialist medical colleges and regional training providers already receive administrative funding to manage training places under the STP and AGPT respectively. Given their experience in handling similar arrangements it may be appropriate that they are nominated as fund holders for the model proposed above, with associated economies of scale, given their current funding. In short, funds would flow from the Commonwealth via the specialist colleges and GPET (and/or the two GP colleges) to regional training providers or equivalent who had successfully bid for places with the appropriate accreditation in place. Decisions about the allocation of funds would be solely the prerogative of the Commonwealth.
It must be noted that there are at present no new funds available within the HWF for the new rural training model and all investments will require redirection from other sources. Both the source of funds and the funding requirements at the different stages could be accommodated as per Figure 4.2 below, which provides an example of the way current funding systems could be used to support the development of the proposed rural pathway model.
In cases such as the STP, removal of funds would not be detrimental to the core program but rather would build on existing program components. Under the 2013 STP priority framework, preference was given to applications which could demonstrate the capacity for an individual trainee to complete the majority (>50%) of training requirements for fellowship in an on-going position in a rural/regional/remote or outer metropolitan setting i.e. where there is potential to advance from 1st year/basic training to fully qualified. Of 150 selected posts in 2013, at least 50 met this requirement. Incorporating these posts into a larger pool of funding, with the requirement for collaboration between local networks, addresses the limitations of ad hoc funding to individual facilities and promotes sustainable, well supported positions in the long term. While there is some potential to redirect existing funding streams to create a new rural training pathway program, establishing these pathways for large numbers of graduates would be likely to require new investment. Notwithstanding the funding limitations, the potential exists to at least trial the proposed model.
Careful consideration should be given to whether initiatives such as the RCTS and UDRH continue to focus on the original mandate of delivering university medical curriculum only, or expand their scope and capacity, through a link to universities as Centres of Excellence to provide an oversight of students through to vocational training. There is merit, should funds be available, to pilot the funding of a position within the RCS/UDRHs to work with appropriate specialist colleges and jurisdictions to support this training, advocate for internships and vocational training positions and mentor those students and graduates who are interested in a rural career. These new positions could become a critical linking point in developing regional solutions to the development of better training pathways.
Continued metropolitan training rotations would often be necessary to ensure educational needs are met, but this type of model would enable graduates to remain based in, and retain strong links to, regional areas while completing their full training program. There would be a range of benefits from this type of approach, as follows:
- Much greater certainty for medical graduates interested in pursuing a rural career pathway;
- A more genuine and measurable expansion of intern training capacity that meets the need to distribute the medical workforce more equitably;
- The development of more effective partnerships between primary care and acute care settings in supporting postgraduate training by developing networked training arrangements; and
- Increased access to services for communities, as graduates will treat patients while they train.
Figure 4.3 below outlines how this type of approach could work in practice, detailing the different steps that could be taken in the process of identifying potential training positions, securing accreditation and funding and finally producing a new rural doctor at the end of the process.
This scenario also helps to create an environment where the burden of teaching is reduced for general practitioners and supports them in their role as educators. This needs to be considered in the current environment of increased numbers of student placements and an overstretched existing rural health workforce. Many of our university RCS leaders have advocated that vertical integration, that is, having registrars and medical students together, will promote teaching as an integral part of a clinician’s life – the teaching load is shared and the students benefit from the clinical knowledge of the more recent graduates.
Clearly this model would require significant development and consultation across the medical education sector before it could be successfully implemented. However similar reforms have been successful in undergraduate medical education (the RCTS program) and specialist vocational training (the AGPT and STP programs) so there is no reason to suggest that a more structured pathway could not be established to link these different stages of training in rural settings.
Figure 4.2: Proposed funding flow – new rural training pathway programD
Figure 4.3: Process for establishing a regional training pathwayD
Under this model, the onus would be on the host settings to negotiate these arrangements at the regional level in order to ensure training quality and sustainability. The model would be particularly applicable to generalist specialist training programs (general practice, general medicine, emergency medicine, psychiatry, general surgery etc). As noted by the Rural Doctors Association of Australia (RDAA) in their 2013-14 Budget submission, a national advanced rural training program (with a strong generalist component) represents one of the most promising ways to ensure patients in rural and remote communities have access to appropriate, high quality care.85
Enhancing activity in this area would also address one of the key issues identified in HWA’s HW2025 report, that a greater focus on generalist specialty training needs to be encouraged. One initial approach could be a position that works with the Royal Australian College of Physicians, as they are in the process of implementing a number of regionally based pilot projects to explore the concept of a model of dual-trained physicians who will have ‘core training in general medicine and further training in an additional specialty’.
