Australia's Rural Health Multidisciplinary Training program: Preparing for the rural health workforce that Australia needs.

Abstract

The Australian health landscape has changed significantly, and we must meet these changes and challenges head on, it has been nearly 25 years since the first University Departments of Rural Health (UDRH) and Rural Clinical Schools (RCS) were established. The first 7 UDRHs were established in 1997 followed by the first RCSs in 2000. The RCS and UDRHs, along with dental faculties offering extended rural placements, and the Northern Territory Medical Program were consolidated under the Rural Health Multidisciplinary Training (RHMT) program in 2016, with regional training hubs introduced in 2017. In this time, Australian universities have responded to and demonstrated targeted strategies that can effectively improve the percentage of health professional graduates choosing to work in rural and remote communities. There are now 21 universities funded under the RHMT program operating 19 RCSs and 16 UDRHs. The RHMT program aligns with the outcomes of the Australian Government’s Stronger Rural Health Strategy.1 In May 2020, the Australian Government received a commissioned independent evaluation of the RHMT program.2 We have had the privilege of working with the Australian Government Department of Health as they develop the response to the evaluation, aiming to leverage aspects of the program that are very effective and to contemporise the program to reflect innovation and changes to health student clinical training and service provision. This editorial will reflect on the history, the impact and the strengthening of focus of the program. Australian health training models are primarily delivered in metropolitan centres, geared towards enrolling metropolitan students, producing health professionals who are most likely to practise in high-density metropolitan centres within familiar health systems. Evidence demonstrates that these training models are not producing the necessary numbers of rural and remote health workforce/s required to service the health and well-being needs of rural, remote and very remote communities.3-5 While Australia has one of the highest ratios of doctors-per-head of population in the world, this workforce is disproportionately distributed across the country, concentrated in urban centres.6, 7 General practitioners can be trained for a concentrated range of office and community care settings, or they can be trained to deliver comprehensive general practice, emergency care and components of other medical specialist care required in rural hospitals and community settings; such doctors are rural generalists. At present, of around 1500 new general practice vocational training enrolments each year across Australia, there are approximately 150 Fellow of the Australian College of Rural and Remote Medicine (FACRRM) (10%) enrolments annually and around 85 Fellowship in Advanced Rural General Practice (FARGP) (6%).8 This does not match the proportion of the Australian population who live in rural, remote or very remote locations. It certainly is not enough to fill the existing employment vacancies in these areas, and it does not address or replace the ageing cohort of existing rural doctors as they retire. Increasing support for the training of rural generalists will thus increase the proportion of the workforce that is suitably trained for rural practice. Increased retention rates of rural practitioners occur when there is identification, engagement and recruitment of rural origin students, and when students and junior doctors are given early and well-supported rural and remote clinical placements.9-13 This approach applies to health professionals who have lived experience in rural and remote communities; they are more likely to make the decision to work rurally. Attracting more people from rural communities to train as health professionals is an important and broadly adopted strategy in building a sustainable rural health workforce.14 Few will understand the life and the needs of rural and remote communities better than those from these communities, including Aboriginal and Torres Strait Islander communities. As a pharmacist and a Deputy Commissioner, Faye McMillan attests to the success of this approach in the growth of the Aboriginal and Torres Strait Islander Health workforce, with her own experiences growing up in rural NSW and continuing to live and work in rural areas. As a rural generalist and Rural Health Commissioner, Ruth Stewart has seen health services, training providers, educators, health professionals and communities co-designing solutions that work for them, making a difference to the lives of rural people. To improve rural health, we need to better understand it. We need to understand the whys of health outcomes and evaluate which interventions and models of care are acceptable and effective. Evidence to inform such answers is growing as a result of research undertaken through the network of UDRH and RCSs. The ongoing presence and engagement of this network within rural communities deepens understandings of the local context, and this experience builds on the collective knowledge and wisdom of the communities. Commonwealth and state governments have responded to evidence of the importance of rural research, rural origin enrolment strategies and rural exposure during training and as a result made significant investments in programs to address maldistribution of the health workforce in Australia. The recent independent evaluation of the RHMT program acknowledges that universities funded through the program continue to provide health students with high-quality rural clinical training experiences. While the evaluation's focus was on the period since the consolidation of the RHMT program in 2016, it acknowledges decades of development of concepts of best practice in rural health education and recognises that universities located in regional, rural and remote communities provide considerable social and economic benefits to local communities. The evaluation provides 29 recommendations for the future, identifying key areas of reform. The reforms are designed to build on the successes of the program incorporating innovations in education, rural models of care, service learning and the value of longer, high-quality rural placements for nursing and allied health students and will be implemented within funding restraints of the program. Those reforms, which can be delivered within the existing funding package, are to be phased in from 1 January 2022 with a focus on key program outcomes such as optimal student selection for rural careers for graduates, strengthening research networks, building in a continuous improvement process at the university and program levels and responding to community and workforce need. Those recommendations for reform that carry with them additional funding requirements would need to be considered by government. Importantly, the reforms emphasise the value and importance of developing the Aboriginal and Torres Strait Islander health workforce by reviewing university policies and developing networks to increase culturally safe employment and career development opportunities for Aboriginal and Torres Strait Islander academics, professionals and students. Consultations undertaken by the department since the completion of the evaluation have identified the inclusion of Aboriginal and Torres Strait Islander administrative staff. Post-evaluation consultations have also highlighted the importance of embedding locally contextualised, cultural competency and responsiveness training in courses, planned to build regional capacity, community responsiveness and reciprocity in preparing this emerging rural health workforce. These reforms refine a program that has been delivering a rural-ready health workforce for over twenty years and will ensure the program continues to build on its successes by preparing a high-quality rural workforce that is representative of rural communities well into the future. Rural communities want to build connections, relationships and trust with local and connected health care professionals. Neither fly-in fly-out services nor a rotating cycle of locum tenens is considered optimal by communities. Rural and remote people and communities are calling for training and service delivery that is close to home and provides continuity of care by known carers. It is currently challenging in many sites to fill the existing positions for senior professionals, and thus, there are often deficiencies in supervisory capacity and therefore in job opportunities for new graduates. This is the environment within which the RHMT program seeks to bring positive change. State and national policy and strategy will need to align to enable this. Drought, bushfires and the COVID-19 pandemic have highlighted the importance of training a rural workforce that resides in community and is able to respond to immediate and future needs. It is our expectation that the refined RHMT program will deliver this and continue providing rural Australians the opportunities to become part of research, teaching and health care teams who serve their communities. Finally, we would like to acknowledge Australia's existing rural and remote health workforce and educators who provide high-quality services and training in rural and remote communities, often in highly challenging environments. The years 2020 and 2021 have been particularly challenging and distressing years for rural and remote communities with devastating natural disasters, followed by the COVID-19 pandemic. Rural health professionals and educators have kept working throughout these compounding challenges. They have provided training opportunities for the future rural health workforce while adapting themselves to new ways of training and delivering care safely. We must celebrate their work, support them and listen to their advice on how to improve the systems of care they work in.