This specialty would need to be accommodated within the rural community. However, it makes sense to trial this approach for a university who is receptive, especially when evidence suggests that facilitating the growth of accessible medical specialist services in small communities could lead to reduced hospital admissions, improved quality of life for patients through reduced interactions with the health care system and the development of system-wide savings over time. HWA has recently announced that it is funding a pilot of ten demonstration projects of the dual training model.
Due to the unique nature of rural general practice, the RDAA and other rural health groups have been advocating for a national pathway for rural generalists since 2009. The rural generalist pathway supports junior doctors wishing to pursue a vocationally recognised career as a rural generalist. The pathway provides doctors with the training, skills and qualifications necessary in providing comprehensive health care in rural and remote Australia.
The pathway would focus on the advanced skills required in rural and remote locations, including emergency medicine, obstetrics, surgery, anaesthetics, indigenous health, mental health etc. The proposed rural generalist pathway addresses similar issues to those described above in the discussion around introducing mechanisms to link rural intern training with specialist positions. The key point of difference is that the current rural generalist pathway proposal is exclusively targeted at upskilling GP trainees, as opposed to building a broader specialist generalist approach.
The Government funded a review of the Queensland Health Rural Generalist Pathway in 2010, through Nova Pty Ltd. The review found that the Queensland Health Rural Generalist Pathway has many positive features, and it has been successful in Queensland to date. The report noted it would be challenging to expand the Queensland rural generalist model nationally due to the different structural, policy and industrial conditions in the jurisdictions across the nation.
In its submission to this review the Australian College of Rural and Remote Medicine (ACRRM) outlined some of the complexities and myriad choices that graduates interested in careers as rural generalist practitioners can currently face in pursuing this career pathway, particularly in those jurisdictions that have not made significant progress in establishing a generalist model.86
ACRRM provided the following diagram in its submission to illustrate this situation, described as the:
Rural generalist scenic routeD
Nova’s 2010 review has been provided to Health Workforce Australia (HWA) for further consideration as part of its broader examination of workforce planning. Once HWA finishes its analysis further work will be required at the Commonwealth level to determine the extent to which national reform and funding support is required to support any proposed new model to build on existing advanced rural skills training options. However, the model described above may provide a platform for a new focus on training both rural generalist specialists and GPs. As shown in Figure 4.2, existing funding programs could be leveraged to provide graduates with more options as they move through the training pathway. This approach could be effective provided current barriers, such as the availability of internships, are addressed.
It is important that the development of rural generalist training pathways and employment arrangements do not focus exclusively on the public sector, but recognise private practice options for rural generalists.
Nursing and allied health rural pathway/funding model
While it is not possible to compare the education and training requirements for nursing and allied health disciplines to medicine there remains a strong argument to support Commonwealth funding to ensure highly qualified professionals are working in rural areas where they are needed. There are some parallels in that access to Medicare by doctors, nurse practitioners and certain allied health professionals remains contingent upon achieving mandated levels of education and registration.
It may be appropriate to adapt the medical rural training pathway model to enhance postgraduate training opportunities and to ensure that the right mix of service delivery is being provided through enhanced skill sets amongst this workforce. Providing training in a rural area for nurses wishing to advance their skills and qualify as a nurse practitioner seems like a logical method to attract and retain such nurses into the future local workforce. Something like a ‘rural nurse practitioner’ pathway could be trialled with Medicare Locals or UDRHs acting as fund holders and administrators.
Developing an outcomes reporting strategy
Measuring the impact of rural education programs and rural incentives schemes is embedded in current performance indicators for some programs at both the participant level (contractual reporting requirements with quantifiable targets) and at Government level (e.g. monitoring Medicare billing data to assess improvements in community access to services).
However, there is potential to improve the evidence base for such investments via the development of more sophisticated key performance indicators (KPIs) under a reporting strategy designed to better measure the impact of programs on the sustainable delivery of services. It has been suggested during this review’s consultations that service outcomes could encompass such indicators as:
- Retention of clinical staff;
- Reduction in the need for rural health services to employ locums;
- Reduction in the need for Fly-In Fly-Out (FIFO) practitioners;
- Reduced need for patients to travel to metropolitan areas for particular services (recognising that some specialist services, particularly diagnostics like MRI will continue to require a hub and spoke approach); and
- Reduced expenditure under (usually state-based) travel and accommodation assistance schemes for isolated patients.
Different KPIs would need to be aligned with the various program objectives as not all service outcomes can be realistically achieved under a single program.
This is illustrated in the case of the RHMT program. If service learning models (see the Broken Hill Allied Health case study above) continue to be supported across the disciplines, this may result in reduced patient travel for some primary and allied health care services. Attempting to measure this may illustrate whether the service learning approach is having an effective impact at the community level.
On the other hand, rural placements for undergraduate health, nursing and medical students are unlikely to impact on the immediate needs for FIFO and/or locum specialists, at least not until after their training is complete, and they hopefully return to the rural areas in which they trained to provide services. Using a KPI on reducing FIFO practitioners might not be appropriate in this case.
Further, some of the suggested service-oriented KPIs listed above are easier to quantify than others. Reduced expenditure and retention of clinical staff would benefit from (presumably) available retrospective data whereas measuring reduction in patient travel and/or need for FIFO practitioners necessitates some broader assumptions around the clinical case load in a specific region across time.
Any introduction of a new outcomes reporting strategy would not negate the importance of continued data gathering and analysis under existing program outcome measures, such as the emerging, encouraging data on increasing the number of new rural doctors as rurally trained students return to rural areas as qualified practitioners.
Although discussed further in the rural recruitment and retention strategies section below, it should be noted that financial incentives are not the only factor in retention of the health workforce in rural areas. As such, KPIs which consider links to professional development, research potential and ongoing training may be equally important. These factors may also have weight under the new proposed regional incentives model, which would encourage distribution of funds with consideration of local needs. This model is discussed in the next section of this chapter.
Chapter 9 of this review discusses the need to develop better outcomes evaluation strategies across all health workforce programs. The potentially enhanced KPIs for rural programs outlined above should be considered in this context.
|Recommendation number||Recommendation||Affected programs||Timeframe|
|Recommendation 4.1||The Commonwealth should take leadership in developing a new, more integrated rural training pathway, linking its investment in rural undergraduate medical training with new support for rural intern places and continued growth in specialist training positions. The model will need to build on existing programs and maintain access to primary care and private sector training though the development of a more networked approach to delivering quality education. This may need to involve some re-profiling of existing investments. It will need to be delivered through a highly collaborative approach involving consortia of key training/accreditation bodies and health service providers. All available policy levers, including contracting and reporting mechanisms, should be directed at incentivising collaboration by local and regional agencies and supporting a local network approach.||AGPT, STP, RCTS PGPPP, HWA clinical training funding.||Medium term – timeframes will be subject to reform of funding arrangements and engagement with stakeholders around new educational models.|
|Recommendation 4.2||The Commonwealth should consider opportunities for extending the approach to building rural training pathways in the allied health, dentistry and nursing disciplines. This will need to retain the core principles of providing a more seamless transition from undergraduate training into rural practice or further professional rural training for students in these disciplines. However, it will be important to note the different structure of postgraduate training in medicine compared to other disciplines.||New funding activity||Medium term – subject to available funds.|
|Recommendation 4.3||The Commonwealth should seek that the Standing Council on Health engage with the national health professional boards and their accrediting agencies to encourage development of intra- and inter-profession courses that enable health practitioners to provide a broader range of services in rural areas.||Nil||Medium term|
|Recommendation 4.4||Commonwealth support to extend rural training at medical schools to cover full degree programs could generate positive outcomes. Current workforce projection data, including the findings of Health Workforce 2025, suggests that the distribution of new graduates needs to be the priority rather than increasing overall graduate numbers. Current proposals in this area should continue to be explored with careful analysis of the costs and benefits of the different models.||RCTS, NT Medical Program.||Longer term – any extension of existing rural medical programs will be subject to funding availability and the development of comprehensive costing models.|
|Recommendation 4.5||The Rural Clinical Training and Support (RCTS) program should expand its focus on supporting multidisciplinary training placements. This activity is already included within the program parameters but needs to be pursued more vigorously, where funding is available. Consideration should be given to RCTS infrastructure needs to support a multidisciplinary approach.||RCTS||Medium term – RCTS activities could begin to expand in this area from 2014.|
|Recommendation 4.6||The mandatory four week rural placements required for all medical students under the RCTS program should be abolished, in favour of increased support for longer-term high quality elective placements which are currently generating good outcomes. Funds released from supporting short-term placements should be redirected towards other priorities within the RCTS initiative. This should include enabling training sites to play an enhanced role in developing integrated vocational training pathways. This would be achieved through supporting new academic positions to play a key role in developing networked training partnerships.||RCTS||Medium term – current placement arrangements could be reformed from the start of 2014, in consultation with medical schools.|
|Recommendation 4.7||The advantages of extending the current RCTS program rural medical student enrolment target approach to other health disciplines should be examined. The target level and the likely implementation cost across the health disciplines would need to be determined, including the resources required by universities to achieve agreed goals.||RCTS||Longer term – funding implications and the ability of other health disciplines to achieve this type of target are more complex issues.|
|Recommendation 4.8||There is strong potential for the network of 11 University Departments of Rural Health (UDRHs) to play a greater role in supporting longer term, more structured, rural training placements for allied health, dental and nursing students. This should be supported by the Commonwealth where funding is available. The service learning model put in place by the Broken Hill UDRH should be explored further, including the cost implications of this model across the UDRH network.||UDRH||Medium term – expansion of UDRH training is subject to funding availability. New activities would need to be progressed during the next funding period.|
|Recommendation 4.9||Any extension of a comprehensive rural training program to cover nursing, allied health and dentistry should be supported by the collection of longitudinal outcomes reporting. The value of adopting a similar approach to the Medical Schools Outcomes Database project, and linking this to national registration data, should be considered.||UDRH and allied health clinical training support programs (SARRAH/ NAHSSS)||Longer term – reflecting long lead times for the development of data systems.|
|Recommendation 4.10||Research activities funded under the core operational grants of the RCTS and UDRH programs need to be examined in consultation with key program stakeholders to ensure they are effective and well-targeted. The Commonwealth should encourage greater rural research collaboration and seek to reach agreement across the UDRH network on an appropriate maximum research proportion of the program’s core operational grant. This process could build on the work of the Research Leaders Network that has been established through Australian Rural Health Education Network (ARHEN).||RCTS, UDRH||Medium term – a new research strategy will require extensive development work and consultation.|
|Recommendation 4.11||There could be benefit for the Commonwealth and for universities in pursuing further consolidation of the RCTS and UDRH programs. This should be pursued on a case-by-case basis, taking into account the willingness of individual universities to pursue integration and administrative efficiencies. This approach will have benefits for some organisations but may not be appropriate in all cases.||RCTS, UDRH||Medium term – case-by-case consolidation could begin to occur as existing funding agreements expire.|
|Recommendation 4.12||Rural health clubs should extend their focus to maintaining the involvement of graduates as they progress into further training beyond university. Expanded activities in this area may require additional funding support.||RHMT||Medium term – subject to available funding.|
65 Medical Training Review Panel Fifteenth Report, Commonwealth of Australia, 2012
66 Department of Health and Ageing, analysis of data from Department of Education, Employment and Workplace Relations 2011, February 2012
67 Department of Health and Ageing, What evidence is there that increasing rural origin admissions and undergraduate rural exposure produces more rural doctors? Literature Review, 2008
68 Senate Community Affairs Reference Committee, The factors affecting the supply of health services and medical professionals in rural areas, Commonwealth of Australia, August 2012
69 MTRP Fifteenth Report, Table 2.12
71 RCTS program consolidated reporting data, Department of Health and Ageing
72 Eley et al, “A decade of Australian Rural Clinical School graduates – where are they and why?”, International Electronic Journal of Rural and Remote Health Research, 2012
73 Grand Rounds are an important teaching tool and ritual of medical education and inpatient care, consisting of presenting the medical problems and treatment of a particular patient to an audience consisting of doctors, residents and medical students.
74 D Playford, D and E Cheong, “Rural Undergraduate Support and Coordination, Rural Clinical School, and Rural Australian Medical Undergraduate Scholarship: rural undergraduate initiatives and subsequent rural medical workforce”, Australian Health Review, 2012
75 The Royal Australian College of General Practitioners (RACGP), which has a large rural doctor membership, has also expressed interest in being able to submit a new tender for the administration of the program.
76 UDRH Program Consolidated Reporting data, Department of Health and Ageing, 2012
77 Urbis Pty Ltd, Evaluation of the University Departments of Rural Health Program and the Rural Clinical Schools Program, report prepared for the Department of Health and Ageing, 2008
78 Department of Health and Ageing, Rural Clinical Training and Support (RCTS) – 2011–2014 Operational Framework, DoHA, 2012, p. 14
79 D Playford and E Cheong, “Rural Undergraduate Support and Coordination, Rural Clinical School, and Rural Australian Medical Undergraduate Scholarship: rural undergraduate initiatives and subsequent rural medical workforce”, Australian Health Review, 2012. See also A Smedts and M Lowe, “Efficiency of clinical training at the Northern Territory Clinical School: placement length and rate of return for internship”, Medical Journal of Australia, 189(3), 2008, pp. 166-168.
80 Senate Community Affairs Reference Committee, The factors affecting the supply of health services and medical professionals in rural areas, Commonwealth of Australia, August 2012, Recommendation 11, p. xvi
81 Including the clinical training plans it is envisaged will be produced by the National Medical Training Advisory Network (NMTAN) which is currently being established by HWA.
82 University of Sydney, Submission to the Review of Australian Government Health Workforce Programs, 2012
83 Urbis Pty Ltd, Evaluation of the University Departments of Rural Health Program and the Rural Clinical Schools Program, 2008
84 Mapping Clinical Placements. Identification of potential Integrated Regional Clinical Training Networks and host organisations. PWC/Phillips KPA December 2010
85 Rural Doctors Association of Australia. Federal Budget Submission 2013-14
86 Australian College of Rural and Remote Medicine, Submission to the Review of Australian Government Health Workforce Programs, 2012